A model that improves health care capacity and access

How are Queen’s University, RNAO, and WoundPedia working together to improve wound care in Ontario?

Wounds are a devastating, costly and increasingly prevalent health issue. Wounds can affect anyone; however, people living with diabetes (over 1 million Ontarians) and seniors (2.1 million Ontarians) are particularly vulnerable. Many people in Ontario live with a chronic wound for years before it is properly diagnosed and treated.

Wound care requires an interprofessional approach. However, most patients with wounds are managed by family physicians, nurse practitioners or home care nurses operating without the support of an interprofessional team. Though well-intentioned, these individuals typically have little specialized skin and wound care training. Medical and other health care professional schools have limited wound care curriculum time. Additionally, there are no licensure requirements for wound care knowledge in Canada.

Wait times for interprofessional wound clinics (few in Canada) vary widely across Ontario’s regions (Abrahamyan et al. 2015). Poor access to wound care expertise has consequences. For example, one can observe the wide variation in the diabetic foot amputation rate per 100,000 Ontarians with diabetes in the North West LHIN (368 per 100,000), where access to expertise is quite limited, with that in Mississauga Halton LHIN (89 per 100,000) (Ontario Ministry of Health and Long-Term Care and Mondal 2013). However, even the Mississauga Halton LHIN amputation rate is higher than ideal and could be significantly improved.

The ECHO model is not the same as telemedicine, where the main goal is to improve ACCESS by using technology to bridge the distance. The ECHO model improves capacity and access simultaneously.

The ECHO model was created in 2003 by Dr Arora, a hepatologist at the University of New Mexico in Albuquerque. Using multipoint video conferencing in an academic/community design, weekly interprofessional rounds connect remote practitioners who present their patients, receive guidance from the academic ECHO specialist team, and then treat their patients themselves. Outcomes, published in peer-reviewed journals were identical in the rural/prison communities and academic clinics, and demonstrated fewer adverse events in the rural/prison communities (Arora et al. 2010; Arora, Kalishman, et al. 2011; Arora, Thornton, et al. 2011).

Providers who participate in these programs report increased knowledge, empathy, comfort and self-efficacy in dealing with these chronic conditions, and have become consultants for other providers in their geographic areas (Arora, Kalishman, et al. 2011). ECHO utilizes a “learning by doing” and “guided practice” model. Cases are sent privately and securely using standardized intake forms.

The ECHO model uses a HUB and SPOKE structure, where the hub (i.e. the interprofessional team) connects weekly via video conferencing with the spokes (i.e. the primary care providers) who present and discuss challenging cases from their practices and develop care plans which reflect evidence-based best practice. This allows spokes to become experts. In addition, they often become local resources for their colleagues, hence increasing system capacity and providing patients with evidence-informed care in their own communities.  

This structure is very compatible with the structures in the RNAO BPSO Designation.*  RNAO provides a set of supports and resources, as well as mentor BPSO organizations who act together to support new BPSOs. Of the over 300 BPSOs in Ontario, over 50% have focused on wound care, however, for this project, RNAO has developed a Regional System BPSO Designation that will enable current BPSO Designated organizations to focus on wound care, to ensure that sustained wound care practices become part of daily practice for all practitioners and teams.

Queen’s University, RNAO, and Woundpedia share a single vision: optimal wound care for all Ontarians. As Hub partners for Project ECHO Ontario Skin and Wound Care, our goal is to increase interprofessional coordinated and integrated wound care capacity across Ontario.

* Spokes in each ECHO round will be eligible for RNAO BPSO designated sites. ECHO and BPSO will cross-recruit; with new ECHO sites being introduced to BPSO and existing BPSO sites being introduced to ECHO.

The Model illustrates the integration of ECHO and RNAO BPSOs programs.

References

Abrahamyan, Lusine, Josephine Wong, Ba’ Pham, Gina Trubiani, Steven Carcone, Nicholas Mitsakakis, Laura Rosen, Valeria E. Rac, and Murray Krahn. 2015. “Structure and Characteristics of Community-Based Multidisciplinary Wound Care Teams in Ontario: An Environmental Scan: Community Wound Care Teams in Ontario.” Wound Repair and Regeneration 23 (1): 22–29. https://doi.org/10.1111/wrr.12241.

Arora, Sanjeev, Summers Kalishman, Denise Dion, Dara Som, Karla Thornton, Arthur Bankhurst, Jeanne Boyle, et al. 2011. “Partnering Urban Academic Medical Centers and Rural Primary Care Clinicians to Provide Complex Chronic Disease Care.” Health Affairs 30 (6): 1176–1184.

Arora, Sanjeev, Summers Kalishman, Karla Thornton, Denise Dion, Glen Murata, Paulina Deming, Brooke Parish, et al. 2010. “Expanding Access to Hepatitis C Virus Treatment-Extension for Community health care Outcomes (ECHO) Project: Disruptive Innovation in Specialty Care.” Hepatology 52 (3): 1124–33. https://doi.org/10.1002/hep.23802.

Arora, Sanjeev, Karla Thornton, Glen Murata, Paulina Deming, Summers Kalishman, Denise Dion, Brooke Parish, et al. 2011. “Outcomes of Treatment for Hepatitis C Virus Infection by Primary Care Providers.” New England Journal of Medicine 364 (23): 2199–2207.