Community Care Access Centres (CCAC) provide home care across Ontario. With our population aging, this form of ambulatory care is growing fast. The demands on the system are leading to new challenges in service coordination and training.

Kevin Woo, nurse practitioner in the Inter-disciplinary Wound Care Clinic at Women's College Hospital explains some of the challenges he and his colleagues observed in a recent study. "In Peel, 25 to 30 per cent of the people cared for by the CCAC have open wounds for more than six months. The numbers have doubled in the last 10 years."

"In Toronto and Peel CCAC, we saw people having their wounds dressed and cared for year after year while the underlying cause was never explored," says Woo. We focused on people with leg wounds, which are often due to poor blood flow or associated with chronic conditions like diabetes. About 30 per cent of people with leg ulcers in both CCAC had no clear diagnosis. Even when the diagnosis was known, people weren't necessarily receiving the best care. For example, evidence shows that compression dressings are the best treatment for the most common kind of leg ulcer. Unfortunately less than 40 per cent of people had dressings that put sufficient pressure on the lower leg to correct pooled venous edema."

Family physicians and CCAC caregivers can refer people to a clinic like the one at Women's College, but the process typically takes several months or more. The oldest group of patients (those 85 years and older) are unlikely to ever visit a specialized clinic. The researchers proposed a study to turn the process around. In the trial, a doctor or nurse practitioner connected to the clinic was called in to assess the patient as soon as a leg or foot ulcer was observed. This expert then worked with the patient's caregivers to develop a best care plan and to connect the patient to other members of the wound care team such as a chiropodist for specialized foot care.

The study made a dramatic difference for participants. All patients had the causes of their wound diagnosed. They were much more likely to receive best practice care. The result: Approximately 50% of diabetic foot ulcers healed within a 4-week period compared to 12% in the regular system. Other wound types also saw improvement.

"Expert assessment may take several hours," says Dr. Gary Sibbald, director of the Wound Care Clinic, "but it can save months of home care service. We estimate a savings of $338 million for home wound care in direct medical costs. We spend $24 million each year, hospitalizing patients when wounds become infected. Often a limb must be amputated. Hospital saving alone can cover the cost of connecting the patient to an expert team at the onset of care."

"As an ambulatory care centre, Women's College Hospital is committed to working with other ambulatory care providers to improve care," says Sibbald. "This issue is a perfect example of how our expertise could prevent tremendous pain and suffering for many suffering and disadvantage aging members of our population."