Stakeholder Feedback on the Chiropody/Podiatry Referral: The Current Model of Foot Care in Ontario

Part II(a):Other Submissions

Note:

The responses within have not been edited by the Health Professions Regulatory

Advisory Council (HPRAC). HPRAC is not responsible for any errors and

omissions found on the submissions. The stakeholder comments are posted

according to access to information guidelines (for guidelines visit, http://www.hprac.org/en/privacy.asp)

Table of Contents Introduction .................................................................................................................................................. 1

Table 1: Responses from Individuals ...............................................................................................3

Table 2: Responses from organizations ......................................................................................... 12 ALYL Inc./Footloose ............................................................................................................................................... 12 Canadian Association for Prosthetics and Orthotics ................................................................................................... 36 Canadian Federation of Podiatric Medicine – Submission A ....................................................................................... 43 Canadian Federation of Podiatric Medicine – Submission B ....................................................................................... 44 Canadian Life and Health Insurance Association Inc. ................................................................................................. 60 College of Chiropodists of Ontario ........................................................................................................................... 64 College of Nurses of Ontario ................................................................................................................................... 80 College of Pedorthics of Canada ............................................................................................................................. 86 Ontario Association of Medical Laboratories ............................................................................................................. 90 Ontario Association of Prosthetists and Orthotists ................................................................................................... 100 Ontario Chiropractic Association ............................................................................................................................ 102

Introduction On June 28, 2007, the Minister of Health and Long-Term Care directed the Health Professions Regulatory Advisory Council (HPRAC) to "review issues relating to the regulation of chiropody and podiatry and provide advice as to whether and how there should be changes to existing legislation regarding these related professions". The Minister asked that the Council include "an analysis of the current model of foot care in Ontario, issues regarding restricted titles, and whether the existing limitations on the podiatrist class of members should continue." To provide context for an upcoming analysis of the regulation of chiropody and podiatry, and to address a broad component of the Minister’s referral, an initial consultation session was held on the current model of foot care in Ontario1. Consultation opened on April 4, 2014 and closed on July 4, 2014. The objective of the consultation session was to gather information on how foot care is delivered in the province; and learn more about the issues facing foot care providers, patients and other involved Ontarians. Participants were asked the following question:

Tell us your (or your organization’s) views on the current model of foot care in Ontario. What do you (or your organization) see as the major issues facing patients, practitioners, and others?

A link to an online survey was posted on HPRAC’s website and stakeholders submitted comments through this route; or by completing the survey and manually sending it into the HPRAC office; or by providing their views in the form of a letter. HPRAC’s consultation process is expected to crystallize broad themes and unanticipated issues; it is not viewed as a quantitative source of stakeholder interests or concerns. By the close of consultation, 198 stakeholders made submissions to HPRAC:

• 178 submissions were submitted online in the form of the survey. Part I of the stakeholder feedback focuses on these submissions.

• 21 submissions were mailed, faxed or emailed to the HPRAC office, in the form of the survey or in the form of a letter. Part II(a) & Part II(b) of the stakeholder feedback focuses on these submissions.

In total HPRAC received 199 submissions.2

1 A second consultation session will be held later in 2014 to address the remaining aspects of the Minister’s referral. 2 One organization made two submissions.

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The following organizations provided a submission to HPRAC on the current model of foot care in Ontario:

• ALYL Inc./Footloose • Canadian Association for Prosthetics and Orthotics • Canadian Federation of Podiatric Medicine – Submission A • Canadian Federation of Podiatric Medicine – Submission B • Canadian Life and Health Insurance Association Inc. • Canadian Podiatric Medical Association • College of Chiropodists of Ontario • College of Nurses of Ontario • College of Pedorthics of Canada • Feet for Life Medical Foot Care Ltd. & Feet for Life School of Podiatric Nursing Inc. • First Choice Foot Care • Giselle's Foot Care • Independent Business Specialty Interest Group of the RPNAO • The Michener Institute of Applied Health Sciences • North Bay Regional Health Centre • North East Local Health Integration Network • North Shore Family Health Team • Ontario Association of Medical Laboratories • Ontario Association of Prosthetists and Orthotists • Ontario Chiropractic Association • Ontario Community Health Centre (unspecified) • Ontario Medical Association, Sport & Exercise Medicine Section • Ontario Orthopaedic Association • Ontario Physiotherapy Association • Ontario Podiatric Medical Association • Ontario Society of Chiropodists • Prosthetics Orthotics Barrie • Pedorthic Association of Canada • Registered Nurses’ Association of Ontario • Rexdale Community Health Centre • South West Local Health Integration Network

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Table 1: Responses from Individuals Question 1: Tell us your (or your organization’s) view on the current model of foot care in Ontario. What do you (or your organization) see as the major issues facing patients, practitioners, and others? Submitter 1 There does not seem to be a clear stipulation about the qualifications necessary for 'advanced foot care' or who may use the title 'Foot Care Specialist' or 'Advanced Foot Care Provider' or even 'Specialist' generally within Chiropody or RHPA legislation. Should there be consideration about protecting the phrase(s) or term and perhaps providing definitions? In the Long Term Care Homes Regulations, a clause about basic foot care services is as follows: Foot care and nail care 35. (1) Every licensee of a long-term care home shall ensure that each resident of the home receives preventive and basic foot care services, including the cutting of toenails, to ensure comfort and prevent infection. 0. Reg. 79/10, s. 35 (1 ). However, what if a resident has an infection, Ingrown toe nails, high risk conditions like diabetes or peripheral vascular issues, corns, or other common issues or such a combination of issues found within this population? Is an unregulated care provider permitted, or should they be, to provide such care? In Long Term Care Homes, unregulated care providers may be hired directly by a resident or family without interference by the home. It is conceivable that an unregulated care provider providing Advanced Foot Care Services may sometimes engage in controlled acts unknowingly since scope of practice Is not defined. Submitter 2 Hello, I am currently in my training in the USA, originally from Ontario. I thought this document may be useful for consideration.

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Submitter 3 I have been invited to write a letter to express my views on the current model of foot care in

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Ontario as well to talk of the major issues facing patients, practitioners and others. To be clear I have not been able to find any documentation which describes the current foot care model in Ontario and am not aware of which issues relating to the regulation of chiropody and podiatry are being reviewed and therefore cannot comment as to any changes if any are needed to the existing legislation. I can and will relate to this committee the experiences I have as a Certified Orthotist. Certified Orthotists at this time are not a regulated profession in Ontario. We have a national body, the Canadian Board for Certification of Prosthetists and Orthotists (CBCPO) which acts as our regulatory association and our profession is held to the highest standards of patient protection available by law within the parameters’ of a regulatory association. As Certified Orthotists in Ontario we have been involved in the process of trying to find a current Ontario regulatory body to allow us to join and be regulated within the authority of their college. This has not been a successful process to date as we are small in numbers and considered competition to some. Currently our profession is in the process of requesting acceptance to the College of Kinesiologists. The path to become a Certified Orthotist is a lengthy one. Prerequisite is a degree usually in the sciences, kinesiology, nursing, engineering and other related fields. There are currently two schools accredited by the Canadian Board for Certification of Prosthetics and Orthotics (CBCPO) for the Clinical Methods in Orthotics/Prosthetics Program. In Toronto the program is a part of the George Brown College (GBC) curriculum. In Vancouver the program is a part of the British Columbia Institute of Technology (BCIT). GBC accepts 8 candidates per year while BCIT accepts only 14 western province residents every two years( even years) as the program is jointly funded by the Manitoba, Saskatchewan, Alberta and British Columbia governments. In Ontario the two year GBC program is coordinated with Sunnybrook Health Sciences Centre and involves the students in clinical experience at Chedoke Rehabilitation Centre in Hamilton and Holland Bloorview Kids Rehabilitation and the Hospital for Sick Children in Toronto. The program is a very hands on learning process with much emphasis on pathologies, abnormal and normal gait, skin tolerances, materials science and manufacturing process and procedures. Certified Orthotists require a diagnosis from a regulated health professional, usually Physiatrists, Orthopedic Surgeons, Neurologists, Oncologists, and Family Practitioners etc. Upon graduation from the program the student must secure an orthotic or prosthetic residency under the supervision of a Certified Orthotist or Certified Prosthetist. Upon completion of 3450 supervised work hours under a Certified Orthotist or Certified Prosthetist the resident may apply to write the National Certification Examination of the Canadian Board for Certification of Prosthetists and Orthotists (CBCPO). As a Certified Orthotist, I have a heavy volume of patients with lower extremity involvement. This lower extremity involvement can be related to disease, injury and/or surgery such as Cerebral Palsy, Spina Bifida, Diabetes Mellitus, Multiple Sclerosis, Muscular Dystrophies, Guillain Barre Syndrome, Amyotrophic Lateral Syndrome, Arthrogryposis, Charcot Marie Tooth, Cerebral Vascular Accident, Polio, Incomplete Spinal Injuries, Acquired Brain Injuries, Motor Vehicle Accidents, Diabetic foot ulcers, Plantar Fasciitis, Posterior Tibial Tendon Dysfunction, Achilles Tendon Tendonitis and Hallux Valgus or Hallux Rigidus, etc. Many of

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these contributing conditions can affect the foot with varying levels of neurological challenges such as low or high tone, muscle wasting, contractures, and varying degrees of sensation from hyper sensation to insensitivity, tissue or tendon/ligament damage. As these above conditions can involve the foot, a Certified Orthotists role is to provide the appropriate orthotic device for each patient based on their medical and biographical history and the findings of a thorough examination including range of motion of joints, muscle strengths, patient goals and sensation of the total lower extremities and observation of static stance and dynamic gait. The theory of subtalar neutral casting is the optimal standard to base the shape capture of the foot. When subtalar neutral is not possible due to excessive foot deformity or surgery the findings of the assessment will guide the best positioning for that particular situation. Casting can be with Plaster of Paris bandages, fibreglass casting tape or foam box depending on the individual patient needs. As the Certified Orthotist, I am responsible for the modifications to the positive mould, for the design of the orthosis and the material choices for each individual patient’s specific needs. Each style of orthosis that encompasses the foot must be designed to allow for the best possible correction, accommodation and /or protection possible while allowing for the optimal gait within the patients abilities. Devices made that encompass the foot are orthoses such as Foot Orthoses (FO), Infra Malleolar Orthoses (IMO), Supra Malleolar Orthoses (SMO), Ankle Foot Orthoses (AFO), Knee Ankle Foot Orthoses (KAFO), Hip Knee Ankle Foot Orthoses (HKAFO) and Reciprocating Gait Orthoses (RGO). Each device can have many different designs as they are designed to meet the specific needs of each patient. As a Certified Orthotist I feel our patients are well served as we are educated to address orthotic issues of the foot, distal and proximal of the ankle, as well as any orthotic issues of the whole body. This knowledge allows the Certified Orthotist to design the appropriate device, distal or proximal of the ankle based on a thorough review of the patient without limits in design or function. As a non regulated allied health profession we possess unique skills to adequately treat feet with orthoses of all styles and have the specific skills and knowledge to assess and justify our treatment plan. As well, as a manufacturer we have availability of all equipment, materials and adhesives on site to properly adjust the orthoses while the patient is present, ensuring the patient that they leave with the adjusted orthoses. My concerns with the foot care model would be that it needs to ensure the patient that they are in fact being assessed by a health care specialist who understands more than just the mechanics and functions of the foot but rather the mechanics and functions of the whole lower extremities, pelvis and torso so that the final determining factor for orthoses design is based on the specific patient results of the thorough examination, not limited to a restricted knowledge of orthoses design or manufacturing limits of the central fabrication facility. The other concern is for those patients who are insensate such as those with Diabetes. There needs to be the ability for the foot care specialist to adjust the orthosis as concerns arise. These patients must have their skin protected and cannot do without their orthoses so adjustments must be appropriately and timely tended to on site.

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Table 2: Responses from organizations Question 1: Tell us your (or your organization’s) view on the current model of foot care in Ontario. What do you (or your organization) see as the major issues facing patients, practitioners, and others? ALYL Inc./Footloose Does not assist nor service the provider(s) (Educated, experienced, Certified Nurses) to service and provide their clients in the community, LTCH, retirement home nor personal clinics. does not allow OHIP billing not even partial payment. Does not assist nor facilitate continuity of billing to/through 3rd party insurance. I've had nothing but trouble to obtain payment for my clients who have 3rd party insurance to claim through Ex. Sunlife, Manulife, Great West Life. Most are of/in our elderly and most vulnerable population. They need assistance for 'below the knee' care which for us nurses in this area include assessments for medical, gait, wound care, skin care, nail care, callous, corns, fungal nails - absolutely no different than a Chiropodist except removing ingrown or freezing. We do use other experienced & educated methods to deal with ingrown nails and other problem challenges. I've been around for 45 yrs as a nurse, 30 yrs as a sole proprietor of which 25yrs has been in the foot care area. I see and hear so much 'under the radar' from staff and administration. Most comments from staff are from after the Chiropodist or Podiatrist has been in a facility to provide care for $20 - a [redacted] mam method and the facility admn believe that's excellent because the price is so cheap and they are fulfilling the requirements of Ministry of Health but then the staff run around applying bandages, band aids, dressings to skin/toes while the clients/residents are sore, bleeding and in pain and don't wish care any more. One facility in Unionville, vetted me, contracted with me, for months agreed to make my company their provider and then, without giving me a signed copy of the contract, witout giving me signed consent forms, without giving me access to the medical info in the charts requested me to come in the next day, room to room service, provide everything myself (not what the discussions and contract stated) plus it was to be a clinic set up but then DOC decided that $35 was too high a price! Home individual visits run (in the industry) for $50-60. Chiropodists are hired at hospital clinics and see clients for 15 mins with no personal attention, just nip, clip, smooth and that's all. Nurses give education, assessment, take their time, check the skin, any wounds healed, not healing, possible future areas of discrepancy. They connect with client/family/POA, document, provide cleansing, massage with emollient cream, often reflexology and a holistic approach and atomosphere. We refer to other providers when needed. Some of us are working/training with Chiropodists to gain further experience and provide the public with alternate provider care. I personally and my colleagues in my associations attend conferences and take courses - 50 i can count certificates for. We are not recognized by the public nor insurance companies. I am currently beginning in a nursing home in Scarborough and should have access and remote access (as I travel and teach in Ontario) to document however, the facility is worried that I might breach confidentiality or someone might see me documenting when I"m outside the homes realm and gain information on the residents. I understand their point of view however, telling them over and over that I am registered with the College, that I've signed a confidentiality agreement, that I abide by all the 47 standards of the college and the BPGs and it's the same as my son a lawyer and his affiliations with his college or my daughter with KPMG and her mandates does not work. i am part of the 'Circle of Care" and they don't

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recognize me. The Public don't recognize Nurses as Independent Business Providers and REGULATED HEALTH PROFESSIONALS. I have a POSITION PAPER i wish to send/present. Please advise to whom or who would read this and work with me on this and in this area.

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Canadian Association for Prosthetics and Orthotics

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Canadian Federation of Podiatric Medicine – Submission A May is Foot Health Month. Join the Canadian Federation of Podiatric Medicine and others around the world as we recognize the beneficial services provided by chiropodists and podiatrists. Prevention and treatment of foot problems are important to maintaining a healthy lifestyle. Click here (http://www.youtube.com/watch?v=G8sQDHDIHIg&feature=youtu.be) to view our educational video. For more information visit www.podiatryinfocanada.ca Stephen Hartman, D. Ch., B. Sc (Podiatric Medicine)

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Canadian Federation of Podiatric Medicine – Submission B

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Canadian Life and Health Insurance Association Inc. Attention: Health Professions Regulatory Advisory Council

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Subject: Initial Consultation- Chiropody and Podiatry Review On behalf of the Canadian life and health insurance industry, we appreciate the opportunity to provide you with our comments on the current model of foot care in Ontario. As requested, we have also provided feedback on issues relating to the regulation of chiropody and podiatry to assist in identifying any potential changes to the existing legislation regarding these related professions.

We welcome the opportunity to work with HPRAC on this initiative. We would be pleased to discuss this with you at your convenience or provide any other information that you would find helpful.

Karen Voin Director, Health and Dental Direct: 416-359-2020

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College of Chiropodists of Ontario

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College of Nurses of Ontario

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College of Pedorthics of Canada Dear Mr. Corcoran,

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On behalf of The College of Pedorthics of Canada please accept the attached letter to HPRAC as support for the Canadian pedorthic profession and the foot care model in Ontario. You have received a submission from the Pedorthic Association of Canada and we fully support the information provided in the document. The Canadian pedorthic profession plays an important role in providing foot care to the Ontario public so please contact me if you require any further information or clarification during your review process. Please confirm receipt of this email. Sincerely, Geoff Powell Executive Director & Registrar

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Ontario Association of Medical Laboratories

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Ontario Association of Prosthetists and Orthotists

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Ontario Chiropractic Association

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