Senior Toronto blog

Like many seniors, my cousin, aged 77, needs help cutting her toenails, so she went to a foot care clinic north of Toronto. The clinician noticed a blister on her baby toe and, without any discussion, promptly cut it open, causing much pain and bleeding. Then she remarked that there was the beginning of an ingrown toenail on the big toe and, again with no discussion, plunged a sharp instrument deep into the toe, causing severe pain and heavy bleeding. After a few days at home, barely able to walk and unable even to put shoes on, my cousin went to her family doctor. The baby toe was infected and would require bathing in warm water and Epsom salts five times a day. Blisters should not be cut open. The injury to the big toe would take about six weeks to heal. My cousin was stuck at home for weeks. How can someone with apparently no understanding of foot care, wound care or even basic first aid have the authority to slice up people’s feet?

Aging is pretty hard on our feet. They support the weight of our bodies and undergo a lot of wear and tear. Some of the most common foot problems in seniors include bunions, corns, calluses, hammertoes, ingrown, thickened or discolored nails, diabetic foot conditions, poor circulation, flat feet and heel pain. Restricted mobility often means we can’t cut our own toenails. So many of us need foot care services. And those services are everywhere: community health centres, family health teams, foot care clinics, long term care, home care, hospitals. How do you choose the care that’s right for you?

Here's where things get murky. This field is just teeming with people with vastly different levels of skill and training, all offering foot care. And they all want our business, so as far as I could tell, none of them wants to help you figure out who can do what. But it matters who you see; anything beyond toenail cutting is a form of health care. You’d think that for the sake of patient protection, somebody would have laid all this out for us, but since I couldn’t find anything, I’ve tried to pull it together myself. Look at all these players:

• Podiatrists. To practice as a podiatrist in Ontario, one must hold a Doctor of Podiatric Medicine degree from one of the nine Colleges of Podiatric Medicine in the United States, or from the podiatry program offered by the Université du Québec à Trois-Rivières. They’re trained in an accredited program and licensed. They can diagnose and treat all manner of foot disorders, order radiographs, prescribe medications, and perform surgery on the bones of the foot. Of all the foot care providers, they are the only group whose services get covered by OHIP, but it’s only partial coverage. You can’t train to be a podiatrist in Ontario, so there aren’t very many of them in the province. You can look for one here.
• Chiropodists can do almost everything podiatrists can do, minus bone surgery and some kinds of prescribing. In Ontario, they’re trained in a comprehensive three-year full-time program at Toronto’s Michener Institute of Education. They’re trained in an accredited program and licensed. You can find a chiropodist here.
• Pedorthists can prepare custom-made orthotics and modify footwear. Pedorthists are not regulated by any college and are not part of the Regulated Health Professions Act. Chiropodists and podiatrists are the only regulated health professionals in Ontario whose legislated scope of practice includes the provision of orthotics. However, pedorthists may join the Pedorthic Association of Canada and voluntarily follow a code of conduct as a requirement of membership. Pedorthists train by taking Western University’s Diploma Course in Pedorthics, with eight online courses and two practicums. You can find a pedorthist here.
• Diabetes educators. Specially trained diabetes educators provide foot care services for individuals living with diabetes. They aim to reduce foot complications associated with diabetes through early intervention, regular monitoring and proper treatment of foot related concerns. To become certified, they must already be registered, licensed health professionals – for example, nurses or chiropodists – whose scope of practice permits them to provide diabetes education, and must have a minimum of 800 hours of practice in diabetes within three years, in order to qualify to write the certification exam. You can find a certified diabetes educator here.
• Foot care nurses. These are professional RNs or RPNs who have taken additional training in foot care. But, as the Canadian Association of Foot Care Nurses cautions on their website, at this time there is no certification process for nursing foot care in Canada that is recognized by provincial regulatory bodies. So the training is all over the map. There are courses available at some of Ontario’s public colleges. Others are offered through private career colleges. Some are run by private businesses. Sometimes foot care nurses running their own clinics create and offer training as part of their business. The clinician who butchered my cousin’s foot got her training in one of those nurse-designed private courses. The programs range in duration from a couple of days to a few months. In other words, it’s the wild west: a bonanza for nurse entrepreneurs and a minefield for foot care patients.
• Personal support workers. Various continuing education courses are available to them, from both public and private programs. The courses vary greatly in scope and depth. The Ontario Personal Support Workers Association has issued a foot care standard of practice document.

So what sort of foot care should you choose? If you’re living in long term care, or are housebound and dependent on home care, then you have to take what’s on offer. But if you live in the community and are mobile, then you can make some choices. Seniors often have more than one foot problem, and the problems are often complicated by systemic disorders like arthritis or diabetes. If all you need is nail-cutting, it doesn’t really matter who you see. But as my cousin learned, a simple cosmetic procedure can quickly cross the line into health care, and then who you see matters very much. If you choose a nurse, you might get a professional registered nurse who has taken several months of training at an accredited college. Or you might get someone who trained in a private facility, spent a few hours in a classroom, watched some videos, and thinks that the best way to treat blisters is to cut them open. So I think the safest bet is to choose a chiropodist. In Toronto, community health centres with foot care clinics staff them with chiropodists. OHIP doesn’t cover most foot care services, but if you have private insurance, you might get reimbursed. Foot care clinics in some community health centres are covered by OHIP. So take your time choosing. Finding good quality foot care should not be a matter of luck.

As we become older and need more support, most of us hope that we can age in place. That probably means that we are likely to need home care. It’s what most of us want, and it helps ease the pressure on hospitals and long term care. But years of underfunding and political tinkering have left home care in tatters. Denial of service, missed home visits, insufficient staff, poorly paid staff, service reductions and cancellations, lack of transparency about who qualifies for what service and for how long, unequal availability of and access to services from one region to another, lack of public reporting about quality of care, care outcomes and system performance – the list goes on and on. Bill 135, the Convenient Care at Home Act, which went into force on June 28, 2024, is the Ontario government’s latest effort to restructure home care. Will it fix this ailing service?

Home care used to be coordinated by 14 organizations called Home and Community Care Support Services, formerly Community Care Access Centres, formerly Local Health Integration Networks. Under the new legislation, these have all been dissolved and replaced by a single corporation, a crown agency called Ontario Health atHome that is responsible for all home care services across the province. They will do this through new entities called Ontario Health Teams, 58 groups comprising for-profit and not-for-profit health care providers including hospitals, doctors, and home and community care agencies. The teams will be responsible for coordinating and providing home care services to people in their local communities. These teams are still being formed. Once they are all up and running, the role of Ontario Health atHome will focus on providing designated Ontario Health Teams and/or other client providers with back-office and care coordination supports, including by assigning care coordinators to work under the direction of client providers. Under this new structure, patients should be able to move seamlessly from one form of service to another, and from one region to another.

But dig around a little, and you start to spot some red flags. Ontario Health atHome is governed by a Board of Directors, all appointed by the Minister of Health. There are no provisions for public meetings of the Board, public notice, public access to Minutes and documents nor any other democratic provisions. There are provisions for audits and reporting to Ontario Health, but not to the public. There is no legally required process for the internal governance, oversight, operations and legal liabilities or other responsibilities of Ontario Health Teams. Bill 135 does not require any standards of transparency, oversight and public accountability for Ontario Health Teams, other than reporting to Ontario Health atHome which itself is also not subject to any such standards. The key functions of care coordination and patient placement, which have always been administered publicly, are now contracted out to the provider agencies. Bill 135 repeals significant clauses in existing legislation that protected clients’ and the public’s interests in home and community care, including the Bill of Rights and complaint processes. These have been replaced by a Patient, Family and Caregiver Declaration of Values for Ontario, an aspirational document with no force in law.

With so little accountability and oversight, the new system primarily creates an environment hospitable to for-profit companies. But here's the problem with privatization in home care: the need to generate profit creates a huge new expense. In a service sector like home care, there aren't many ways to generate that profit. It has to come from cutting back on service and keeping wages low. For-profit service providers will be tempted to cherry-pick patients with simple, short-term needs, and limit access to care for patients with more complex, longer-term problems. There is a conflict between the need of private companies to produce a profit, and the need for patients to receive appropriate, quality care.

So who benefits from this restructuring of home care? Here’s a hint: it’s not us.