Healing wounds through community and continuity of care

HN Summary

• Humber River Health’s outpatient Vascular Clinic delivers preventative, community-rooted wound care, providing continuous specialist follow-up for patients with chronic and complex vascular wounds in a high-needs population.

• A highly collaborative, multidisciplinary model keeps patients out of the Emergency Department, coordinating care between vascular surgeons, nurses, primary care providers, and community partners to manage wounds at the lowest appropriate acuity.

• By integrating hospital and community pathways, the clinic improves equity, continuity, and outcomes, empowering patients to participate in their own care while preserving emergency capacity and supporting system-wide efficiency.

At Humber River Health’s (Humber) outpatient Vascular Clinic, wound care is continuous, preventative, and deeply rooted in the realities of the community it serves. The clinic provides specialist assessment and management for patients with vascular conditions, many of whom live with chronic and complex wounds that require long-term follow-up. 

As part of the multidisciplinary team that supports this clinic, vascular surgeons play an important role in shaping a comprehensive, longitudinal approach to wound care. This team of physicians contribute critical expertise in circulation assessment, medical optimization, wound debridement, and care coordination, working closely with nursing staff, fellow physicians and community partners to address the many factors that influence healing over time.

The urgency of this work is clear when viewed through the lens of Northwestern Toronto’s demographics. Humber serves a community with a greater prevalence of chronic conditions compared to the rest of Ontario. This community has the highest number of seniors over the age of 80 in Ontario, a figure expected to double by 2036. In addition, Humber’s catchment area has long been identified as among the lowest rates of people connected to a primary care physician in the province. These realities demand care that are not only clinically excellent, but equitable, accessible, and connected to the community.  

“Socioeconomic factors play a huge role in wound development and healing,” explains Dr. Kerry Graybiel, vascular surgeon and Chief of the Division. “In our catchment area, we see high rates of diabetes, end-stage renal disease, and vascular conditions, all of which significantly increase the likelihood of lower-extremity wounds.”

The clinic is a fast-paced and highly collaborative environment. Patients are typically referred through their family physician or Humber’s Apotex Emergency Department (ED) and may often return weekly or monthly for ongoing care. 

“In one half-day clinic, we can see up to 30 patients,” says Leeanna Hamilton, a registered nurse who has worked at Humber for over 25 years. “We assess wounds, remove and clean dressings, and work closely with physicians to determine next steps.” 

Within the clinic, Dr. Graybiel and his colleagues provide advanced wound assessment and management, including debridement, draining infections, taking samples to guide antibiotic treatment, and biopsies. In some cases, wounds referred for treatment are identified as dermatologic conditions or malignancies, allowing for earlier diagnosis and appropriate referral. 

Appointments vary depending on wound severity and complexity, some visits require significant nursing time and collaboration. Common cases seen in the clinic include diabetic foot ulcers, venous stasis wounds related to venous insufficiency, arterial or ischemic wounds caused by poor circulation, and post-operative wound management. Without consistent monitoring and intervention, these conditions can deteriorate quickly, often resulting in emergency visits or hospital admission. 

“The goal is preventative care,” says John Reyes, a registered nurse who works in the clinic. “By managing wounds here, we prevent them from getting worse and we keep patients out of the Emergency Department whenever possible.” 

That preventative approach is especially important given Humber’s Apotex ED is the busiest in the province, seeing nearly 135,000 patients annually and receiving almost double the number of ambulances as neighbouring hospitals. Patients who require regular monitoring, maintenance, or reassurance are able to receive care in a scheduled, supportive environment rather than turning to the ED for non-critical concerns. This approach improves continuity of care for patients and supports system flow across the organization by preserving emergency capacity for those who need it most.  

“The goal is always to manage patients at the lowest appropriate acuity,” says Dr. Graybiel. “We are actively developing dedicated ED-to-home and hospital-to-home pathways so patients can be funnelled directly to us rather than defaulting to emergency care.” 

Collaboration beyond the hospital walls is central to the clinic’s success. The team works closely with Ontario Health atHome and community nursing agencies. These partners play an important role in supporting patients outside of clinic visits, particularly for those with mobility challenges or limited access to transportation. Together, the hospital and community teams reinforce self-care practices, ensuring patients are active participants in their own healing.

“We encourage patients to take part in their own care,” adds Amy Kang, a registered nurse at the clinic. “We discuss diet, activity, dressing compliance, and then follow up to see if treatment is working. That communication with community partners makes a real difference.”

What distinguishes Humber’s model is the infrastructure built around coordination, beyond the operating room. Rather than focusing solely on revascularization, the vascular surgery team works closely with clinic nurses, family physicians and community partners to ensure antibiotics are appropriate, dressings are effective, risk factors are managed, and care plans are adjusted quickly when healing stalls. This behind-the-scenes coordination represents a large portion of the work required to achieve successful wound outcomes.

“Vascular surgeons are very good at revascularization, but if you don’t have the clinic, resources, or the communication with community nurses to coordinate care for many of these cases, we are essentially just doing surgery and hoping for the best,” says Dr. Graybiel. “Also, if we can provide the same or better care using existing community infrastructure, that’s a win for patients, for the hospital, and for the system.”

Many of these ED-to-home and hospital-to-home integrated pathways are now being formalized in partnership with Ontario Health atHome and are expected to roll out in the coming months, strengthening the clinic’s ability to manage patients at the most appropriate level of care. Looking ahead, this team sees this approach as both scalable and transferable. Lessons learned through integrated care projects across multiple Ontario Health regions demonstrate that, with strong community partnerships and shared accountability, this model can be adapted across geographies to support far larger patient populations.

Ultimately, the work of Humber River Health’s outpatient Vascular Clinic extends beyond treating individual wounds. It is about delivering equitable, preventative care to a community with complex health and social needs, while empowering patients to remain as active participants in their own healing. Through close collaboration between nurses, physicians, and community partners, the clinic provides consistent, high-quality care that helps patients maintain stability, independence, and dignity, often over many years. 

Shahana Gaur works in communications at Humber River Health.