Reducing Duplication in Wound Care — Creating Space to Connect

Much of our health system is moving toward place-based models of care — including home-based services, neighbourhood-focused hubs, and more coordinated primary care teams. These approaches hold real promise. When people have stable housing, it becomes easier to plan visits, deliver supplies, and provide continuity of care.

For people experiencing homelessness or housing instability, however, that same direction does not, on its own, resolve existing gaps. Ontario Health at Home functions best when someone has a home to anchor care around. When they do not, access to even basic wound supplies can become inconsistent — not because the care is complex, but because the system is not always built for mobility.

I’ve cared for people whose wounds were clinically straightforward, but whose lives made healing almost impossible. People without a fixed address. People living in shelters or encampments. People discharged from hospital with instructions that assumed a fridge, running water, storage space, transportation, and a phone number that would be answered.

As a nurse, I can assess, debride, and plan. But too often, I find myself navigating a system that was never designed for the realities my patients are living in.

These lived realities are where system design and clinical care intersect most sharply.

In community nursing, this mismatch shows up in very practical ways. Ontario Health at Home plays a critical role in coordinating nursing services and access to publicly funded wound care supplies, and its processes are well designed for people who have a stable place to receive care. Challenges arise when someone does not have a consistent location or reliable way to be contacted. In these situations, care can become harder to initiate or sustain — not because the need is unclear, but because the system is oriented around place.

Over time, I have learned that meaningful care does not always require new policies or programs. Sometimes it requires using the existing system more creatively — with consent, transparency, and respect for each clinician’s role. By coordinating timing, sharing assessment information, and approaching community nurses as partners rather than gatekeepers, it is often possible to close care gaps without breaking rules or compromising professional boundaries.

We see similar inefficiencies at the transition from hospital to community care. Hospital-based Nurses Specialized in Wound, Ostomy and Continence Care may complete thorough assessments and recommend gold-standard interventions such as compression therapy or offloading devices prior to discharge. Yet those same recommendations often need to be reassessed and re-approved by a second community-based clinician before supplies can be ordered. This duplication delays treatment, increases workload, and places patients at risk during an already vulnerable transition.

None of this reflects a failure of individual clinicians or organizations. It reflects a system that asks people to work in silos, even when their goals are aligned. When communication breaks down between hospital and community teams, patients absorb the cost — through delays, deterioration, and preventable readmissions.

This is where connection matters. When we create space to understand one another’s constraints, roles, and realities, collaboration becomes possible. Reducing duplication is not about doing less work — it is about doing the right work together, so that care can move more smoothly from hospital to home and into the community where healing actually happens.

This post reflects professional observations shared for educational and quality-improvement purposes.