​​The health system can often seem fragmented and confusing to navigate for patients and families seeking specialized support. One challenge is that while primary care has traditionally been the access point for other services, it is not well integrated with hospital and other community resources. That's why hospitals and Ontario Health Teams are focusing on ways to strengthen collaboration to create more seamless care between primary care, specialists and community health services.

“Seamless Care Optimizing the Patient Experience, or SCOPE, supports and empowers a collaborative network between primary care providers (PCPs), hospitals, and community services through a single point of access to an inter-professional care team," says Dr. Pauline Pariser, SCOPE Medical Director and Primary Care Lead for University Health Network and Women's College Hospital. “This creates tangible solutions and reduces wait times for physicians by connecting with the SCOPE team in real time to identify and improve gaps in patient care. It also helps reduce Emergency Department visits and re-admissions," adds Dr. Pariser.

Since introducing SCOPE at North York General Hospital (NYGH) in December 2021, providers were immediately receptive, utilizing the dedicated telephone service to connect to a range of services, including a Nurse Navigator, on-call Internist, Medical Imaging, Access Point, Palliative Care, support for seniors and General Surgery. The General Surgery pathway is unique to NYGH and enables physicians to refer into the urgent general surgery clinic in a more streamlined way.

“We onboarded an extremely large number of PCPs in a short period of time and our call volumes have surpassed our targets," says Amanda Mohamed, NYGH Project Manager for SCOPE. “

One of the many benefits of SCOPE is being able to track the types of calls through the Nurse Navigator who is the first connection for all calls coming into the SCOPE hotline.

 “Through this data, we can identify the needs of North York PCPs, and use this information to drive the development of future SCOPE pathways," adds Mohamed.

As of September 30, 2022, 174 primary care providers have enrolled into the program, which is a partnership between NYGH and its Ontario Health Team, North York Toronto Health Partners (NYTHP). During the month of September, 79 calls were made by PCPs in North York who also have the option of conveniently sending an email or e-referral through Ocean (North York eReferral) to connect to SCOPE. Of those calls, 78 % of patients avoided having to visit the Emergency Department.

North York General is also working with its NYTHP partner, Better Living Health and Community Services, to help strengthen community connections and broaden the impact of the program. It is also partnering with Access Point, a resource for patients and their PCPs to access individualized mental health and addictions support services.

“Not only are we providing many ways for providers to easily connect, in my role I'm able to work with a network of SCOPE nurse navigators across Toronto and bring key learnings back to my peers at NYGH," says Kylie Gabatin, Nurse Navigator for SCOPE.

North York General serves a local population of about half a million people, which is larger than most medium sized cities across Canada. It is also home to one of Toronto's most culturally diverse and rapidly growing areas with a higher proportion of seniors than any other areas of the city.

“Digital health is enabling the health system to be more proactive and personalized when it comes to patient care and connection between providers," says Dr. Steve Kahane, Family Physician and North York Primary Care Co-Lead for SCOPE, who works alongside Co-Lead, Dr. Jodi Sonshine. “SCOPE encourages primary care physicians to feel comfortable reaching out and asking questions about patients in a very supportive, collaborative environment. In doing so, we're connecting people with the care and services they need in a more seamless way."

North York General's bold Digital Health Strategy (DHS) is essential to how the organization is meeting changing community and health system needs. SCOPE is one of many initiatives that are improving health experiences and outcomes while driving integrated care. 

SCOPE is a well-established program offered at hospitals across the Greater Toronto Area (GTA), with more than 1,500 registered primary care providers across nine SCOPE sites.  Visit www.scopehub.ca to learn more about the SCOPE program at other hospitals.