SCOPE (Seamless Care Optimizing Patient Experience) is a North York General Hospital (NYGH) and North York Toronto Health Partners (NYTHP) initiative that supports and empowers a collaborative network between primary care providers (PCPs), hospital, and community services through a single point of access to an inter-professional care team. Registered SCOPE providers will connect with a dedicated telephone service to access support from internists, diagnostic imaging, NYGH resources and community services. As part of North York General’s digital health offerings that will give health care providers and the community better access to more seamless care options, SCOPE is a well-established program offered at hospitals across the Greater Toronto Area (GTA), including University Health Network (UHN), Women’s College, Unity Health, and others and has been adopted by more than 1,000 primary care physicians in the GTA. Visit www.scopehub.ca to learn more about the SCOPE program at other hospitals.
Learn more about the initiative by watching the SCOPE video:
Our Vision
The vision is to provide all primary care providers practicing within the North York area equitable access to interdisciplinary supports.
Benefits
Gain direct and centralized access to a range of services and providers through a dedicated phone line.
Opportunity to collaborate with the SCOPE team to identify and improve gaps in patient care.
Help reduce Emergency Department visits and re-admissions.
Core Services Include:
Description
The Nurse Navigator provides general advice and assistance navigating hospital and community resources, access to specialist care and other North York Toronto Health Partners (NYTHP) services. As well, through the Nurse Navigator’s ability to track majority of the calls that come through the SCOPE hotline, their goal is to collaborate with the North York PCP community to shape SCOPE offerings based on the needs of our PCPs.
Case Study
Situation:
A PCP called SCOPE regarding a newly diagnosed 11 y/o patient with type 1 diabetes.
SCOPE Intervention:
The Nurse Navigator was able to connect the PCP with the NYGH Diabetes Education Centre with a specialized program for children and teens. The program consists of a team of endocrinologist, pediatrician, RN, dietician, and social worker to help educate and support the patient and their family. Through the NYGH Diabetes Education Centre, the patient and their family received support on managing the disease, education on coping skills and additional information on available financial support.
Description
Our Community Support Service partners can facilitate referrals to support seniors, including:
Co-pays are required for some services. Subsidies are available.
Case study:
Situation:
A PCP called concerned about their elderly patient who lives at home alone and feels lonely and isolated. The patient also expresses that she can cook at home but finds it difficult getting around and grocery shopping.
SCOPE Intervention:
The Seniors Hotline coordinator was able to arrange friendly visiting to combat the patient’s feeling of loneliness, as well as sent a referral to one of our six partner agencies for grocery delivery and transportation services. In addition, the patient was informed about possibility to be connected to Meals on Wheels program as an option for affordable and nutritious meals. As an outcome, patient received information about services in the community, has been connected to these services, and feels less isolated. Client will also remain on a case management caseload so that staff can continue to monitor her progress and check in on her.
Description
The Mental Health Navigator supports Primary Care Providers and their patients through community resource navigation and facilitating physician-to-physician consultations through the Telephone Advice Psychiatry (TAP) program. The Mental Health Navigator will answer questions around mental health resources and assist in navigating appropriate services and supports for your patients.
Case Study
Situation:
A PCP calls with a patient who is experiencing anxiety and has been referred to an outpatient program but is on a long waitlist
SCOPE Intervention:
The Mental Health Navigator provided the PCP with information on local community supports, such as free walk-in services, short-term counselling, and peer support groups. The PCP was also connected with a psychiatrist through the TAP program for advice on medication management for their patient.
Description
General Internal Medicine (GIM) on-call can offer consultation or advice for non-emergent, acute issues and facilitate referrals to the Baruch Weisz clinic.
Case Study
Examples non-emergent, acute issues that our GIM-on-call can provide consultation for:
Acute VTE
Acute blood work abnormalities (low platelets, low hgb, etc.)
Acute stroke symptoms not requiring ER visit (not general neurology)
Cellulitis
Non-emergent, acute chest pain
Non-emergent, acute SOB/cough
Imaging abnormality (e.g., needs work up for malignancy)
Situation:
A PCP received the bloodwork of a young woman whose hemoglobin was 75 g/L, and ferritin < 1. The patient denied any sources of bleeding, and was asymptomatic with the exception of feeling fatigued. The patient was not on any blood thinners. The PCP called SCOPE to speak to GIM-on-call.
SCOPE Intervention:
Given the presentation and history of the patient, GIM-on-call advised the PCP to fax a referral to the Baruch Weisz. The PCP indicated on the referral form that they were a part of the SCOPE program, and that the referral was approved by GIM-on-call. The Baruch Weisz clinic connected with the patient and the patient was seen in 3 days, with an arrangement to have an IV iron infusion.
Description
SCOPE providers can speak with a member of the diagnostic imaging team who can help answer questions about tests and results, and refer directly to the radiologist on-call.
Case Study
Situation: A PCP was concerned about a patient who presented to their office with redness and swelling on their left lower calf. The PCP wanted the patient to have an urgent ultrasound to rule out DVT and avoid an ED visit if possible.
SCOPE Intervention: The charge technologist and booking clerk coordinated an appointment for the patient to have an ultrasound to rule out DVT within 4 hours. The patient went to their scheduled ultrasound appointment, and the PCP called back to follow up regarding the ultrasound results. The patient did not have a DVT and was able to avoid an ED visit.
Connect with the Gynaecologist-on-call for case consultation
Facilitation of referrals to Urgent Gynaecology Clinic
Description
Through the nurse navigator, primary care providers can access support in finding the most appropriate palliative care resource for the patient within NYGH or in the community. MD to MD consult is also available for non-urgent inquiries. Also, SCOPE Palliative Care has a dedicated clinic for non-urgent palliative patients who fall outside of the eligibility criteria for the Freeman Centre for the Advancement of Palliative Care and Supportive Care program in NYGH. They can be seen by a palliative care physician in the hospital.
Description
MD to MD consults and advice for non-emergent acute issues
Baruch Weisz clinic referrals can be seen in approximately a week
Description
Connect with the paediatrician on call for advice or consultation
The nurse navigator can also provide advice and help you connect your paediatric patient to the appropriate clinic if needed
“I’m really impressed with the quality and efficiency of the Support for Seniors service through SCOPE. I had a service coordination question for one of my patients. In the past, I would have likely spent a significant amount of time searching online to answer my question and provide my patient with the support he needed. By calling the Support for Seniors service, I was able to get the answers I needed quickly and improve the care I could provide to my patient.”
“SCOPE was able to help arrange same day CT imaging for my patient who had a fall, thus avoiding the need to send her through the ED.”
“What a great experience! The GIM on call returned my call within 10 minutes. It was evident that she had the time to listen to the details, recommend a visit to Baruch Weisz and strategize on how to make it patient- centred (i.e. – combine an infusion with a med consult visit) to avoid multiple visits for this frail elderly patient.”
“Thank you to the SCOPE team! The nurse navigator was able to help in finding the appropriate palliative care support for in home services for my patient very quickly.”
