SCOPE [Seamless Care Optimizing the Patient Experience]

SCOPE Logo

 

What is SCOPE? SCOPE is a virtual, interdisciplinary program connecting Primary Care Providers (PCPs) in the community to real-time supports when they need it most.

Through a single point of access, SCOPE quickly connects PCPs to local providers who can help with urgent consultations, diagnostic imaging, curated home and community care, mental health, and navigating other services available in acute care or in the community.

Learn more about SCOPE by checking out our program infographic or by watching the program video below:

Interested in the program?

The CW OHT SCOPE Program is open to any Primary Care Providers (Family Physicians or Nurse Practitioners) practicing in Brampton, Malton, West Woodbridge, or North Etobicoke.

The CW OHT SCOPE Program is only open to members of the CW OHT.

Signing up for the program is administered by Women’s College Hospital (WCH) through their online portal.

Once you register, your application will be forwarded to the CW OHT SCOPE Program. By clicking the link below, and signing up through WCH, you agree to abide by the CW OHT’s Collaborative Decision Making Arrangement (CDMA) framework.

Click here to sign up!

To participate in the SCOPE Program, as the Primary Care Provider, you are required to follow the following expectations, to ensure the program continues to operate smoothly:

  1. Arrange follow up in a timely fashion directly with your patients and/or their guardian as a result of all investigations or interventions that have been ordered through the SCOPE Program.
  2. Conduct all necessary follow ups with the patient following any use of the SCOPE program for the patient’s care, including follow up in the event of a specialist consult or in the event of a patient attending a specialty clinic.
  3. After faxing any referrals to any of the SCOPE Program services, follow up the fax with a phone call to the appropriate SCOPE provider in a timely manner. When faxing to the Nurse Navigator, it is your responsibility to follow up if you haven’t heard back about the referral. Faxing a referral does not necessarily mean acceptance to a clinic and some referrals may be declined.

For Current SCOPE Users:

When calling SCOPE to speak to an internist, the following could occur:

  • Internist advises sending your patient to emerge
  • Internist recommends booking patient at the Urgent Medical Clinic
  • Internist provides telephone advice (Note: Call back time is within 1hr)
  • Referral Form:

When calling SCOPE to speak to the mental health team, the following could occur:

  • You will be connected to a psychiatrist
  • The team will help you navigate resources for your patient
  • The team will conduct a warm transfer to Canadian Mental Health Association Peel Dufferin to follow up with the patient
  • Access an urgent psychiatry consult (within 7 days) if your patient meets the Urgent Mental Health Clinic criteria.
  • Referral Form:

When calling SCOPE to speak to the diagnostic imaging team, the following could occur:

  • Your patient is booked for an urgent test
  • You are transferred to the on-call radiologist for a consultation
  • Referral Forms: (all DI referral forms need to be followed up by a SCOPE call.)
  • Fax Numbers:
    • Corporate SCOPE fax line located at Brampton Civic Hospital: 905-494-6405

When calling SCOPE to speak to the nurse navigator the following could occur:

  • The Nurse Navigator will refer your request to the appropriate service, where someone will connect with you directly to discuss your patient’s case
  • The Nurse Navigator will be able to answer your question right away
  • The Nurse Navigator will take back your request and get back to you with a response same day or next day (depending on the nature of the request)

Referral Forms:

When calling SCOPE to speak to a care coordinator following could occur:

  • The Care Coordinator will assist you with navigating home and community resources for your patient
  • The Care Coordinator will help you fulfill any urgent IV antibiotic/hydration/chemo disconnect needs
  • The Care Coordinator will help you facilitate urgent allied support for your patient (nursing, physiotherapy, occupational therapy, social work, and personal support care)
  • Referral Form:

Have feedback to share about a specific case or your SCOPE experience?

To contact the team click here, or scan the QR code:

Why Is It Needed?

In Ontario, there are roughly 7,800 PCPs that do not have access to a multidisciplinary team.

Often PCPs face difficulty navigating and connecting their patients with complex chronic conditions to the resources they require.

Time spent navigating the system means that PCPs unaffiliated with teams have less support to provide direct clinical care and patients wait longer for the resources they need.

The SCOPE model connects PCPs to specialists and other care providers to provide urgent access to advice for their patients. Urgent is defined as a plan of care for the patient needs to be determined within 48 hours, with the exception of Home and Community Care Coordination, where urgent is defined as within 4 hours OR services required by 8 p.m. the next business day. Using a central phone number, the SCOPE model connects providers to interprofessional advice/resources.

SCOPE Team

  • Emily Cichonski

    SCOPE Program Manager

  • Sandra Agyemang

    Nurse Navigator

  • Dr. Mehry Kianfar

    SCOPE Primary Care Lead

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