The Central West Ontario Health Team’s (CW OHT) SCOPE (Seamless Care Optimizing Patient Experience) Program helps primary care physicians and nurse practitioners (NP) quickly connect patients to specialized health and community services through a phone call, text, or email.
Through SCOPE, primary care physicians and NPs are connected to a Nurse Navigator who can support timely outpatient referrals and clinical guidance. By making these connections easier to access, the program helps patients reach the services they need while supporting care outside the Emergency Department when appropriate.
The results speak for themselves: 96 per cent of potential Emergency Department visits were avoided through SCOPE-supported navigation.
“What makes SCOPE so valuable is the shared commitment and collaboration behind it: family physicians, nurse practitioners, navigators, and hospital and community partners working together to find solutions to the challenges patients face,” said Dr. Mehry Kianfafr, SCOPE Primary Care Lead. “At its heart, SCOPE is about making the health system easier to navigate so that primary care providers can enable patients to access the right care at the right time.”
Six years of growth and impact
In October 2020, the CW OHT launched the SCOPE Program, with the goal of creating a new way for primary care physicians and NPs to quickly connect patients to specialized health and community services.
Six years later, SCOPE has grown significantly, expanding its reach, pathways and impact across the Central West community.
“Supporting this program from conceptualization to where we are today has been one of my proudest accomplishments,” said Emily Cichonski, SCOPE Program Manager. “This program is built by primary care, for primary care. It has proven to demonstrate immense value to primary care physicians and nurse practitioners and their patients, both within our local program and how this model has spread across the province.”
When SCOPE first launched, just 18 users accessed the program through five pathways: General Internal Medicine, Nurse Navigation, Mental Health, Diagnostic Imaging, and Home and Community Care.
Today, SCOPE supports 314 users across 11 pathways, connecting primary care providers with an expanding network of specialized services.
The program now includes General Internal Medicine, Nurse Navigation, Mental Health, Diagnostic Imaging, Home and Community Care, Peel Public Health, Early Pregnancy Clinic, Acute Surgery Clinic, Wound Care, Pediatrics and Fracture Clinic, along with a partnership with OB Care Connect.
Since its launch in October 2020, the SCOPE Program has supported more than 2,000 calls, helping primary care providers navigate care options and connect their patients with the services they need.
“By enabling immediate, interdisciplinary co-management when a patient is in acute distress, SCOPE has allowed complex care to be managed safely in the community, delivering an exceptional Emergency Department diversion rate,” said Dr. Tanya Sehgal, a current SCOPE user and the program’s inaugural lead. “Thank you for your continued collaboration and shared commitment to wrapping robust structural support around family physicians & their patients to make our entire healthcare ecosystem more sustainable.”
Responding to community needs through collaboration
SCOPE’s development is driven by collaboration across primary care, hospital departments and community partners. As needs emerge, these partners work together to identify opportunities to expand the program and establish pathways that make services more accessible to primary care providers.
The CW OHT’s SCOPE Physician Advisory Council, consisting of 6 physicians, contributes to this work by identifying opportunities to strengthen connections and improve access to care. Partner departments also play an important role in developing pathways, sharing their expertise and helping providers navigate the services available to their patients.
This collective approach allows SCOPE to evolve alongside the needs of the community, building stronger links between primary care and the broader healthcare system.
At the heart of SCOPE are the navigators who make these connections happen every day. We would like to recognize:
- Sandra Agyemang: General Internal Medicine and Nurse Navigator pathways, including Early Pregnancy Clinic, Acute Surgery Clinic, Wound Care Clinic, Urgent Paediatric Assessment Clinic, Fracture Clinic, Peel Public Health and OB Care Connect partnership
- Dora Antwi and Simarpreet Sandhu: Mental Health pathway
- Diagnostic Imaging Clerical Team: Diagnostic Imaging pathway
- Tamara Allison: Home and Community Care pathway
Their expertise, responsiveness and commitment to collaboration are an essential part of SCOPE’s impact.
Looking ahead
From five pathways and 18 users to 11 pathways, a growing network of partners and hundreds of users, SCOPE has continued to evolve alongside the needs of primary care and our community.
As we celebrate six years, we are proud of what has been achieved, and even more excited about what comes next.
Thank you to our navigators, Physician Advisory Council, partner departments, primary care providers and all those who continue to help make SCOPE a seamless connection between primary care and the specialized support our community needs.
If you or someone you know is interested in joining the SCOPE Program, please email our team at [email protected].
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