Hear what primary care providers, specialists and patients are saying about SCOPE.

Single Point of Access to Hospital and Community Resources

Internal Medicine Specialist

The SCOPE Internist provides you with advice over the phone and access to available supports, including:

  • Laboratory investigation
  • Non-invasive cardiac testing
  • Radiology
  • Subspecialty support

Examples of medical problems that can be managed:

  • Cardiology: atypical chest pain, low risk chest pain, arrhythmia, new-onset atrial fibrillation, congestive heart failure
  • Infections: cellulitis, pneumonia, diabetic foot, wounds, pyelonephritis
  • COPD / SOB / Respiratory infections / Asthma
  • Headaches
  • Work-up for abnormal test results
  • DVT/PE investigations and treatment
  • Cancer / Leukemia / Tumours
  • Anemia
  • Diabetes
  • Syncope

Home and Community Care Coordinator

The Home and Community Care Coordinator provides support for patients with existing home and community Care services, accepts referrals for new patients, and provides information about home and community care and other community-based services.

When you refer a patient to home and community care, the Care Coordinator completes a comprehensive assessment and links the patient to the appropriate health system and community resources, which could include:

  • Nurses
  • Nurse Practitioners
  • Pharmacists
  • Physiotherapists
  • Dieticians
  • Social workers
  • Speech Language Pathologists
  • Personal support workers
  • Occupational therapists

Examples of cases that can be referred to the Home and Community Care Coordinator:

  • Fragile elderly / homebound / socially isolated clients
  • Failure to cope / patient safety
  • Dementia / cognitive decline
  • Caregiver stress / burnout
  • Mental health / depression
  • Chronic disease management

Nurse Navigator

The SCOPE Nurse Navigator provides you with:

  • Assistance navigating SCOPE services
  • Searches for appropriate hospital-based resources in the GTA
  • Communication between yourself and physicians in the hospital
  • Access to resources in the community which may be difficult to acquire
  • Expedited patient care when possible

Examples of when to call the Nurse Navigator:

  • Specialist referral (GI, Cardiology, Urology, Neurology, Neurosurgery, Orthopaedics, Obstetrics)
  • Mental Health, Depression, Addiction, Urgent Psychiatry
  • Diabetes Education
  • Rapid Diagnostic Clinics for Oncology
  • Follow-up on the status of referrals, results, and specialist visits
  • Resources to assist with patient case management

Medical Imaging

SCOPE Imaging provides you with better access to medical imaging services for urgent patient needs and for informational and navigational support. When you call, you will be connected to a call centre which will direct your call to the appropriate expert, including on-call radiologists.

Examples of services offered:

  • Support in selecting the most appropriate test
  • Radiology consult (subspecialty consult, report interpretation)
  • Urgent imaging (triage and expedited imaging for urgent cases)
  • Urgent reporting (expedited reporting for urgent cases)
  • General navigation and informational support during imaging service
  • Same-day imaging services (x-ray, ultrasound, nuclear medicine)
  • Access to an MRI Standby list at Women’s College Hospital

Medical Imaging sites included:

  • Mount Sinai Hospital
  • Princess Margaret Hospital
  • Toronto General Hospital
  • Toronto Western Hospital
  • Women’s College Hospital

Brain Tumour Patient Diagnosis and Care Story

  • Primary care provider meets with patient
    Identified patient needed a CT scan with an average 3-month wait
  • Needs of the patient changes
    Suspected presence of brain tumour due to reoccurring symptoms
  • Contacts SCOPE for assistance
    Received direct access to diagnostic imaging and CT scan was booked for the following day
  • Patient receives urgent care
    2 days after the diagnosis of the brain tumour, the patient had undergone neurosurgery

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How has SCOPE helped?

“Excellent service. SCOPE has had a profoundly positive impact on my ability to provide care to my patients, decreased sense of practicing in isolation and increased feeling of connectivity to the medical community.”

Dr. Claudio Borgono, SCOPE Physician

“The Scope model has been a significant catalyst for primary care physician involvement in our OHT…a game changer regarding physician engagement.”

Valerie Carter, VP Strategy and Stakeholder Engagement at William Osler

Case Studies

Nurse Navigator

Reasons for Referrals:

  • The primary care provider (PCP) connected with SCOPE regarding a 38-year-old patient with a 3-4 month history of difficulty with mobilization, poor balance and leg weakness.
  • 20 years ago this patient was diagnosed with Multiple sclerosis (MS), was treated and symptoms abated

How SCOPE Helped:

  • SCOPE Imaging: helped arrange an urgent MRI; findings were consistent with MS.
  • SCOPE Nurse Navigator: The PCP referred the patient to St. Michael’s Hospital MS Clinic (currently a 3 week wait to process a referral). The PCP connected with the Nurse Navigator for access to expedited care.
  • SCOPE Nurse Navigator helped facilitate an urgent referral to a community based Neurologist. The PCP was able to speak with the Neurologist for an over the phone consultation and an appointment was arranged for the patient for the following morning.

Home and Community Care

Reasons for Referrals

  • Primary care provider connected with SCOPE regarding a 65-year-old patient with a new diagnosis of Stage 4 lung cancer.
  • Requested referral to Palliative Care Team. 

How SCOPE Helped

  • SCOPE Coordinator contacted client and spouse on the same day to conduct initial assessment.
  • Patient had been sleeping on a lazy boy chair as he was unable to get comfortable in his bed. TC-LHIN Coordinator ordered a hospital bed with delivery the following morning.
  • Patient was referred to TC-LHIN Palliative Care Team connected with Temmy Latner program.
  • Home visit conducted with SCOPE Coordinator and Palliative Coordinator to ensure a warm transfer of care.
  • Patient now connected to Palliative Care Physician and in-home Nursing care.

Additional Services

Collaborative Care Case

Reasons for Referrals

  • 28-year-old female who experienced a traumatic brain injury during a motor vehicle accident in the fall of 2017
  • In January 2018, patient was referred to SCOPE:
    • Mental Health regarding persistent anxiety and query PTSD
    • Headache Clinic for post-traumatic headache

How SCOPE Helped

  • Mental health SW and headache NP coordinated a referral to MBSR group, while patient pursued psychotherapy through insurance. Headache clinic continued to follow patient.
  • In early December 2018, patient presented to ED following rapid onset of stuttering and whole-body tremors.
    • Patient followed up with headache clinic NP, who coordinated rapid referral to SCOPE MH program for psychiatric assessment
  • SCOPE psychiatrist assessed patient within 2 weeks and provided medication recommendations to PCP
  • SW and NP were both available for patient contact if needed.
  • PCP followed up with psychiatrist regarding medication side effects in January, which was managed with a quick phone consult.
  • Result: Patient has been stable with steady improvement since ED visit.

Navigation Case

Reasons for Referrals

  • 50-year-old male experiencing recurrent major depressive episode (MDE)
  • Both he and his family having a difficult time managing his symptoms
  • Poor understanding of depression
  • History of good response to medication during first MDE several years prior

How SCOPE Helped

  • SCOPE involvement (~1 month)
  • Shared care approach with primary care provider (PCP)
  • Comprehensive review of treatment records
  • Rapid psychiatric assessment to assess diagnosis (psychotic depression)
  • Social Worker available for almost daily support calls with patient and family members
  • Provided acute shared support to PCP until patient stabilized with medications
  • Social Worker available for low-barrier/light-touch support for months following initial involvement