SCOPE was launched as a quality improvement collaboration between Women’s College Hospital, University Health Network, and the Toronto Central LHIN Home and Community Care in 2012. It was designed in response to the following concerns identified by primary care providers:

• Timely access to specialist care
• Single point of access to services
• Assistance with homebound patients
• Access to hospital

The objective of SCOPE is to strengthen relationships between hospitals, community services, and primary care in order to improve care delivery for complex patients that may not have access to an interdisciplinary care team.

Other SCOPE Programs:

• Mid-West (University Health Network/Women’s College Hospital)
• West (St. Joseph’s Health Center)
• Mid-East (St. Michael’s Hospital)
• North (Sunnybrook Health Sciences Center)
• East (Michael Garron Hospital)
• Scarborough Health Network
• William Osler Health System
• Humber River Hospital

SCOPE Niagara

SCOPE Niagara launched in May 25, 2022. The SCOPE model promotes patient-centred interdisciplinary care, which is the foundation of Ontario Health Teams (OHT).

SCOPE has the potential to:

• Reduce emergency department visits
• Provide patients with more equitable access to team-based care and specialists
• Establish an effective channel to deliver best practices and emerging standards of care
• Provide an opportunity for ongoing physician engagement

Nurse Navigator: Sarah Furnival  SCOPENiagara@niagarahealth.on.ca 

GIM Physician Lead: Dr. Lorraine Jensen

Medical Imagining Physician Lead: Dr. Ali Jahed

Nephrology Physician Lead: Dr. Danny Lagrotteria

Palliative Care Physician Lead: Dr. Andre Maddison

General Internal Medicine (GIM)

Situation: A PCP called in regarding a patient with a 3-week history of shakiness and a recent diagnosis of hyperthyroidism (blood work revealed a TSH 0.01 mIU/L and T4 of 26 pmol/L). The patient was tachycardic but normotensive. The PCP wanted to discuss this patient with the GIM on-call to see if there are any red flags to monitor for and appropriate next steps.

SCOPE Intervention: The GIM on-call recommended initiation of beta-blocker therapy and urgent referral to endocrinology. The GIM-on call provided name and information of endocrinologist accepting new patients within the organization to ensure a timely referral for this patient.

Home and Community Care Support Services

Situation: An elderly patient with a recent fall and confined to bed was experiencing pain and had no support services arranged. The PCP called to see what in-home options could be set up to prevent an emergency department visit and keep the patient in her home.

SCOPE Intervention: The Home and Community Care Coordinator was able to arrange in-home physiotherapy to help with the patient’s mobility and rehabilitation, as well as PSW support to help with bathing and other ADLs. The patient was very happy she was able to stay at home and get the support she needed.

Registered Nurse/System Navigation

Situation: A patient with impaired vision due to cataracts had missed multiple appointments. A cataract surgery was scheduled, but the patient was unable to recall when or where it was. The PCP was concerned about how the patient was coping and that he would not be able to follow through with his surgery and other appointments. The patient lives in a senior’s apartment complex but has no family or social supports.

SCOPE Intervention: The Nurse Navigator connected with the eye clinics to determine when the surgery was, as well as the pre-operative instructions. Nursing services were arranged for eye drop administration and education, as it was determined the patient needed assistance with this. The patient had both cataract surgeries done and long-term case management services arranged to assist him to appointments in the future.

Diagnostic Imaging

Situation: A PCP was concerned regarding a patient’s redness, swelling and pain in the right lower calf. The patient was on anticoagulation therapy at home, however, the PCP was hoping to get an ultrasound done as soon as possible to determine if the patient had a DVT. As the patient was resistant to going to the hospital, the PCP asked that for the results of the ultrasound to be shared with him when available, so if there was a DVT it could be treated at home versus the patient going to the emergency department.

SCOPE Intervention: SCOPE team able to work with bookings to get patient into ultrasound within the next 2 hours. The technologists were aware of plan of action to call PCP at an after hour’s number in the event that the ultrasound was positive for a DVT.

"I believe this is great service for physicians in busy practices and patients who really needs urgent attention. I LOVE THIS SERVICE! Thanks for all you do." -Dr. Vinodbhai Patel, Chippawa Medical Centre

“SCOPE Niagara allows me to manage vulnerable, medically complex clients in the outpatient setting, preventing unnecessary ED visits and facilitating treatment in familiar settings. This is essential for my client population who face many challenges including poor mental health, substance use and insecure housing, resulting in poor tolerance for lengthy visits to the ED. The service is easy to navigate, response times are quick, and staff are personable and helpful.” -Michelle Goodburn, Nurse Practitioner, Quest Community Health Centre

“I was very impressed with the service that SCOPE offered for my family doctor in coordinating my care with the GIMRAC clinic and Diagnostic Imaging. I was not required to have long wait times in the ER for appointments, scans and blood work. All of my appointments have scheduled times, which helps with time management, work and family. I have come across great staff with a lot of knowledge, patience and understanding throughout the entire process. Dealing with a lot of pain, it was awesome that SCOPE and my family Dr. were able to coordinate with the hospital and setup a scan appointment and a doctor follow up for me the same day. I was going to spend hours in the ER among many sick people waiting for a scan and care. SCOPE ensure I did not have to wait for hours, rather I showed up at my scheduled time for the scan and follow up. Thanks for the, great job, great care, great service. Keep up the great work.” -Lukas Gotfryd, Patient

When in doubt, you can always call SCOPE. We will try to help you with your patient request, no matter how big or small.

Yes. As a consultation service, the SCOPE team will work with the primary care provider to ensure the best care for the patient. If a referral is required, Niagara Health will work with the primary care provider to ensure that the appropriate care is provided.