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About the Program

Format: A single point of access supports physicians with both hospital and community resource navigation and quickly connects family physicians to known providers who can help with urgent consultations, imaging requests and curated home and community care.

Cost: Free

Highlights: 

  • A shared virtual inter-professional care team for family physicians.
  • A single, centralized, standardized point of access to support Health System Navigation.
  • Real-time consultation and support for complex and urgent patients.
  • Access to mental health supports and care coordination for structurally vulnerable patients through Telemedicine Impact Plus (TIP) Program
  • Access to Chronic Headache Program

Partner Information:

Help you care for your patients

SCOPE (Seamless Care Optimizing the Patient Experience) is a virtual, inter-professional team that is based on developing meaningful relationships with allied health professionals and specialists who value primary care. The program was co-designed and co-created by family physicians to reduce fragmentation and maximize efficient use of services. Through SCOPE, family physicians can obtain:

  • Assistance in navigating both community and hospital resources through a dedicated nurse navigator and home and community care coordinator.
  • An on-call general internal medicine specialist for expedited phone consultation and in-person assessment, as required.
  • An on-call diagnostic imaging consultant for advice on appropriateness of imaging, interpretation of results, and expedition of urgent imaging.
  • Access to Care Coordination for Complex marginalized patients
  • Access to Chronic Headache Clinic at Women’s College Hospital (available on Ocean Platform as well)
  • Some sites provide Mental Health services as well
  • Low-barrier access through phone, eFax and OCEAN eReferral platform (pilot sites).

Improve patient outcomes

  • Timely access to services, more comprehensive care, and coordinated care follow up.
  • Improvement in the care provided for complex/co-morbid patients.
  • Avoid unnecessary emergency department visits.

“I have been working with a SCOPE nurse navigator for a year now, and her help with navigating urgent referrals, or sometimes determining which type of specialist to refer a patient to, has been extremely impactful and an invaluable asset for my practice.”

– Dr. Jane Chow Primary Care Physician – North Toronto

Sites currently offering SCOPE

Download the map.