16.D Implementing SCOPE: Transforming Primary Care through Seamless Integration (Canada)
| Friday, May 16, 2025 |
| 3:00 PM - 4:00 PM |
| Room 5 - Fernando Pessoa |
Speaker
Dr Pauline Pariser
Canadian
Primary Care Lead
Women's College Hospital
Implementing SCOPE: Transforming Primary Care through Seamless Integration
Abstract
Background
SCOPE (Seamless Care Optimizing the Patient Experience) is an innovative, interdisciplinary program, co-designed with patients and primary care providers (PCPs), providing real-time support through a single access point. Integrated with hospitals, PCP offices, and community services, SCOPE aims to ease the navigation challenges for PCPs without interdisciplinary teams, equitably improving patient care and enhancing workforce capacity and capability. Since its 2012 launch, SCOPE has provided over 3,200 PCPs at 18 Ontario sites with access to urgent consultations, offering over 100 streamlined clinical pathways, diagnostic imaging, home and community care services, mental health resources, and guidance in navigating acute and community services. It consistently reports high patient and provider satisfaction levels, deferment from emergency rooms of over 80%, and generates high-quality replicable data that encourages secondary adaptations in other hospitals and geographic regions.
Audience
This workshop is intended for frontline PCPs, hospital administrators, community partners, and healthcare leaders interested in implementing and adapting integrated care models that bridge primary, acute, and community services.
Approach
• Introduction (10 minutes): Overview of the SCOPE model and its impact since inception, focusing on collaborative practices enabling sustained success
• Case Study Presentation (25 minutes): Three different case studies to explore SCOPE's application in founding, emerging, and rural sites, specifically highlighting unique enablers and challenges:
1. Founding sites:
• Partnership and collaboration between hospital and community specialists, primary care providers and patients.
• Buy-in and engagement from senior leadership focusing on shared system goals
• Transparency of data and shared accountability via system-wide governance and leadership
2. Emerging sites
• Community partnerships creating low-barrier access points sensitive to evolving needs of diverse communities
• Creation and evaluation of distinct clinical pathways supporting population health-based care delivery
• A collaborative community of practice among like-minded hospitals, facilitating shared knowledge and addressing care gaps
3. Rural/Small Urban sites
• Consideration of geographic challenges and local culture to inform high-touch outreach and digital solutions
• Critical role of high-caliber nurse navigators that foster a circle of trust transcending regional and healthcare boundaries
• Incremental QI approach responsive to evolving health needs and advocating for policy revisions to challenge outdated practices
Interactive Group Work (30 minutes):
Attendees will join facilitated roundtable discussions, reflect on region-specific current primary care integration and identify specific enablers and challenges in implementing programs like SCOPE. Through collaborative dialogue and interactive polling, participants will explore key success factors, regional variations, and practical strategies that drive effective program adoption.
Feedback Session (15 minutes):
Group sharing of insights on their proposed strategies, with facilitators summarizing key takeaways.
Closing and Q&A (10 minutes):
Final wrap-up, summarizing key concepts and next steps for participants interested in translating the SCOPE model to their own healthcare contexts.
Outcomes
By the end of the workshop, participants will:
• Gain practical knowledge of the SCOPE program's structure and implementation strategies.
• Be able to actualize core concepts, including partnership building, patient and provider co-design, and leadership engagement, to create similar models tailored to their unique healthcare environments.
Session Duration: 90 minutes
SCOPE (Seamless Care Optimizing the Patient Experience) is an innovative, interdisciplinary program, co-designed with patients and primary care providers (PCPs), providing real-time support through a single access point. Integrated with hospitals, PCP offices, and community services, SCOPE aims to ease the navigation challenges for PCPs without interdisciplinary teams, equitably improving patient care and enhancing workforce capacity and capability. Since its 2012 launch, SCOPE has provided over 3,200 PCPs at 18 Ontario sites with access to urgent consultations, offering over 100 streamlined clinical pathways, diagnostic imaging, home and community care services, mental health resources, and guidance in navigating acute and community services. It consistently reports high patient and provider satisfaction levels, deferment from emergency rooms of over 80%, and generates high-quality replicable data that encourages secondary adaptations in other hospitals and geographic regions.
Audience
This workshop is intended for frontline PCPs, hospital administrators, community partners, and healthcare leaders interested in implementing and adapting integrated care models that bridge primary, acute, and community services.
Approach
• Introduction (10 minutes): Overview of the SCOPE model and its impact since inception, focusing on collaborative practices enabling sustained success
• Case Study Presentation (25 minutes): Three different case studies to explore SCOPE's application in founding, emerging, and rural sites, specifically highlighting unique enablers and challenges:
1. Founding sites:
• Partnership and collaboration between hospital and community specialists, primary care providers and patients.
• Buy-in and engagement from senior leadership focusing on shared system goals
• Transparency of data and shared accountability via system-wide governance and leadership
2. Emerging sites
• Community partnerships creating low-barrier access points sensitive to evolving needs of diverse communities
• Creation and evaluation of distinct clinical pathways supporting population health-based care delivery
• A collaborative community of practice among like-minded hospitals, facilitating shared knowledge and addressing care gaps
3. Rural/Small Urban sites
• Consideration of geographic challenges and local culture to inform high-touch outreach and digital solutions
• Critical role of high-caliber nurse navigators that foster a circle of trust transcending regional and healthcare boundaries
• Incremental QI approach responsive to evolving health needs and advocating for policy revisions to challenge outdated practices
Interactive Group Work (30 minutes):
Attendees will join facilitated roundtable discussions, reflect on region-specific current primary care integration and identify specific enablers and challenges in implementing programs like SCOPE. Through collaborative dialogue and interactive polling, participants will explore key success factors, regional variations, and practical strategies that drive effective program adoption.
Feedback Session (15 minutes):
Group sharing of insights on their proposed strategies, with facilitators summarizing key takeaways.
Closing and Q&A (10 minutes):
Final wrap-up, summarizing key concepts and next steps for participants interested in translating the SCOPE model to their own healthcare contexts.
Outcomes
By the end of the workshop, participants will:
• Gain practical knowledge of the SCOPE program's structure and implementation strategies.
• Be able to actualize core concepts, including partnership building, patient and provider co-design, and leadership engagement, to create similar models tailored to their unique healthcare environments.
Session Duration: 90 minutes
Paper Number
223
Biography
Dr. Pariser is Associate Medical Director, Primary Care Lead for the SCOPE Provincial Program at University Health Network (UHN) and Women’s College Hospital and Senior Advisor to the Social Medicine and Population Health Program at UHN.
Her research interests include advancing primary care integration and co-designing compassionate models of care with people with lived experience.
As Professor in the Department of Family and Community Medicine, University of Toronto, she has been recognized with teaching and leadership awards from her department, the Ontario Medical Association, the College of Family Physicians of Canada and the Ontario Ministry of Health and Long-term Care.
Ms Beatrise Edelstein
Canadian
Vice President, Post Acute Care and Health System Partnerships
Humber River Health
Implementing SCOPE: Transforming Primary Care through Seamless Integration
Paper Number
223
Biography
Beatrise Edelstein is the Vice President, Post Acute Care and Health System Partnerships with over 19 years of progressive leadership experience. She is a Certified Health Executive, Certified in Change Management with Prosci®, and received her Master of Health Science in Health Administration from the University of Toronto.
In her role, she is responsible for planning, developing, leading and evaluating health system transformation initiatives across acute, post-acute, community and long-term care sectors with the focus on stakeholder engagement and partnerships, leveraging the latest innovations and research through an equity-focused lens.
Kathleen Kirk
Canadian
Manager, Schulich Faily Medicine Teaching Unit & Integrated Care Services
Humber River Health
Implementing SCOPE: Transforming Primary Care through Seamless Integration
Paper Number
223
Dr Karen Fleming
Department Head, Family and Community Medicine
Sunnybrook Health Science Centre
Implementing SCOPE: Transforming Primary Care through Seamless Integration
Paper Number
223
Kittie Pang
Canada
Project Manager
Sunnybrook Health Sciences Centre
Implementing SCOPE: Transforming Primary Care through Seamless Integration
Paper Number
223
Biography
Dr. Karen Wang, MEd, MD, FRCPC, MSc, is an Assistant Professor and Director of the Child & Adolescent Psychiatry Residency Program at the University of Toronto. She provides inpatient care for complex mood and anxiety disorders at Sunnybrook Health Sciences Centre and co-chairs its Quality Improvement Steering Committee. Dr. Wang developed the SCOPE-KIDS program, offering rapid-access mental health support to youth through North Toronto’s primary care network. Her academic focus includes innovative program development and quality improvement to reduce wait times and improve mental health outcomes by bridging primary and specialized care with a collaborative, holistic approach.
Mrs Nancy Veloso
Associate Vice President, Clinical Programs
Scarborough Health Network - Scarborough Ontartio, On - Scarborough, On
Implementing SCOPE: Transforming Primary Care through Seamless Integration
Paper Number
223
