Seamless Care Optimizing the Patient Experience

SCOPE is a platform that promotes collaborative work between primary care, hospital services, and community health partners to serve patients with complex needs.


SCOPE is a virtual interprofessional care team that supports primary care providers through a single point of access. Family physicians and nurse practitioners registered with SCOPE can connect to internists, outpatient services, diagnostic imaging, and home and community care services.

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Description of Services

Press 1: Internist on-Call

The Internist on-call provides the primary care provider with an immediate consultation and urgent assessment and management of their patient’s medical conditions.

Home and Community Care Support Services (HCCSS)

The HCCSS Coordinator can facilitate access to home and community resources for patients with complex or chronic care needs and/or existing LHIN Home and Community Care clients.

Press 3: Nurse Navigator

The Nurse Navigator provides general advice and assistance navigating hospital and community resources and access to specialist care and other OHT services. The Nurse Navigator also acts as the access point for: Mental Health Resources, Fracture Clinic & Plastics Clinic

Press 4: Diagnostic Imaging

SCOPE providers can access diagnostic imaging personnel who can escalate urgent imaging requests, answer questions about different tests and results, and refer directly to the radiologist on-call.

Register Now

SCOPE launched at Humber River Health in January 2021. SCOPE will be evaluated as part of a Quality Improvement initiative.

Click here to sign-up

SCOPE 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 reports

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.

Over the years, the program has expanded to ten sites across Ontario. Over 60% of unaffiliated primary care providers in Toronto now having access to SCOPE.

Other SCOPE Programs:

  • Mid-West Toronto (University Health Network/Women’s College Hospital)
  • West Toronto (St. Joseph’s Health Center)
  • Downtown-East Toronto (St. Michael’s Hospital)
  • North Toronto (Sunnybrook Health Sciences Center)
  • East Toronto (Michael Garron Hospital)
  • Scarborough (Scarborough Health Network)
  • Central-West Toronto (William Osler Health System)
  • North York (North York General Hospital)
  • Halton Healthcare
  • Muskoka and Area Ontario Health Team
  • Niagara Health
  • Markham and North Uxbridge (Oak Valley Health)
  • KW4 Ontario Health Team (St. Mary’s General Hospital and Grand River Hospital)


Humber River Health SCOPE

SCOPE at Humber River Health launched in January 2021, with 20 PCPs registered for the program. 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 and pragmatic 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

As of June 2022, Humber River Health SCOPE has over 140 PCPs registered with the program and has received over 900 calls and helped avert 175+ ED visits.

Access to General Services and Resources

The Health Line
Directory and search tool for health care and community resources across Ontario

Access to Specialists Directory

Ontario Telemedicine Network (OTN) – Health Services Directory
Use the directory to access specialists and community health services anywhere in Ontario


Diabetes Education Clinic at Humber River Health
The diabetes education team helps patients and their family better understand, control, and manage their diabetes through individual and group education classes.

Diabetes Canada
Tools and resources for healthcare providers and patients with diabetes

Home & Community Care Support Services

Home and Community Care Central LHIN delivers local health care services such as home and community care, access to community services, and long-term care home placement. 
Services offered include (but are not limited to):
  • Care Coordination
  • Information & Referral
  • Nursing
  • Physiotherapy
  • Occupational Therapy
  • Speech Language Pathology
  • Personal Support
  • Dietetic Services
  • Medical Supplies & Equipment Rental
  • Determine eligibility, manage waitlists & coordinate admission:
    • Long-Term Care
    • Assisted Living
    • Adult Day Programs

Specialized services include:

  • Rapid Response Nurses
  • COPD Pathway (NWT OHT)
  • Telehomecare
  • Palliative Nurse Practitioners
  • Mental Health & Addiction Nurses
  • Nursing Clinics (e.g. IV therapy, injections, wound care, post surgical care, catheter care, ostomy support, drain management, central line flushes, etc.)

Mental Health Resources

Access Point
A centralized point where you can apply for individual mental health and addictions support services and supportive housing

Behavioural Supports Ontario
Provides tools, resources, and information for older adults with complex and responsive behaviours associated with dementia, mental health, substance use and/or other neurological conditions

CAMH – Community Resource Sheets
Community mental health resources and agencies

Provides an online search tool and 24/7 telephone or online chat support for help with addiction, mental health, and problem gambling resources

Canada-wide directory and search tool for mental health resources and general mental health information.

211 Toronto
Directory and search tool for community and social services in Toronto, Durham, Peel, and York Region

Pain Clinics

Toronto Academic Pain Medicine Institute (TAPMI)
TAPMI is a comprehensive, interdisciplinary academic pain program serving as the hub for chronic pain care in Toronto

Rapid Access Clinics

Addiction Services for York Region (ASYR) – Rapid Access Addiction Medicine (RAAM)
RAAM clinics are drop-in clinics for people looking for help with their problematic substance use such as alcohol, cannabis, cocaine or opioids

Seniors Care

Lumacare offers day programs and services to senior and elderly individuals

Regional Geriatric Program
Specialized Geriatric Services (SGS) are a range of health care services, which use a comprehensive geriatric assessment to diagnose, treat and rehabilitate older adults living with frailty with complex and multiple medical, functional, and psychosocial issues

Toronto Seniors Helping
The Toronto Seniors Helpline is a single point of access for seniors and caregivers to receive information and access to the community, home, and crisis services

Telemedicine Resources

Ontario Telemedicine Network (OTN) – Virtual Care for Providers
Ontario Telemedicine Network (OTN) – Telehomecare for COPD and Heart Failure

General Internal Medicine (GIM)

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 (HCCSS)


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 HCCSS 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.

Nurse Navigator


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 Geriatric Outreach Team (GOT), H&CC, and various eye clinics to determine when and where 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


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.



Dr. Patrick Safieh
SCOPE Primary Care Provider Lead
Dr. Andrew Duncan
Beatrise Edelstein
SCOPE Program Director
Dr. Jonathan Mandel
SCOPE Radiology Lead
Victoria Zefkic
SCOPE Nurse Navigator
Amelia Surujpaul
SCOPE H&CCSS Care Coordinator