Seamless Care Optimizing the Patient Experience “+” Streamlined Access to Outpatient Services

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.

For more information, visit the SCOPE Hub website.

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.

Press 2: Home and Community Care Coordinator

The Home and Community Care 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.

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+ launches at Humber River Hospital in January 2021. SCOPE+ will be evaluated as part of a Quality Improvement initiative.
Click here to sign-up

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 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 eight sites with 60% of unaffiliated primary care providers in Toronto now having access to SCOPE.

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+

SCOPE+ at Humber River Hospital is launching in January 2021. 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

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 Hospital
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

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

Dr. Patrick Safieh
Primary Care Provider Lead
Dr. Andrew Duncan
Beatrise Edelstein
Program Director, Seniors Care, Inpatient Medicine,
Allied Health & Ambulatory Services
SCOPE+ Clinical Lead
Mehdi Somji
Director of Integrated Health Systems,
Partnerships & Family Practice
SCOPE+ Operations Lead
Victoria Zefkic
SCOPE+ Nurse Navigator