Department of Medicine

Chair's Column: Innovations in Primary-Specialty Care for Complex Medical Patients: The Value of Partnership

Mar 6, 2018
Dr. Gillian Hawker
Gillian Hawker

As some of you know, internal medicine was not my initial path. After medical school here at U of T, I entered residency in family medicine. Although I clearly rerouted to medicine, the year I spent in family medicine very much influenced my development as an internist and rheumatologist. I got to see the ‘other side’ of the patient referral process – the hectic pace of the primary care physician’s (PCP) practice where you have no idea what problem the patient is going to arrive with. I did a lot of home visits, which really added to my understanding of my patients within the context of their whole lives.

Perhaps this is why I am determined to ensure that our residents and fellows leave our training programs with a sound understanding of their role as specialists in delivering integrated, complex medical care. Delivering such person-centred care requires a true partnership with our referring PCPs. A respect for the challenges they face in practice, and a willingness to be there for them (and of course for their patients) when they need advice or help. And the availability of e-technologies, like e-consultation, shared databases for test results and communication by text or email, provides an enormous opportunity to perform this role even better.

Among our departmental strategic priorities is the alignment of physician training with future population needs. Given the aging population and resulting increasing complexities – in other words illness – of our patients, more than ever we specialists need to find ways to support the provision of health care in the community by PCPs and other primary care providers. There is no longer capacity in our hospitals – even in the ambulatory spaces within these hospitals – to wait for patients to land at the hospital or ED door. We need to ensure that we expose our trainees to novel models of primary-specialty care that helps keep people out of hospital.

We have a very creative department. There are likely many such innovations in care at work. I fear, however, that brilliant innovations are not routinely spread to other sites, missing the opportunity to enhance overall care in our population and potentially duplicating efforts. We cannot afford to do so. So, with the hope that every medical specialty will consider piling on board, I thought I would use this column to highlight one such innovation: SCOPE.

SCOPE - Seamless Care Optimizing the Patient Experience

SCOPE was initiated in 2012 under the auspices of the MOHLTC-funded BRIDGES initiative. SCOPE was one of nine care innovations designed and tested to reduce unnecessary emergency department (ED) visits and hospitalizations of patients with complex health care needs.

SCOPE began as a quality improvement partnership between hospital (UHN and WCH) and community providers (Toronto Central CCAC initially) in Toronto to support family physicians. The goal was to improve access to high-quality care for their complex patients. A subset of PCPs with high volumes of ED visits to UHN for their patients was initially targeted. These physicians were provided with a single point of access (by phone, email or text) to a team comprised of a General Internist (GIM) located at WCH in the Acute Ambulatory Care Unit (AACU), a Nurse Navigator located at UHN and a Home and Community Coordinator. They were also provided e-access to PRO – Patient Reports Online.

Using Lean Start-up methodology and major engagement with the target PCPs, a direct consultation service was created and refined, with rapid prototyping and “pivots” to find a fit between the new service and the public need. Early work identified the need to incorporate Medical Imaging in the core team, so a single point of contact to the UHN/Sinai/WCH Joint Department of Medical Imaging (JDMI) was added. (Figure 1)

The SCOPE platform


Figure 1: The SCOPE Platform

Since then, other specialty services have approached the team to join, and SCOPE has shifted to becoming a platform connecting a growing number of PCPs to a growing number of specialty services efficiently through a central hub.

Today, SCOPE provides a single point of access to a comprehensive range of interdisciplinary supports to 220 family physicians. In addition to JDMI support, through the SCOPE platform, PCPs have access to:

  • Health coaches for chronic disease management in marginalized populations\
  • Palliative care
  • Pain management (the Toronto Academic Pain Medicine Initiative)
  • Telemedicine IMPACT+ multi-disciplinary consultation clinics (patients, families/caregivers, the primary care team, community care providers and hospital-based specialists are brought together in real time and space to assess the medical, functional and psychosocial needs of the patient)
  • Addictions medicine (Substance Use and Rapid Access Addictions Medicine program)
  • Mental health care (social worker with psychiatry support)
  • General Neurology starting with the Headache Clinic
  • UHN Nephrology - centralized e-consult initiative was launched January 2018

The SCOPE team handles roughly 300-350 PCP requests per month. Of the approximate 11,000 contacts since inception, roughly one-third each are to GIM (34%) and the Nurse Navigator (33%). (Figure 2) Common reasons for consultation with GIM include for patients with chest pain, cellulitis, possible venous thromboembolism, abnormal lab values/imaging, and arrhythmia. PCP contacts may result in a brief phone consultation with the PCP to guide care, an official e- or in-person consultation in the WCH AACU, or a recommendation that the patient to be seen in an ED.

Scope Impact - Patient and Physician Experiences

Figure 2: SCOPE Contacts (Nov 2016 – January 2018; n=3,773)

SCOPE Impact - Patient and Physician Experiences

Mixed methods qualitative and quantitative studies have been undertaken and are ongoing to evaluate the effect of SCOPE on patients’ and PCPs’ experiences. One paper has been published and two others are currently under review. These evaluations indicate that SCOPE has helped to build capacity and community between isolated PCPs and the hub. In a recent survey of participating PCPs (130/164 or 79.3% response rate), an impressive 97.6% reported that SCOPE enabled timely access to specialists and 96.9% were satisfied with SCOPE’s ability to improve access to specialist consultative services. An example email from one participating PCP is as follows:

March 14, 2017 - 62 year old female patient presents with sudden onset of pruritus. On exam she clearly is jaundiced. I order blood work and get the results the same day. Contact with the WCH AACU results in same day US of abdomen/pelvis on March 15, which recommends CT scan of the pancreas due to a dilated common bile duct and pancreatic cyst. Through SCOPE diagnostic imaging a CT scan appointment is set up the next day. The internist reviewed the case with me and concurred with my investigations. Abdominal CT scan report is faxed to me on March 16 querying Pancreatic Cystic Adenocarcinoma. Through One-mail all studies are sent to (chief of surgery), who responds to me that day, recommending and copying a second surgeon. Later that day the second surgeon emails an appointment in pancreatic clinic on March 23. A referral is sent to the surgeon’s office by One-Mail.

All of this is done expeditiously without the patient having to go to the emergency department. This is the amazing value of SCOPE using many of its services. Thank you!!!!

In qualitative interviews performed by a Master’s student at IHPME, SCOPE was reported to have provided clinically useful supports in a trusting, collaborative manner. Contextual and historical factors including strained relationships between hospital specialists and community PCPs, and PCPs’ feelings of responsibility, isolation, disconnection and burnout influenced readiness to engage. SCOPE provided an opportunity for PCPs to build meaningful relationships, reconnect to the broader healthcare system, and redefine their roles. For many PCPs, reestablishing connections reaffirmed their role in the system and enabled a more collaborative care model.

Patients have also reported excellent experiences with SCOPE. One wrote a letter, which read as follows:

I was recently referred to SCOPE and the AACU at WCH by my primary care doctor… I had a number of complex problems which were getting worse rapidly. (PCP) suspected a kidney problem and had referred me to a nephrologist at TGH. Unfortunately, that appointment had to be postponed. Meanwhile, I was suffering from bone pain and had become immobilized and frightened. My fatigue, which precipitated the whole investigation, and my kidney function test were all getting worse.

At the WCH AACU the next morning I was given a CXR, ultrasound and blood and urine tests. A pharmacist took a full history of my medications. I was examined by an internist, who took a very thorough history. After looking at the preliminary results, (internist) confirmed the kidney diagnosis and gave me a set of signs to watch for so I would know when to seek further medical attention. Some of the blood work took time for the results to come back, so I returned two weeks later. A nurse-practitioner went over all the results with me.

When I met with the nephrologist on January 21st I really got it as to how important that SCOPE referral was. …the nephrologist had the internist’s report and all the results in front of him. With all that data, he was able to give me a diagnosis of probable (confirmed later) multiple myeloma. Not a happy diagnosis to receive, but I was glad to finally have a narrative that put all the pieces together and get on with the treatment plan. It was all that data gathered through SCOPE & AACU that enabled the cancer diagnosis to happen so quickly. I’m so glad this program exists.

Avoiding ED Visits with SCOPE

A randomized controlled clinical trial has not been undertaken to evaluate the efficacy of SCOPE to reduce ED visits and hospital admissions. But, ask anyone who’s been involved in SCOPE and they will tell you this is a better way to provide care. After each encounter, SCOPE team members are asked if the encounter avoided an ED visit. Based on responses, about half of the contacts to GIM (over 500 patients), 38% of contacts to the Nurse Navigator and 39% of urgent contacts to medical imaging are felt to have averted an ED visit. This is a lot of patients! For this reason, the Ontario MOHLTC has established and funded a five-year plan to scale up SCOPE.

Scaling-Up SCOPE

New SCOPE hubs are being launched at St. Mike’s, St Joe’s, Sunnybrook and Michael Garron hospitals. A major challenge to this expansion, however, is payment for the GIM physician role. We all know that ambulatory GIM is less remunerative than in-patient care. At WCH, the GIM physician role receives a stipend to offset lost income, but this may not be possible elsewhere. For this reason, incorporation of SCOPE within the GIM hospital-based team has been the default. For example, in some hospitals the team is led by a Nurse Navigator situated in the local GIM/Medicine clinic who can access GIM, home/community care resources, and local medical imaging as well as some centralized services like IMPACT+.

A lot of people deserve thanks for this work – in fact, too many to list all here. But I would like to recognize two people who have been on this journey from the beginning: Drs. Pauline Pariser from Family Medicine and our very own General Internist, Tara O’Brien, who directs the WCH AACU. These two have worked tirelessly to make this happen and we are very grateful.

Summary and Next Steps

The SCOPE experience underscores how centralizing referrals helps our PCP partners ensure they get their patient to the right specialist in a timely manner with the necessary tests and information to get an accurate diagnosis and treatment plan. It also helps relieve the pressures on our emergency departments and in-patient services. And of course, avoiding the ED is what our patients generally want!

I would like encourage you, therefore, whatever your specialty or programmatic focus, to consider how you, too, might contribute your services to the SCOPE platform. You can find more information about SCOPE and how to access SCOPE services here.

Finally, I am sure there are other initiatives that are bringing PCPs and specialty medicine together to enhance the patient experience and outcomes. I’d really like to know about yours! Please let me know by emailing me at