What’s working: SCOPE’s ‘secret sauce’ for supporting doctors who aren’t part of a health team

Just more than a decade since it launched in Toronto, the Seamless Care Optimizing the Patient Experience program—or SCOPE for short—has grown from a single-site virtual navigator service that in its first year supported 30 family doctors, to 18 sites serving about 2,800 FPs and nurse practitioners.What hasn’t changed is the way SCOPE provides a single point of contact to connect primary care providers who aren't affiliated with a health team to a community of practice that includes specialists, internists, medical imaging providers and home care coordinators.In Ontario, where the program operates, there are about 7,800 unaffiliated primary care providers who don’t have access to a multidisciplinary health team. This makes it hard for these providers to connect patients with complex or chronic conditions to the care they need. In many cases, the primary care providers end up sending patients to emergency departments.The development of SCOPE started with a study of 50 family medicine practices that had the highest number of emergency department visits to Toronto Western Hospital.“We asked them: What would you need to better look after your patients in the community and not send them to hospital?” recalled Dr. Pauline Pariser, founder of SCOPE, which is funded by the province. “They said they want a single point of access—with one number to call—and they want relationship-based care because that’s what family medicine primary care is all about. So they didn’t want a different person each time they called.”With this in mind, SCOPE was designed with an infrastructure that put a nurse navigator as the bridge between the primary care providers enrolled in the program and providers in the community.Each enrolled primary care provider is assigned to a particular SCOPE site manned by a nurse navigator—or two navigators at bigger sites—dedicated to that site. In total, SCOPE today has 20 nurse navigators “who pick up the phone when you call and they get back to you,” said Dr. Pariser, who is a full professor at the University of Toronto's Department of Family and Community Medicine and co-chair of the Mid-West Toronto Family Practice Network, a non-profit organization representing family practitioners looking to improve and coordinate primary care through the healthcare system.“And they all have this philosophy of follow-up and follow-through,” she added. “They never drop the ball, they don’t say ‘here’s the number to call, good luck with that.’ They actually round back and ask ‘Did that work? Did you get through, what else can I do for you?’ And they do it in record time.”Dorothy Wedel, a SCOPE nurse navigator who has been with the program since its inception in 2012, said her job is to “make it easy, make it simple and let the work happen in the background”—and then get back to the doctor or nurse once she has the solution.“So much of what we do is virtual, but every conversation I have and the tasks that I do brings me right back to my ICU and emerg days, where I’m shoulder-to-shoulder with the doctor,” said Wedel. “With SCOPE, sometimes I have doctors who say to me ‘I just need to pick your brain, what do you think about this?’ They need somebody that understands how the health system works and can put it all together in a way that gives them the support they need when they need it.”Of the 180 primary care providers she supports—mostly doctors, with a few nurse practitioners and midwives—between 35% to 40% call regularly, said Wedel. In most cases, providers rarely make repeat calls for the same request because SCOPE helps them build in-house capacity and resources.Dr. Pariser said while primary care providers enrolled in SCOPE are assigned to a particular site, they’re not necessarily restricted to the resources in that site’s community of practice. “What the nurse navigators do is they become a community of practice for each other,” she explained. “You might be in an area that doesn’t have a neurosurgeon but the nurse navigator in another area has access to neurosurgery so she can help you with your surgical consults. This has become absolutely revolutionary when it comes to our underserved communities.”As an example, Dr. Pariser cited a doctor in the southwestern Ontario region of Kitchener-Waterloo whose patient was diagnosed with multiple sclerosis. The patient needed to see an MS specialist, but there were none in the community.“So the nurse navigator in Kitchener-Waterloo connected with her colleagues and nurse navigators at St. Mike’s (hospital in Toronto) and they were able to organize a consultation with an MS specialist from Toronto to help that family doctor,” recalled Dr. Pariser, noting that SCOPE now has more than 50,000 health resource contacts in the communities it serves.SCOPE boasts consistently high satisfaction among its enrolled primary care providers, with 91% reporting they were satisfied with the program’s ability to speed up the timing of consults and 82% saying they felt better equipped to support patients with mental health issues. Among patients, select SCOPE services such as mental health have earned a satisfaction rate of 85%.The program also has an emergency department diversion rate of about 82%. “It doesn't make sense that when we have patients with uncomplicated fractures, that they go to the emergency room, they sit there for many, many hours and then they're given an appointment for the fracture clinic,” said Dr. Pariser. “We skip the middle step and just have a direct referral to the fracture clinic. We set it up through SCOPE.”The program’s secret sauce, she added, is the nurse navigator whose triage expertise identifies the right resource and who ensures specialists get the right information. It also helps to have established and proven clinical pathways—a total of 64 to date that includes pathways for fracture, pediatrics, palliative care, wound care and mental health.Dr. Pariser said on average the program gets six requests a week from physicians who want to join SCOPE but don’t have a site in their area.“The word is out that this is something that is helpful to them,” she said.

What’s working: SCOPE’s ‘secret sauce’ for supporting doctors who aren’t part of a health team

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