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SCOPE Newsletter
Spring 2016

Seamless Care Optimizing the Patient Experience (SCOPE) is a quality improvement collaborative offered in partnership by UHN, WCH, CCAC, and Toronto family physicians. The SCOPE service resembles a virtual interdisciplinary team that facilitates greater access to hospital-based interdisciplinary resources and other specialist care. SCOPE aims to help reduce avoidable ED visits and hospital readmissions for complex patients in need.

In this Issue:
Telemedicine IMPACT Plus
Welcome Michelle!
Events Recap
Patient Case
Patient Testimonial

(416) 603-6418

Fax: 416-603-5303
We're bringing ConnectingOntario straight to you first!

ConnectingOntario (formerly ConnectingGTA) is a browser-based regional electronic health record system that offers timely information on your patients and will replace PRO as it is phased out. ConnectingOntario allows you to access clinical reports, hospital reports including ED and discharge summaries, diagnostic imaging reports, lab results, CCAC assessments, and more. SCOPE doctors are the first wave of primary care physicians in the community to be offered access.

Privacy and user training is required for full access to ConnectingOntario. Our first in-person group training event took place on April 21, 2016. A follow-up group training workshop will be arranged to complete the onboarding process. Details will be communicated in a faxed invitation.

You can still participate in group training if you missed the first seminar, or you may call SCOPE (option #3) or email us to arrange private training in your office to enable any of the aforementioned eHealth Ontario services.

FACT: If you already have ONE ID, your onboarding to ConnectingOntario is expedited. ONE Mail is also integrated under ONE ID services, all managed by eHealth Ontario.

Testimonial from a SCOPE physician: "It was easy to do. I had my ONE Mail up and running the day after the SCOPE seminar. It is the only way for community doctors to communicate securely with specialists and participating agencies such as CCAC. I have already begun to use it with great results."

Click here for more info on ConnectingOntario
Click here for more info on ONE Mail

Did you know? You can access SCOPE by email

In addition to phoning us, you can access all SCOPE services via email:

Option 1    Internist On-call:
Option 2    CCAC Care Coordinator:
Option 3    Nurse Navigator:
Option 4    Medical Imaging:
Telemedicine IMPACT Plus: now offering incentive for referrals

Refer to TIP for rapid access to psychiatric assessment and internal medicine case consult.

We are offering a $50 Starbucks gift card to the first 30 physicians who refer to TIP. Referrals will be eligible for participation in a research study to evaluate the impact of TIP clinics. To refer, call SCOPE (option #3) or email us.

Telemedicine IMPACT Plus clinics are a one-time case conference for primary care physicians and their complex patient with multiple chronic conditions. As part of the TIP service, you receive the dedicated support of a nurse facilitator, who works up your patient in preparation for this consultation between you, a psychiatrist, internist, social worker, CCAC coordinator, dietician, and pharmacist. The meeting yields new solutions for alleviating the symptoms of your patient’s priority chronic conditions and interprofessional supports for you to further manage the patients who keep you up at night. Physicians are welcome to contact SCOPE if they are interested in a greater level of involvement in this study beyond referring patients. 

TIP recently launched its national randomized controlled trial research study to be compared as the intervention for Ontario against another interprofessional model of care for complex patients in Quebec. 
Welcome Michelle Simpson, SCOPE CCAC care coordinator

We would like to welcome Michelle Simpson to the SCOPE team as our dedicated CCAC care coordinator. Michelle has been working with the Toronto Central CCAC since 2012. Originally from Ottawa, Michelle graduated with a BSW from McGill University and an MSW from the University of Toronto with a specialization in Gerontology. Michelle has 15 years of experience working in multiple healthcare sectors including acute care, rehabilitation, long-term and community care, and has extensive training and knowledge of elder abuse assessment and interventions. Prior to working with SCOPE, Michelle was the WCH Virtual Ward Care Coordinator, providing intensive case management services to support clients with complex chronic conditions transitioning from hospital to community. Michelle looks forward to working with you and your patients!

Next SCOPE event: Breast Oncology CME on May 25, 2016

Our next CME event will be hosted at Princess Margaret Hospital. This Partners in Care workshop will feature Dr. D. Warr on the latest practices in breast cancer treatment and supportive psychosocial services for oncology patients. Details to follow in a faxed invitation or you may pre-reserve your space by emailing SCOPE.
Event Recap: Gynecology CME Event, January 28, 2016
On January 28, Women’s College Hospital hosted a well-attended CME exclusively for SCOPE physicians on gynecology best practices. Featured topics included gynecology for mature women: menopause and hormone therapy by Dr. Wendy Wolfman; gynecology for young women: birth control and abortion by the Bay Centre for Birth Control; and OB care for and by family physicians. 

The feedback we received from you during the breakout discussions are currently under review, with further discussions planned over the following months. To start, we are addressing the gaps in gynecology services you identified by developing care pathways and annotated resource lists for colposcopy, cysts, AUB, and menopause.

Event Recap: WCH Primary Care Showcase, April 27, 2016
In April, 20 primary care physicians attended a CME event hosted at WCH. The purpose of the showcase was to highlight the new developments and services offered in medical imaging and diagnostics at WCH. Presentations by Drs. Heidi Schmidt and Narinder Paul from JDMI focused on cardiac imaging and specialized services offered at WCH including walk-in x-ray, ultrasound, and nuclear medicine. Dr. Sacha Bhatia provided cardiac testing case studies and approaches to the diagnosis of cardiac challenges commonly seen in primary practice. Dr. Jakov Moric presented an overview of the respiratory tests and educational opportunities currently offered at WCH. Dr. Sandra Kim and Anita Colquhoun followed with a summary on the quality of BMD testing available at WCH, as well as information on appropriateness of referrals. This showcase of specialty services helps to further build partnerships within the community and raise awareness on the many opportunities and developments in medical imaging and diagnostics.
Patient case study: SCOPE option #2 - CCAC care coordination

A 92 y/o patient with advanced dementia was found wandering in the community. Her family physician, who the patient had not arranged to see in many years, was contacted. The patient was found without food in her fridge and without familial supports in Toronto. The patient’s family (located in Vancouver) was concerned that she was no longer able to live independently. The family physician called SCOPE for support.

The patient and family physician were immediately connected with the dedicated CCAC care coordinator for SCOPE. She visited the patient the following day to complete a capacity assessment, begin a crisis placement process, initiate an Occupational Therapy home safety assessment, and enable PSW services for personal care and safety check. 

This intervention avoided an ED visit and potential admission. In the end, through coordination facilitated by SCOPE, the patient’s family decided to relocate the client to LTC in Vancouver. 
SCOPE patient testimonial

I was recently referred to SCOPE and the AACU at Women’s College Hospital by my primary care doctor. 
I had a number of complex problems which were getting worse rapidly. Dr. M. suspected a kidney problem and had referred me to a nephrologist at TGH. Unfortunately that appointment was postponed until late January as the specialist had a family emergency. Meanwhile I was suffering from a lot of different bone pains in my spine, legs and feet. I had become almost immobile and was very frightened. The fatigue which precipitated the whole investigation was getting worse. I had some blood work done which indicated that the kidney problem was getting worse. The Christmas holiday was coming and I was concerned that I might need emergency dialysis. I saw Dr. M. on Dec 23 in a panic. She referred me to SCOPE.
I arrived at the AACU at Women’s College Hospital the next morning. I was there for about 6 hours. I was given a chest X-ray, an ultrasound and had much blood and urine work done. A pharmacist took a full history of my medications. I was examined by an internist, Dr. Geetha Mukeerji, who took a very thorough history. After looking at the preliminary results she confirmed the kidney diagnosis. She 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.
It wasn’t until I met with my nephrologist on January 21 that I really got it as to how important that SCOPE referral was. Instead of having to go through all those tests after meeting the nephrologist, in, no doubt, many different clinics, probably waiting long times for some of them, instead, the nephrologist had all the results in front of him. He had the internist’s report right there. With all that data, he was able to give me a diagnosis of probable (confirmed later) multiple myeloma – bone marrow cancer. 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.

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SCOPE · Toronto Western Hospital, UHN · 399 Bathurst St., 13-MP-319 · Toronto, ON M5T 2S8 · Canada

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