Parisa Mehrfar, SCOPE Program Director, Dr. Pauline Pariser, SCOPE Primary Care Lead, and Yulia Biberberg, SCOPE Project Coordinator

Better Together

Using partnership and collaboration to ensure that no patient is left behind

Healthcare is like an ecosystem – all organisms (organizations) play an important role in its balance, which comes from ensuring the optimization of patient care. Every factor depends on every other factor, which is why it’s so important that healthcare organizations work together to address complex and pervasive issues head-on. As a leader of multiple provincial partnerships focused on expanding access to care, Women’s College Hospital (WCH) is working with system partners to ensure that no patient is left behind.

Locally, partnerships have grown stronger through the creation of the Mid-West Toronto Ontario Health Team (MWT-OHT). Launched in November 2020, this model brings WCH together with four other downtown hospitals and more than 40 community organizations to better connect patients and providers in their community and create a more seamless healthcare experience. The MWT-OHT was instrumental in the COVID-19 response for downtown Toronto’s west-end for testing as well as vaccinations. This partnership continues beyond the pandemic as a community-oriented healthcare approach becomes embedded into everyday processes, making healthcare more accessible.

Creating networks based on a “single point of access to care” model has also been a gamechanger for patients and providers. By making the system easier to navigate, patients can access care faster and more seamlessly. WCH has been a proud partner in developing and supporting the growth of these models through programs like SCOPE and META:PHI. 

SCOPE: Creating a Seamless Experience for Patients and Providers

The health system can be difficult to access, not just for patients, but for providers as well. Primary care providers (PCPs) across 15 sites in Ontario now have access to live navigators who can help with orientation and resource matching. SCOPE (Seamless Care Optimizing the Patient Experience) is a virtual interprofessional care team that connects PCPs in real-time with a wide range of healthcare resources, including a general internist, home and community care coordinators and medical imaging, among others. By calling SCOPE’s centralized phone number or sending a secure message through the eHealth Centre of Excellence Ocean platform, PCP’s can receive immediate support.

The program was co-designed and co-created by PCPs to reduce fragmentation and maximize efficient use of healthcare services. WCH and the University Health Network comprise the SCOPE Coordination Hub, leading its scale and spread provincially.

“SCOPE is a complementary virtual team for PCPs to help them and their patients navigate the complex healthcare system,” shares Parisa Mehrfar, Program Director of SCOPE. “The SCOPE team is constantly evolving in response to local needs to ensure patients are getting timely access to high-quality care. This collaboration between the primary care providers, SCOPE nurse navigators, as well as the hospitals and the community, creates a seamless experience for providers and their patients.”

META:PHI: Breaking Down Barriers to Substance Use Care

The META:PHI program (Mentoring, Education, and Clinical Tools for Addiction: Partners in Health Integration) was created to be a pillar of strength for people with substance use disorders in Ontario. Since its inception in 2014 with eight rapid access addiction medicine (RAAM) clinics, the program has expanded to meet the needs of vulnerable communities with 75 clinics, new guidelines for accessing lifesaving medications used in opioid agonist treatment, and the coordination of distribution for take-home naloxone kits to emergency departments.

META:PHI Care Model

The META:PHI care pathway is a fully integrated system in which patients receive evidence-based care at every step. “Addiction providers have been quite isolated. Addiction is an orphan discipline and traditionally separate from the healthcare system entirely. Our job at META:PHI has been to integrate this care into the healthcare system through education, training and building networks,” shares Dr. Meldon Kahan, Medical Director of META:PHI. “Our goal for the future of META:PHI is to work with Ontario Health to set clinical standards and provide training to ensure all clinical settings are routinely offering lifesaving and inexpensive interventions to all patients who might benefit.” 

Programs like META:PHI and SCOPE wouldn’t be possible without the partnerships that drive them. WCH is steadfastly committed to the power of partnerships to better balance the health system and improve patient care. Working together across the health system to support timely and effective care builds capacity and supports individuals in Ontario toward better, healthier futures.

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