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Home » SCOPE

Overview

SCOPE (Seamless Care Optimizing the Patient Experience) is a virtual interprofessional program that connects primary care providers through a single point of access to hospital services. Family physicians and nurse practitioners registered with SCOPE can quickly connect to internists, select outpatient services, and diagnostic imaging through a dedicated SCOPE Navigator. For more information, visit www.scopehub.ca

 

How SCOPE Works

Primary Care Providers call the SCOPE line at 905-848-7592 and speak with the SCOPE Navigator. The SCOPE Navigator will triage the call and direct Primary Care Providers to the appropriate service. 

Description of Services

The following pathways are available for Primary Care Providers in Peel by calling the SCOPE Navigator: 

1. SCOPE Navigator

The SCOPE Navigator supports Primary Care Providers by helping them navigate hospital and community resources, while also coordinating access to specialist care and Ontario Health Team (OHT) services. The Navigator serves as the single point of contact for all services available through SCOPE.

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The SCOPE Navigator provides:

  • General advice and help accessing hospital and community resources
  • Support with communication between primary care and hospital physicians
  • Access to hospital/OHT-based services, when available

Examples of how to leverage the SCOPE Navigator:

  • Assistance finding a specialist or expediting appointments due to changes in a patient’s condition
  • Timely access to select outpatient services
  • Assistance with referral processes for external community resources

Information collected by the SCOPE Navigator during a call:

  • Reason for the Call
  • Patient Information (name, DOB, Health Card #, phone number, address)
  • Call back information

Depending on the urgency of your question, the SCOPE Navigator will:

  • Answer your question right away, or
  • Triage your request and connect you with the most appropriate service

Case Studies:

1. SCOPE Navigator call regarding a 54-year old female with recent debulking of a brain mass by a Trillium Health Partners’ neurosurgeon. Pathology results recently identified a glioblastoma, but the follow-up appointment was not for another 4–6-week time. Family physician was hoping if the follow-up appointment could be expedited.

SCOPE Intervention:

SCOPE navigator connected with the relevant neurosurgeon and the follow up appointment and radiation treatment was expedited.


2. SCOPE Navigator received a call from a primary care provider regarding a 68-year old patient with previous back surgery and difficulty getting off opioid analgesics, the Primary Care Provider sought advice as to what addiction clinic options were available.

SCOPE Intervention:

SCOPE Navigator shared appropriate community resources.

2. Primary Care Provider’s Consultation with General Internal Medicine on-Call

The General Internal Medicine (GIM) Specialist on-call offers Primary Care Providers timely consultations, clinical assessments, and management recommendations for patients with complex or urgent medical concerns. This service enables direct access to Internist support through SCOPE.

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A phone consultation with a GIM Specialist provides:

  • Expert guidance to primary care providers in managing complex patient cases
  • The option to arrange a virtual visit for the patient, if appropriate
  • Coordination of referrals to suitable outpatient services in the hospital or community through the SCOPE Navigator

Examples of how to leverage the SCOPE Navigator for GIM consultations:

  • Guidance on the next steps for patients with complex medical history
  • Second opinion on complex medical issues
  • Cardiac concerns: atypical chest pain, arrhythmia, new-onset atrial fibrillation, hypertension
  • Infections: cellulitis, diabetic foot, wounds
  • SOB NYD / Respiratory infections
  • DVT / PE investigations and treatment

Depending on the urgency of your question, the SCOPE Navigator can:

  • Connect you with the internist on call for a peer-to-peer consultation
  • Provide information about rapid access to other outpatient services

Case Studies:

1. A PCP called SCOPE in regarding a patient with a 3-week history of shakiness and a recent diagnosis of hyperthyroidism (blood work revealed a TSH 0.01 mIU/L and T4 of 26 pmol/L). The patient was tachycardic but normotensive. The PCP wanted to discuss this patient with the GIM on-call to see if there are any red flags to monitor for and appropriate next steps.

SCOPE Intervention:

The GIM on-call recommended initiation of beta-blocker therapy and urgent referral to endocrinology. The GIM-on call provided name and information of endocrinologist accepting new patients within the organization to ensure a timely referral for this patient.


2. A family physician called SCOPE regarding a 69-year old patient with a newly diagnosed atrial fibrillation on blood thinners, and had impending travel.

SCOPE Intervention:

SCOPE navigator set up a General Internal Medicine (GIM) phone consultation within 16 minutes of the initial call. GIM provided advice with respect to medication changes and follow-up with cardiology.

3. Patient’s Virtual Visit with General Internal Medicine on-Call

Through SCOPE, Primary Care Providers can also refer their patients for a virtual video-based visit with the General Internal Medicine Specialist for urgent consultations, assessments and management of patients’ medical conditions.

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A phone consultation with a GIM Specialist provides:

  • Timely management of non-urgent, episodic conditions
  • Guidance on medically complex issues
  • Helpful for patients who would benefit from accessible, virtual care

Case Studies:

A HealthPod assessment was arranged for a 74-year-old male with diabetes who presented with a 10-month history of a non-healing toe wound. Previous management included blood work, referral to Infectious Diseases to rule out osteomyelitis, and a Doppler study. During his HealthPod visit, the patient reported bilateral leg edema.

A Primary Care Physician called SCOPE: regarding a 67-year-old female who experienced an unwitnessed fall on her driveway, resulting in rib fractures. The patient did not recall any chest discomfort, palpitations, dizziness, or neurological symptoms prior to the fall. She did not think she lost consciousness and believed she may have tripped on uneven pavement. Her past medical history included neurological investigations for Parkinson’s disease, with unknown results.

SCOPE Intervention:

The General Internal Medicine (GIM) consultant recommended repeat lab work and Doppler, wound packing, medication adjustments, and follow-up care to support ongoing management.

SCOPE Intervention:

A General Internal Medicine (GIM) consultation was arranged. Investigations including blood work, transthoracic echocardiogram (TTE), and 48-hour cardiac monitoring were unremarkable. Given her history and presentation, head imaging was not pursued due to a previously normal MRI in 2022. Follow-up was scheduled in 4–6 weeks to review findings and assess for any recurrence.

4. Diagnostic Imaging

Through SCOPE, Primary Care Providers can access diagnostic imaging services, including X-ray, ultrasound, CT, and MRI, for select clinical indications. They can also consult directly with the radiologist on-call for test selection and result interpretation.

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Urgent DI Clinical Indications:

X-Ray Ultrasound CT
CXR - r/o pneumonia
R/o foreign body ingestion
R/o Limb fracture
Abscess / superficial infection
Appendicitis
Cholecystitis / biliary colic
Early pregnancy / r/o ectopic
Epididymitis / torsion
Renal colic
Ovarian cyst
DVT
Stroke / TIA / ICH
Appendicitis
Colitis
Diverticulitis
Pulmonary embolism
Renal colic
Possible limb occult fractures

Examples of how to leverage the SCOPE Navigator for diagnostic imaging services:

  • Support in selecting the most appropriate test
  • Obtaining subspecialty radiology consult (second opinion consultation of outside imaging or report interpretation)
  • Urgent imaging (triage and expedited imaging for urgent cases)
  • Urgent reporting (expedited reporting for urgent cases)
  • General navigation and informational support during imaging service
  • Same-day imaging services (x-ray, ultrasound, CT)

Depending on the urgency of your question, the SCOPE Navigator can:

  • Provide you with information about radiologist services
  • Help you navigate the radiology request
  • Connect you to the on-site on-call radiologist for consultation

Case Studies:

Primary Care Provider called:

A 27-year-old female with a history of right iliac fossa pain. PCP requested expedited pelvic ultrasound to rule out appendicitis.

A PCP was concerned:

About redness, swelling, and pain in a patient’s right lower calf. The patient was on home anticoagulation and resistant to hospital care. PCP requested an urgent ultrasound to check for DVT with the hope of managing at home if needed.

SCOPE Intervention:

SCOPE facilitated an ultrasound appointment within hours. Diagnostics were negative for appendicitis but a growth on the ovary was found. The Emergency Department visit was avoided, and follow-up diagnostics arranged.

SCOPE Intervention:

The SCOPE team arranged an ultrasound within 2 hours. The radiology team was instructed to notify the PCP immediately if the scan showed a DVT, allowing for home-based treatment planning.

5. Orthopedic Clinic

Primary Care Providers can refer adult patients (18+) with non-urgent musculoskeletal conditions, such as mild arthritis, low back or neck pain, tendinitis, or rotator cuff tears, directly to an orthopedic specialist. Referrals can be submitted through SCOPE or sent directly from the physician’s office. Please note that patients with fractures, motor vehicle accidents, WSIB related concerns, or with established chronic pain disorders are not eligible for this pathway.

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Examples of appropriate referrals:

  • Suspected or confirmed mild joint arthritis
  • Low back or neck pain of orthopedic origin
  • Tendinitis or bursitis
  • Suspected rotator cuff tears

Exclusions:

  • Fractures
  • Motor Vehicle Accidents (MVA)
  • WSIB claims
  • Patients with established chronic pain disorders
  • For moderate to severe OA of the hip and knee, please consider referral to the RAC Program

How to refer:

  • Complete Ortho Clinic referral form (attach PDF referral form here)
  • Submit via fax or send directly to 416-521-4140 through the physician’s EMR

Depending on the urgency of your question, the SCOPE Navigator can:

  • Provide referral support and confirm eligibility
  • Guide you through the referral process or alternate pathways
  • Facilitate timely access to orthopedic consultation when appropriate

Referral Forms:

6. Ontario Health atHome

The SCOPE Navigator supports Primary Care Providers who have referred a patient with complex or chronic care needs to Ontario Health atHome services (formerly HCCSS) to expedite initiation of services. Services can include home and community care resources for both new and existing clients.

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The following services can be accessed from Ontario Health atHome. Additional resources can be reviewed with the SCOPE navigator as needed:

  • Care coordinator
  • Nursing clinic
  • Nursing at home
  • Rapid Response Nursing
  • Nurse Practitioners
  • Physiotherapists
  • Dieticians
  • Social workers
  • Speech Language Pathologist
  • Personal support workers
  • Occupational therapists

Examples of cases that can be referred to the Ontario Health atHome Coordinator:

  • Fragile elderly / homebound / socially isolated
  • Failure to cope / patient safety / home safety assessment
  • Dementia / cognitive decline
  • Caregiver stress / burnout
  • Chronic disease management
  • Wound care / drainage care / referral to nursing clinics (IV medications)
  • Housing support
  • Patients requiring assessment and planning for Long Term Care

Case Studies:

An elderly patient with a recent fall and confined to bed was experiencing pain and had no support services arranged. The PCP called to see what in-home options could be set up to prevent an emergency department visit and keep the patient in her home.

SCOPE Intervention:

The SCOPE Navigator connected them with the Ontario Health atHome Coordinator to arrange in-home physiotherapy to support the patient’s mobility and rehab, as well as PSW support for bathing and other ADLs. The patient was very happy to stay at home and receive needed care.

7. Virtual Dermatology Pathway

This pathway supports access to virtual consultations for a range of non-urgent skin, hair, and cosmetic concerns. Primary Care Providers or patients (with a referral from primary care) can submit dermatology referrals through DermCafé.ca using photos and a brief form. The process takes only a few minutes, and patients receive a link to book their appointment with a licensed dermatologist. For help navigating this referral process, providers can contact the SCOPE Navigator.

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Inclusion Criteria for DermCafé include:

  • Acne and acne scarring
  • Rosacea
  • Facial pigmentation concerns (e.g., melasma)
  • Wrinkles and anti-aging consultations
  • Facial rashes (e.g., seborrheic dermatitis, perioral dermatitis)
  • Keratosis pilaris
  • Limited eczema (e.g., hand eczema)
  • Limited psoriasis
  • Contact dermatitis
  • Male and female pattern hair loss
  • Hyperhidrosis (excessive sweating)
  • Common pediatric dermatology conditions: eczema, cradle cap, hemangiomas, and more. Children under 18 may attend virtually with a parent and do not need to be present on camera if high-quality images are provided. However, older children who can participate are encouraged to join the video visit.

Exclusion Criteria for DermCafé Virtual Care:

  • Requires In-Person Dermatology Referral or Assessment:
    • Concerns not clearly visible in photos
    • Suspicious moles or possible skin cancers
    • Lesions inside the mouth or in genital/anal regions
    • Scalp conditions and non-pattern hair loss
    • Total body or regional skin checks
    • Severe eczema or psoriasis
    • Large or congenital birthmarks
  • Requires In-Person Care from the Outset:
    • Widespread or complex rashes
    • Skin wounds or ulcerations
    • Wart treatment
    • Procedural needs (e.g., skin biopsies or excisions)
    • Medical emergencies
    • Requests for controlled substances

Note: This is not an exhaustive list. When in doubt, consult the SCOPE Navigator for guidance on referral pathways.

 

More About SCOPE

SCOPE 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 who may not have access to an interdisciplinary care team. Over the years, the program has expanded to the following 16 sites across Ontario. For more information, visit the SCOPE Hub website.

 

How to Register for SCOPE

Are you a Primary Care Provider but not yet registered for SCOPE?

To register for SCOPE, you can either submit the form online or fax the fillable form:

Online: Fax:
Please scan the below QR code or click
here to submit the form:

QR code

  1. Click here to download the form
  2. Complete the form and fax it to (416) 521-4146 (Attn: Liz Gabison – SCOPE Navigator)

 

 

 

 

 

Testimonials

👤

"The SCOPE program has allowed me to have access to same day diagnostic imaging, something that was only available with the patient being sent to ER. My patients are very appreciative of this service, specifically being able to avoid the ER department. As community physicians, we do not have the ability to refer patients to the AIM clinic. The SCOPE program has created a very efficient pathway to have a similar service available to community physicians."

— Dr. Salesh Budhoo

👤

"I really appreciate your getting the Ultrasound done, it saved her an ER visit."

— Dr. Ali Damji

👤

"The SCOPE navigator service has allowed me to ensure timely care for my patients when they’ve needed a time-sensitive consultation with a specialist or an urgent imaging study. This serves as a model to how effective outpatient primary care should be. No patient should be waiting in an emergency room for hours waiting for an urgent imaging study or consultation, when it can be arranged in a timely fashion through a more organized and efficient system. The SCOPE navigator serves as a model for that system in our region. We truly appreciate your services."

— Dr. Fady Akladios

👤

"The PCPs I speak to have been grateful for the support and someone to have in real time on the other end of the call, to have specialists to consult with regarding patient care, and to receive expedited diagnostics as required especially when dealing with complex patients."

— Liz Gabison, SCOPE Navigator

 

Meet the Team

Dr. James Pencharz

Dr. James Pencharz

Primary Care Co-Lead at Mississauga Health

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Dr. James Pencharz is the Primary Care Co-Lead at Mississauga Health. He is a family physician with the Credit Valley Family Health Team and has been in practice since 2009, providing comprehensive family medicine.

He is an active educator with the University of Toronto, Faculty of Medicine department, teaching medical students and residents for the past nine years. He is the former Site Program Director for the Trillium Health Partners – Credit Valley Hospital Family Medicine Residency program. From 2009 – 2014, he also worked as a hospitalist physician at THP- Credit Valley Hospital.
Dr. Sohal Goyal

Dr. Sohal Goyal

Chair, Mississauga Health Primary Care Network

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Dr. Goyal is the Co-Chair of the Mississauga Ontario Health team and one of the Regional Primary Co-Leads for Ontario Health. He is also the Chair of District 5 at the Ontario Medical Association (OMA) and was on the board of the Section of General and Family Practice at the OMA.

In his 20-year career, Dr. Sohal Goyal has established a vast network of healthcare relationships. Dr. Goyal is an assistant clinical professor with McMaster University Department of Family Medicine. His passion is to support and engage community physicians.
Dr. Sheikh Amin

Dr. Sheikh Noor Ul Amin

THP Physician Lead for SCOPE

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Dr. Amin joined THP in 2018. He completed his Family Medicine Residency at The University of Manitoba and a fellowship in Sport and Exercise Medicine at the University of Toronto. Through the course of the COVID 19 pandemic, Dr. Amin was instrumental in supporting as the Physician Lead for both the THP Vaccination program and the THP COVID 19 Assessment Centres.

He is the current Co-Chair for the MOHT Data Strategy Table and serves on the Board of Directors for the Mississauga Primary Care Network.
Dr. Eshan Fernando

Dr. Eshan Fernando

Clinician Innovator at THP Solutions & Virtual Care GIM Lead

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Dr. Fernando is a Clinician Innovator at THP Solutions and supports General Internal Medicine physicians involved in our Virtual Solutions Clinic.

Dr. Fernando has been practicing as a General Internal Medicine specialist for the past 6 years at Trillium Health Partners. He is also the Division Head of General Internal Medicine at Trillium Health Partners.

Dr. Fernando is passionate in building sustainable and supportive care for patients served by Trillium Health Partners.
Barbara (Basia) Gorczyca Abel

Barbara (Basia) Gorczyca Abel

Project Director, Health System Innovation

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Basia is the Project Director of Health System Innovation supporting SCOPE development. She has held progressive leadership positions as manager at THP Solutions and Manager of Operations at Insight Health Solutions in the WSIB Specialty Programs and Insight Health Solutions Wellness and Rehabilitation.

Basia is a registered physiotherapist who graduated from the University of Toronto in 2003 with a Bachelor of Science: Physical Therapy. She has an Honours Bachelor of Science: Specialization in Human Kinetics, Minor in Psychology from the University of Guelph (1999) and Masters in Health Management from McMaster University (2024).

Basia is passionate about collaborating to develop innovative solutions that enhance the design and delivery of high quality, equitable health care.
Lindsay Wingham-Smith

Lindsay Wingham-Smith

Executive Director, Mississauga Health & Co-Lead, Mississauga Health SCOPE

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Lindsay Wingham-Smith is a transformational health system leader with a proven track record of integrating and advancing complex regional and provincial initiatives by leveraging strong cross-sector relationships with key stakeholders.

Prior to joining Mississauga Health, she was the Vice President, Home and Community Care at the Home and Community Care Support Services Toronto Central (HCCSS) and was Vice President, Health System Capacity Access and Flow at Ontario Health (OH) Toronto Central Region.

Lindsay holds a Master of Social Work from the University of Windsor and a Bachelor of Social Work from Carleton University.
Vicky DeFreitas

Vicky DeFreitas

Manager Partnerships & Interim Manager Insight Health Solutions Wellness and Rehabilitation

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Vicky DeFreitas is an Occupational Therapist who joined THP in January 2019. She earned her Bachelor of Business Administration from Wilfrid Laurier University and her Master of Science in Occupational Therapy from McMaster University. She holds a Status-Only Appointment as a Lecturer in the Department of Occupational Science and Occupational Therapy at the University of Toronto.

Currently, she serves as the Manager of Partnerships and Interim Manager of Wellness and Rehabilitation at Insight Health Solutions at THP.

She is passionate about harnessing innovation and collaboration to drive positive change in patient care and outcomes.
Liz Gabison

Liz Gabison

SCOPE Navigator, SCOPENavigator@moht.ca

Read Bio
Liz Gabison is the SCOPE Patient Navigator at Trillium Health Partners (Mississauga and Etobicoke).

Liz graduated from the University of Toronto with her Bachelor of Science, York University with a Bachelor of Education, the Canadian Memorial Chiropractic with her Doctor of Chiropractic and from the University of Fredericton with her Masters in Business Administration.

Liz has experience working in both hospital and community settings and has most recently worked as an assessor in the MSK WSIB specialty programs and in the OHAP program side by side with the Orthopaedic Surgeons and Primary care providers. Prior to her role as an assessor, Liz worked as a Director of Clinical Operations at Cira Medical, and as a Case Manager in the insurance sector. She also has extensive experience in the Vocational Rehabilitation industry.

In her role as SCOPE Patient Navigator, Liz will provide primary care providers with assistance navigating hospital and community resources to support primary care and improve patient care needs.
 

Frequently Asked Questions

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Who can call SCOPE?

Primary care providers and their clinical staff who are registered with SCOPE are eligible to use this service. For more information on registration, please visit www.moht.ca/scope.

I’m not sure if my request is appropriate for SCOPE. How can I find out?

When in doubt, you can always call SCOPE. We encourage you to reach out—we’ll do our best to assist with your patient request, no matter how big or small.

What options do I have for communicating with SCOPE?

You are encouraged to contact us by phone at 905-848-7592. For confidential patient information, you may email our SCOPE Navigator, Ms. Liz Gabison, at SCOPENavigator@moht.ca. Please ensure that any personal health information is sent via a secure server.

What do I need to include in a patient referral package?

Your referral package should include:

  • Up-to-date patient information
  • Relevant health history
  • Reason for referral
  • The patient’s primary language
  • Any applicable family or caregiver contact details

Can SCOPE help my patients who live outside of the Mississauga/Etobicoke Region catchments?

Yes. The SCOPE Navigator can help you connect with specialists and outpatient programs near your patient’s home. If your patient requires Home and Community Care Support Services, the Navigator will help refer them to their local regional provider. Additionally, the on-call internist is available for telephone consultations for patients anywhere within the Greater Toronto Region.

My patient needs mental health support and/or case management. What should I do?

One-Link provides coordinated access to several addiction and mental health services within Mississauga and Halton. With one referral and intake process, your patient can access a range of support services.

My patient has an abnormal lab result and limited medication options due to their medical history. Can you provide advice on the management plan?

Absolutely. Please call SCOPE at 905-848-7592 and we’ll help arrange a phone consultation with our General Internal Medicine specialist to review the case and provide recommendations.

 

Learn More About Us

Want to learn more about SCOPE? We’d love to hear from you.

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