Scaling SCOPE-KIDS: Building Capacity for Child- and Youth-Centered Integrated Care Across Ontario

Background: Timely, coordinated care for children and youth with complex health needs remains a challenge for primary care providers (PCPs) and families in Ontario. Fragmented care pathways often result in delays, duplication, and unmet needs. SCOPE KIDS was developed to address these challenges by supporting PCPs with integrated pathways, specialist access, and coordinated navigation to improve care continuity and patient outcomes.

 

Approach: SCOPE KIDS was co-designed with PCPs, hospital specialists, and community partners, ensuring that the model reflected clinical realities and local contexts. Lessons from the original implementation—such as workflow integration, family engagement strategies, and strengthened connections between PCPs and pediatric specialists—guided the structured approach for scaling.

 

The program integrates mentorship and implementation support from the original site to new SCOPE sites, fostering shared learning and sustainability through ongoing knowledge exchange. An evaluation framework, based on the RE-AIM model (Reach, Effectiveness, Adoption, Implementation, and Maintenance), measures both clinical outcomes and operational effectiveness. Continuous stakeholder engagement ensures the model remains responsive to population health needs.

 

Results: Since its inception, SCOPE KIDS has received 143 referrals, including 84 psychiatric consultations. Of these, 71% were successfully seen within one month of referral—an impressive turnaround considering holidays and family scheduling constraints. Currently 44% of psychiatric consultations involved moderate or high case complexity, demonstrating the program’s reach into high-need populations.

 

Patients have reported meaningful reductions in symptoms across all assigned rating scales, with particularly notable improvements on depressive measures (averaging a 27% reduction). Qualitative feedback from PCPs highlights increased confidence in managing pediatric mental health and improved integration between primary care and hospital-based services.

The mentorship and implementation support structure will help facilitate rapid adoption of best practices, accelerated local learning, and reinforced sustainability across diverse settings. Lessons learned from implementation barriers and systemic challenges are shared to inform ongoing improvement and adaptation as the program expands.

 

Implications: SCOPE KIDS provides a replicable, evidence-informed model for strengthening the pediatric and youth primary care workforce by building capacity, skills, and inclusivity. The program demonstrates how mentorship, co-design, and iterative adaptation can sustain and scale integrated care models that align with local population health priorities.