Abstract
Primary Care is widely acknowledged as the cornerstone for authentic system integration in healthcare (Ontario Ministry of Health, 2022). Historically, however, collaboration with Primary Care has been hampered by fragmentation due to the absence of a unified Primary Care organization (Misra et al., 2020). Enter the Seamless Care Optimizing Patient Experience (SCOPE), a pioneering virtual interdisciplinary team designed to foster relationships and trust within the broader healthcare system. SCOPE functions as a barometer, alerting stakeholders to the specific needs of Primary Care. This article explores SCOPE's innovative role in connecting solo and small group practice primary care providers (PCPs), hospitals, and communities in Ontario.
The effectiveness of team-based primary care models like SCOPE in enhancing patient outcomes and reducing Emergency Department visits and avoidable hospitalizations is substantiated by robust evidence (Pariser et al., 2020). The grassroots development of SCOPE involves a strategic partnership with Sunnybrook hospital, leveraging its support to address the unique needs and barriers faced by local PCPs. This includes enhancing access to specialists, home care, and system navigation. Detailed tracking of engagement with Sunnybrook SCOPE informs continuous improvement and expansion of SCOPE pathways. Communication channels, such as phone, email, social media, and office visits, facilitate comprehensive insight into PCPs' workflows and administrative challenges. Continuous feedback mechanisms, including surveys, interviews, and regular meetings with the Physician Advisory Group (PAG), contribute significantly to shaping SCOPE's evolution.
As SCOPE expands across Ontario, gaps in standardized core offerings become apparent, necessitating a nuanced understanding of local contexts and Primary Care needs. This program evaluation employs Quality Improvement (QI) surveys and interviews to glean insights from both Sunnybrook SCOPE users and their patients. These highlight SCOPE's efficacy in addressing care needs while pinpointing areas for further investigation. QI interviews with SCOPE PCPs delve into reasons behind pathway usage, identify care barriers, and propose enhancements for future utilization. Findings emphasize the importance of bi-directional communication and co-design with stakeholders. Recognizing the absence of a universal approach to health system integration with Primary Care, SCOPE's commitment to adapting to local contexts makes it an adaptable model for international audiences.
SCOPE's commitment to building trust through a community of practice, service-oriented approaches, and regular communication positions it as a progressive force in advancing primary care (Pariser et al., 2020). The next phase involves standardizing core elements across SCOPE sites and establishing a platform for PCPs to openly share challenges, fostering an environment of honest collaboration. In conclusion, SCOPE stands as a transformative initiative, navigating the intricate landscape of Primary Care, fostering collaboration, and contributing to the evolution of a people-centered healthcare system.