Abstract
Background: In Ontario, Canada, access to timely healthcare is increasingly challenging, despite substantial public funding and a well-established primary care system. This challenge is evident as patients’ medical needs have become more complex, requiring coordinated and comprehensive care . Halton's healthcare access is fragmented, inequitable, and slow, leading to complex patients relying on emergency departments (EDs) for conditions that could be effectively managed elsewhere. In response, primary care providers (PCPs), specialists, hospitals, and patient advocates collaborated to create the integrated Halton Seamless Care Optimizing the Patient Experience (SCOPE) program to improve healthcare delivery in Halton’s mixed rural and urban communities.
Approach: Halton region consists of three distinct municipalities with unique demographic and healthcare challenges, that share a tri-site hospital network, approximately 400 PCPs, home and community-based services, and long-term care homes. Oakville is an urban center with a large tertiary care hospital serving young and middle-aged families. In contrast, Milton is Canada’s fastest-growing city, featuring a diverse, largely immigrant population and a newly expanded hospital. Halton Hills is rural with small communities and the oldest, smallest hospital, serving a largely senior population.
The Halton SCOPE program assists PCPs by decreasing administrative burden in navigating care for non-emergent complex patients to specialized services. The program was designed by an interdisciplinary coalition co-chaired by a PCP and the CEO of a home care organization, including patient and family advisors, local health sector representatives, and hospital leadership. Using a grassroots approach, the coalition identified local population health needs through engagement sessions. Key success factors included physician champions connecting isolated PCPs, in-kind support from hospitals and home care, a feedback mechanism for program evolution, an inclusive strategy for identifying real-time patient needs and access to resources beyond Halton via the SCOPE nurse navigator network. Consequently, PCPs have expressed appreciation for the program’s transparency, reliability, integration, and accessibility.
Results: Since its inception in 2021, the Halton SCOPE program has managed nearly 3,000 calls, expanded its services from three streamlined clinical care pathways to nine, and registered approximately 286 PCPs. The program boasts impressive ED diversion rates: >80% rate for urgent pediatric care; >90% for nurse navigators and urgent diagnostic imaging. Each pathway begins with a specialized nurse navigator consultation, guiding the PCP through services, including:
- Cardiology and internal medicine consultations within 24-48 hours.
- Prompt management of pediatric issues, such as neonatal jaundice and breastfeeding difficulties.
- Access within one week for:
oorthopedics for adults and children with non-hip-related fractures.
odirect access to ultrasound or CT imaging for urgent conditions like first-trimester bleeding or stable head injuries.
- Remote at-home monitoring for patients recovering from COPD, heart failure, or COVID-19.
Implications: Halton’s SCOPE program has significantly improved access to specialized care, effectively reducing unnecessary ED referrals. This enhances system efficiency, optimizes public fund utilization, boosts workforce capacity, and improves the experience for patients and providers. By addressing key aspects of the healthcare crisis, the program serves as a promising model for similar initiatives across Ontario, potentially inspiring further policy and practice improvements.