Kitchener, ON | January 31, 2023 - Connecting primary care providers to specialized care that their patients need is helping to reduce visits to Emergency Departments and is easier than ever through a project known as SCOPE. St. Mary’s General Hospital and Grand River Hospital have been a part of the project since 2022 working alongside the KW4 Ontario Health Team (OHT).

Seamless Care Optimizing the Patient Experience (SCOPE) connects primary care providers to specialists, hospitals, community care and mental health resources to support patients to get the right resources they need at the right time. For patients, it reduces avoidable visits to Emergency Departments and hospital re-admissions by connecting them to the care that they need directly.

St. Mary’s and Grand River receive funding through the province to support SCOPE—funding that was renewed recently for the coming year. It’s one of the many ways that St. Mary’s and Grand River work with the Kitchener, Waterloo, Wellesley, Wilmot and Woolwich Ontario Health Team (KW4 OHT), comprised of health and wellness partners, to create a local healthcare system that better meets the specific needs of our communities.

“I work with primary care providers alongside KW4 OHT to help with the pressures of trying to find options for those patients that are challenging or the ones that ‘keep you up at night’,” says Kimberley Marshall, Registered Nurse at St. Mary’s and Nurse Navigator for SCOPE. “As the Nurse Navigator for K-W, I can make those phone calls, do the research and come back to the primary care provider with options to support the patient’s needs.”

“SCOPE provides primary care providers with an extra ‘helping hand’ when encountering a complex health challenge for a patient,” says Dr. Neil Naik, family physician and Clinical Lead for the KW4 OHT SCOPE program. “As a primary care provider, thanks to SCOPE I am not struggling to find an answer to the challenging problem of where I send a patient with a unique medical condition or needs. SCOPE has helped to bridge this by providing seamless communication, so patients have the right care, at the right time, and at the right place. SCOPE is the backbone for the future of our public system.”

There is no cost for primary care providers to register. Once registered, they are provided direct and centralized access to a range of resources and providers such as:

• Navigation Hub – access to a resource nurse navigator and homecare coordinator for assistance with linking to hospital and community resources
• Internal Medicine – for phone-based consultations and rapid access to an assessment
• Medical Imaging – for advice on appropriateness of imaging, interpretation of results and to expedite urgent imaging
• Home and Community Care – access to a dedicated home and community care coordinator who provides curated care for patients

In addition, SCOPE has a robust listing of online resources for patients such as advance care planning, chronic disease management, how to register for assistance in finding a doctor or nurse practitioner, and more.

“SCOPE provides support to primary care providers to help direct them to resources for their patients they may not otherwise be aware of may have difficulty accessing,” says Krysta Simpson, Director of Medicine, IPAC and Allied Health at St. Mary’s who oversees the program at the hospital. “This will help to promote keeping patients in the community and avoiding the emergency department.”

Learn more about SCOPE: scopehub.ca 

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More Information:

Dayna Giorgio | Manager, Communications

St. Mary’s General Hospital

dgiorgio@smgh.ca | 519-895-6540

Cheryl Evans | Manager, Communications and Engagement

Grand River Hospital

cheryl.evans@grhosp.on.ca | 226-749-0689

Background

St. Mary’s General Hospital is home to the Regional Cardiac Centre, Regional Chest Program and Regional Eye Program. As leaders in our field recognized globally for world-class, innovative healthcare, our vision of “Inspiring Excellence. Healthier Together” is not just about our approach to patient-centred care, it’s also about our commitment to our staff. 

For nearly a century, St. Mary’s has provided compassionate care to our community serving over 1,000,000 residents locally and beyond each year. We are the second-largest acute care hospital in the St. Joseph’s Health System with a team of over 2,000 staff, physicians and volunteers dedicated to ensuring patients receive the highest-quality care possible. 

Grand River Hospital is one of Ontario’s largest community hospitals with an outstanding team of 5,000 dedicated health care workers and volunteers. We provide services and support to more than 840,000 residents at our two campuses and satellite locations in Waterloo Region and Guelph Wellington. We take pride in the ways we collaborate with our health system partners, our region’s academic and innovation communities, and diverse community stakeholders as we work toward providing a world class experience for patients, families and team members. 

Grand River Hospital and St. Mary’s General Hospital are working together to plan for the future of hospital-based services to meet the needs of the growing community of Waterloo Region and beyond. “Building the Future of Care Together” is a joint project to build a new joint hospital and modernize hospital facilities, so our community has access to the highest quality care, technology and infrastructure to be healthy, now and in the future. Learn more and join us as we build the future of care, together.