Seamless Care Optimizing the Patient Experience (SCOPE) - Co-designing the scaffolding for primary care integration

Background: SCOPE is a quality improvement initiative that addresses the challenge of an aging population’s increasing care needs and the reduced capacity of primary care providers (PCPs) unaffiliated with interdisciplinary teams, to manage this population. SCOPE aims to integrate care so that patients and their families experience one care team across primary, community and hospital sectors. SCOPE’s success in offering a virtual interdisciplinary team via a centralized hub rests on grassroots co-design with PCPs and their patients. Since launching in 2012, SCOPE has grown from 30 PCPs located in one region in Toronto (Canada), to support over 300 PCPs in 4 regions. To date SCOPE has received approximately 15,000 total calls, currently averaging >400 calls/month. Half of these calls were perceived to have avoided an ED visit. The majority of SCOPE physicians (97.7%) felt they are able to access specialty care in a timely manner. Qualitative research demonstrated that PCPs felt less isolated, more confident in managing complex patients, and that their patients received more comprehensive care with more appropriate usage of healthcare resources. SCOPE was recognized in 2018 with a provincial integration award. Aims and Objectives: Demonstrate the co-design process to inform the model Reveal the infrastructure that facilitates linkages Convey an adaptable communication strategy to drive primary care integration Establish key metrics to measure successful adoption and sustainability Frame first principles for successful scale and spread of a patient-centered, provider-enhanced model Format: The SCOPE workshop will use didactic and experiential interactive learning methods to meet its objectives: Patient Narrative Video: Mr. Kandil Gudka (5 minutes) Context of co-design strategy: Dr. Pauline Pariser, Primary Care Lead, University Health Network (UHN) (6 minutes) Key elements of SCOPE Model: Acute Ambulatory Care Unit: Dr. Tara O’Brien, Medical Director, Women’s College Hospital (WCH) (7 minutes) Home and Community Care: Marni Salkovitch, Toronto Central LHIN (5 minutes) Nurse Navigation: Magdalena Rybak, UHN (5 minutes) Radiology: Dr. John Kavanagh, Chief of Radiology, WCH (7 minutes) Evaluation, Patient Outcomes and Process Measures: Dr. Pauline Pariser (5 minutes) Scale and Spread: An interactive forum using breakout groups to respond to standardized practices in building sustained relationships with PCPs and patients and what can be customized to local contexts, highlighting: patient and PCP co-design, integrated home and hospital care, and an incremental maturity model. Participants will have the opportunity to reflect how these methodologies are adaptable to their local settings (40 minutes; 25 minutes for discussion and 15 minutes report back) Facilitated by SCOPE team Closing Remarks/Questions: SCOPE team (10 minutes) Target Audience: Primary care thought leaders, hospital and community service managers, patients and consultants interested in primary care integration. Learnings/Take Away: SCOPE offers a transferable platform connecting primary care to hospital and community resources and building a community of practice SCOPE demonstrates proof of concept to successfully engage patients and providers in implementing a primary care integration strategy SCOPE provides the scaffolding to link other services as determined by local needs