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Seamless Care Optimizing the Patient Experience (SCOPE) connects primary care providers to specialists, hospitals, and community 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.


SCOPE is a platform that allows services to be added based on community and hospital needs (e.g. mental health supports, registered nurse health coaches, headache programs, pharmacy and palliative care). It can also help identify and improve gaps in care. The program aims to help reduce avoidable Emergency Department visits and hospital re-admissions for patients in need.


Primary care providers in the KW4 region have access to the SCOPE Nurse Navigator through telephone, email and Ocean e-referral. By connecting with the Nurse Navigator, you will be able to access our Hospital based pathways to GIMRAC, Urgent Imaging, and Cardiology or Respirology with the Dyspnea pathway, potentially diverting unnecessary Emergency Department visits. The Nurse Navigator will assist in connecting you to Community Resources and may assist in finding resources outside of the region for those really complex patients. The SCOPE Nurse Navigator Network allows for your patients who live outside of our region, assistance in accessing Specialty services closer to their home. As the KW4 SCOPE program grows, we will continue to develop access to resources within our community to assist our PCPs with this ever-evolving and often complex health care system.

We want to celebrate the 1 year anniversary of SCOPE and the amazing team behind it. The collaborative efforts of St. Mary’s General Hospital, Grand River Hospital, KW4OHT, and OCEAN are making this program so successful! Here are a couple of successes since the program began one year ago:

  • Successful presentations to our Health Care Community (Primary Care Council Meeting July ‘22, Primary Care Council and Specialist Council Joint Townhall Nov’22) 

  • 40-50 current PCP users with e-referral

  • 150 referrals to date 

  • 3 successful Pathways (GIMRAC, Urgent Imaging, Dyspnea)

  • Continued development of pathways and future pathways (e.g. Iron Infusion)

  • Development of partnerships and collaborations within the Hospital system and the Community (e.g. CSS Navigation development with Community Care Concepts)

“For anyone who hasn't tried the SCOPE program yet, it's been so helpful for a patient of mine I was having trouble connecting to services/referrals. The nurse who runs it, Kim, seems amazing. Highly recommend trying it! It's on Ocean.”

There is no cost for Primary Care to utilize this service, it is sponsored and supported by KW4 OHT in collaboration with St. Mary’s General Hospital and Grand River Hospital. Our SCOPE Nurse Navigator can be contacted by phone, through email or Ocean e-referral, and will provide support to access Specialists, Hospital Services and Community Resources.


If you are interested in learning more about the SCOPE program, see As the SCOPE program evolves in the KW4 region, we strive to emulate this well-developed program and bring more access to our community. Thank you for your support.

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