SCOPE launched as a quality improvement collaboration between Women’s College Hospital, University Health Network, and the Toronto Central LHIN Home and Community Care in 2012. It was designed in response to the following concerns identified by primary care providers:
- Timely access to specialist care
- Single point of access to services
- Assistance with homebound patients
- Access to hospital reports
The objective of SCOPE is to strengthen relationships between hospitals, community services, and primary care in order to improve care delivery for complex patients who may not have access to an interdisciplinary care team.
Over the years, the program has expanded to over 14 sites across Ontario.
Some of the other SCOPE Programs in the region:
- Mid-West Toronto (University Health Network/Women’s College Hospital)
- West Toronto (St. Joseph’s Health Center)
- Downtown-East Toronto (St. Michael’s Hospital)
- North Toronto (Sunnybrook Health Sciences Center)
- East Toronto (Michael Garron Hospital)
- Scarborough (Scarborough Health Network)
- Central-West Toronto (William Osler Health System)
- Humber River Hospital
- North York (North York General Hospital)
- Halton Healthcare
- Muskoka and Area Ontario Health Team
- Niagara Health
- Markham and North Uxbridge (Oak Valley Health)
- KW4 Ontario Health Team (St. Mary’s General Hospital and Grand River Hospital)
Mississauga Health SCOPE
SCOPE in Mississauga launched in March 2023, with 30 PCPs registered for the program. The SCOPE model promotes patient-centred interdisciplinary care, which is the foundation of Ontario Health Teams (OHT).
The goal of SCOPE is to:
- Reduce emergency department visits
- Provide patients with more equitable and pragmatic access to team based care and specialists
- Establish an effective channel to deliver best practices and emerging standards of care
- Provide an opportunity for ongoing physician engagement
Resources for Primary Care Providers
Access to General Services and Resources
The Health Line
Directory and search tool for health care and community resources in Mississauga, and across Ontario. The Directory for Mississauga can be found here.
Directory and search tool for community and social services in Toronto, Durham, Peel, and York Region
Access to Specialists Directory
Ontario Telemedicine Network (OTN) – Health Services Directory
Use the directory to access specialists and community health services anywhere in Ontario
Peel Senior Link: A variety of programs and services to help seniors live independently.
Getting the right care: Specialized Navigation Services
Mississauga Health is developing a centralized health system Navigation service to support patients and providers to easily identify the right services to meet their needs.
General Internal Medicine (GIM)
A PCP called in regarding a patient with a 3-week history of shakiness and a recent diagnosis of hyperthyroidism (blood work revealed a TSH 0.01 mIU/L and T4 of 26 pmol/L). The patient was tachycardic but normotensive. The PCP wanted to discuss this patient with the GIM on-call to see if there are any red flags to monitor for and appropriate next steps.
The GIM on-call recommended initiation of beta-blocker therapy and urgent referral to endocrinology. The GIM-on call provided name and information of endocrinologist accepting new patients within the organization to ensure a timely referral for this patient.
Home and Community Care Support Services (HCCSS)
An elderly patient with a recent fall and confined to bed was experiencing pain and had no support services arranged. The PCP called to see what in-home options could be set up to prevent an emergency department visit and keep the patient in her home.
The HCCSS Coordinator was able to arrange in-home physiotherapy to help with the patient’s mobility and rehabilitation, as well as PSW support to help with bathing and other ADLs. The patient was very happy she was able to stay at home and get the support she needed.
A patient with impaired vision due to cataracts had missed multiple appointments. A cataract surgery was scheduled, but the patient was unable to recall when or where it was. The PCP was concerned about how the patient was coping and that he would not be able to follow through with his surgery and other appointments. The patient lives in a senior’s apartment complex but has no family or social supports.
The Navigator connected with the Geriatric Outreach Team (GOT), H&CC, and various eye clinics to determine when and where the surgery was, as well as the pre-operative instructions. Nursing services were arranged for eye drop administration and education, as it was determined the patient needed assistance with this. The patient had both cataract surgeries done and long-term case management services arranged to assist him to appointments in the future.
A PCP was concerned regarding a patient’s redness, swelling and pain in the right lower calf. The patient was on anticoagulation therapy at home, however, the PCP was hoping to get an ultrasound done as soon as possible to determine if the patient had a DVT. As the patient was resistant to going to the hospital, the PCP asked that for the results of the ultrasound to be shared with him when available, so if there was a DVT it could be treated at home versus the patient going to the emergency department.
SCOPE team able to work with bookings to get patient into ultrasound within the next 2 hours. The technologists were aware of plan of action to call PCP at an after hour’s number in the event that the ultrasound was positive for a DVT.
I want to thank you so very much. My patient now has her radiation [appointment] all set up for next week.
The PCPs I speak to have been grateful for the support and someone to have in real time on the other end of the call, to have specialists to consult with regarding patient care, and to receive expedited diagnostics as required especially when dealing with complex patients.
Mississauga Health SCOPE Team
Dr. James Pencharz
Primary Care Co-Lead at Mississauga Health
Dr. James Pencharz is the Primary Care Co-Lead at Mississauga Health. He is a family physician with the Credit Valley Family Health Team and has been in practice since 2009, providing comprehensive family medicine.
He is an active educator with the University of Toronto, Faculty of Medicine department, teaching medical students and residents for the past nine years. He is the former Site Program Director for the Trillium Health Partners – Credit Valley Hospital Family Medicine Residency program. From 2009 – 2014, he also worked as a hospitalist physician at THP- Credit Valley Hospital.
Dr. Sohal Goyal
Chair, Mississauga Health Primary Care Network
Dr. Goyal is the Co-Chair of the Mississauga Ontario Health team and one of the Regional Primary Co-Leads for Ontario Health. He is also the Chair of District 5 at the Ontario Medical Association (OMA) and was on the board of the Section of General and Family Practice at the OMA.
In his 20-year career, Dr. Sohal Goyal has established a vast network of healthcare relationships. Dr. Goyal is an assistant clinical professor with McMaster University Department of Family Medicine. His passion is to support and engage community physicians.
Dr. Ali Damji
Division Head of Primary Care, Trillium Health Partners
Dr. Damji has been involved in the development of the program along with primary care leaders within MOHT and PCN and community PCPs.
Dr. Damji is the current Division Head of Primary Care at Trillium Health Partners. Dr. Damji is also currently the Quality Improvement Program Director and Addiction Medicine Curriculum Lead for the Credit Valley Family Health Team. In addition, he is an Executive Member of the OMA Section of General and Family Practice, and a founding member of the Mississauga Halton Primary Care Network.
Dr. Damji is excited to participate in progressive projects that help Family Physicians in their offices.
SCOPE GIM Physician Lead
As the Physician Lead for the Virtual Care program at Trillium Health Partners, Dr. Shaan Chugh has been actively involved in the development and implementation of the program.
Dr. Chugh has been practicing as a General Internal Medicine specialist at Trillium Health Partners for the last 6 years. He is also the Medical Director for THP Solutions and has been working in long term care for the past five years.
D. Chugh is passionate about caring for elderly and primary care patients’ GIM needs and excited to participate in THP’s Virtual Care program.
Liz Gabison is the SCOPE Patient Navigator at Trillium Health Partners (Mississauga and Etobicoke).
Liz graduated from the University of Toronto with her Bachelor of Science, York University with a Bachelor of Education, the Canadian Memorial Chiropractic with her Doctor of Chiropractic and from the University of Fredericton with her Masters in Business Administration.
Liz has experience working in both hospital and community settings and has most recently worked as an assessor in the MSK WSIB specialty programs and in the OHAP program side by side with the Orthopaedic Surgeons and Primary care providers. Prior to her role as an assessor, Liz worked as a Director of Clinical Operations at Cira Medical, and as a Case Manager in the insurance sector. She also has extensive experience in the Vocational Rehabilitation industry.
In her role as SCOPE Patient Navigator, Liz will provide primary care providers with assistance navigating hospital and community resources to support primary care and improve patient care needs.
Virtual Care Operations Lead
Mr. Andrew Bidos is the operational manager of Virtual Care. In addition, he supports Insight Health’s Musculoskeletal Teams.
Mr. Bidos is passionate about healthcare improvement and has over 16 years of both clinical and managerial experience in various public and private healthcare organizations.
With a passion to improve healthcare quality for elderly population, Andrew looks forward to work with LTCHs for seamless LTC Virtual Care operations.
Director, Mississauga Ontario Health Team &
Co-Lead, Mississauga Health SCOPE
Lindsay Wingham-Smith is a Transformational health system leader with a proven track record of integrating and advancing complex regional and provincial initiatives by leveraging strong cross-sector relationships with key stakeholders. With more than 15 years spent in both clinical and leadership roles at all levels of the system, Lindsay knows what truly drives continuous growth and optimization of programs, policies, and strategies with innovative and sophisticated approaches. Evolving our healthcare system to meet the needs of our population into the future means continually pushing the boundaries of what is possible through engagement of staff, stakeholders, and the community.
A Registered Social Worker, Lindsay holds both an Honours Bachelor and Master of Social work, as well as a post-graduate diploma in Forensic Social Work, in addition to post-graduate work in Project Management and Six Sigma methodologies.
Project Director, Health System Innovation
Hayley recently joined the team as the Project Director of Health System Innovations supporting SCOPE operations. She has held progressive leadership positions, most recently as the Manager of Virtual Clinics and Interim Program Director of SCOPE at Women’s College Hospital.
In her position, Hayley was responsible for overseeing the clinical care delivery of Women’s Virtual (WV) across the COVIDCare@Home, LTC+, eConsult, and SCOPE programs. Previously, Hayley was the Manager of Strategic Projects at Women’s College Hospital Institute for Health Systems Solutions and Virtual Care (WIHV).
Hayley has her PMP and Master’s in Public Health from Queen’s University.
Frequently Asked Questions
I am not sure if my request is appropriate for SCOPE. How can I find out?
When in doubt, you can always call SCOPE. We will try to help you with your patient request, no matter how big or small.
My patient needs mental health support and/or mental health case management, what should I do?
One-Link provides coordinated access to a number of addictions and mental health services within Mississauga and Halton through one referral and intake assessment process.