SCOPE (Seamless Care Optimizing the Patient Experience) is a virtual, multidisciplinary, hub-based program that supports solo, community-based primary care providers (PCPs) in Toronto to navigate appropriate hospital and community services for patients with complex medical and psychosocial needs. A strongly identified need for mental health support led to the development of a mental health team consisting of a social worker and a psychiatrist in Fall 2016. Taking an iterative approach to adapt to PCP and patient needs, and with increasing efficiency, at 4 years of operation, the program has grown to serve 100 PCPs, with a total of 2121 referrals. SCOPE-MH uses a stepped-care approach, keeping the patient in the PCP’s care; connecting patients with appropriate and least intensive services; and, promoting equitable care and use of existing resources. The program’s level of intervention therefore varies in intensity, providing resource navigation, counselling, short-term case management, bridging support, psychiatric consults, and brief follow-up as needed. Past PCP and patient feedback, and referral tracking, have highlighted the success of direct patient support, particularly for patients with psychosocial complexity and who face barriers to accessing care through traditional pathways. The integration of social and psychiatric care, and the development of strong links with PCPs, has allowed SCOPE to develop as a flexible, low-barrier access service, resilient to the pandemic’s pressures around care delivery. Currently, a formal quality improvement (QI) evaluation is being conducted, which takes into account the impact of the Covid pandemic and the resulting shift to virtual care delivery. The evaluation follows the RE-AIM framework, measuring Reach, Adoption, Implementation and Maintenance (Midboe, Martino et al. 2018). To help us understand both patients’ and PCPs’ experiences, the evaluation includes a survey of Patient Reported Experience Measures (PREMS, n=30) related to the service and qualitative surveys with PCPs (target n=100). We will also collect demographic information, mental health diagnosis, and level of support received with the SCOPE MH program. We expect that the results of the QI evaluation will allow SCOPE MH to implement changes to further improve patient outcomes, create enhanced care pathways, and promote integrative and collaborative care. As of March 2021, there are 8 unique SCOPE hub sites, serving 829 PCPs total across Toronto and the GTA (Greater Toronto Area). The results of the evaluation will also inform expansion of care to other communities outside the initial area in which SCOPE-MH was developed (Midwest Toronto area).
- To examine the changing mental health and psychosocial needs, in the context of a global pandemic, as identified by solo PCPs and their patients.
- To identify the benefits of a mental health program composed of a small, virtual multidisciplinary team and describe the challenges of expansion.
- To understand the importance of evaluating services using a QI protocol that includes patients and physicians’ experiences to ensure equitable care.