INSPIRE PHC - Primary Health CAre Program:INnovations Strengthening PrImary Healthcare REsearch
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Research Leads

Dr. Onil Bhattacharyya Dr. Onil Bhattacharyya
The Frigon Blau Chair in Family Medicine Research, Associate Professor, Department of Family and Community Medicine, Faculty of Medicine at the University of Toronto
Dr. Noah Ivers Dr. Noah Ivers
Family Physician at Women's College Hospital, Post-Doctoral Fellow with the Department of Family and Community Medicine, University of Toronto
Gillian Hawker (Project Co-Lead), Pauline Pariser (Project Co-Lead), Jeffrey Hoch
Laura Pus
Project Manager
Research Project Links

PC Reform
Optimizing quality, access, integration and equity in Ontario primary care

Care in the Home (TAPESTRY)
Primary health care linking with community (TAPESTRY-CM)

Community Linkage - SCOPE
Enhancing PHC linkages with home care and hospitals (SCOPE)

Specialist Linkage -eConsult
Creating new PHC linkages with specialists

Knowledge Translation Exchange (KTE)

Sex and Gender Analysis

Research Projects...

Community Linkage:
Enhancing PHC linkages with home care and hospitals (SCOPE)
SCOPE-Seamless Care Optimizing the Patient Experience


- Seamless Care Optimizing the Patient Experience - is a partnership between Women's College Hospital (WCH), Mount Sinai Hospital (MSH), University Heath Network (UHN) and the Toronto Central Community Care Access Centre (CCAC) that integrates primary, acute and community care by assisting Family Physicians whose practices are located in the Mid-West Toronto Health Link.

The primary goal of SCOPE is to support Family Physicians in caring for their complex patients by improving linkages with acute and community care.


Click here to see full posterFamily doctors enrolled in SCOPE are provided with a one-number to call service with extensions to:

Direct General Internal Medicine consultations – offers phone and email consultations between the family doctor and a Internal Medicine staff physician at WCH. The Internal Medicine specialists may also refer patients for rapid clinical assessment in Acute Ambulatory Care Unit (AACU).

CCAC Care Coordination – provides in home assessments, case management, facilitates access to community-based resources and home care.

Acute Care Nurse Navigator – facilitates access to specialist care, diagnostic testing, and hospital.

Medical Imaging Hub- better access to medical imaging services, both for urgent patient needs, and for informational and navigational support.

Family Doctors are also provided with in-office access to hospital records through Patients Results Online (PRO).




SCOPE includes a formal scientific evaluation in the form of a randomized control trial (RCT).
Approximately 30 physicians will be enrolled in the intervention arm and will be provided with access to the SCOPE services, as described, and 20 physicians will be enrolled to a wait list control arm. Using a control group is the most rigorous method of determining the intervention effect. Upon completion of the study SCOPE services will be made available to all participating physicians.

Ongoing management of the project is based on the principles of continuous improvement; thus, resources and supports may expand and evolve as determined by feedback obtained from participants.


The final evaluation of SCOPE will examine monthly rates of Emergency Room visits and hospitalizations by patients of participating practices (as measured using Health Administrative Databases) as well as patient experience of care surveys.

Secondary outcomes that will be considered include:

  • costs associated with the intervention
  • number, pattern and outcome of contacts with each element of the intervention
  • family physician satisfaction


  • “It is so easy for me to just pick up the phone and call SCOPE, the Internist On-Call at Women’s College Hospital speaks with me immediately.  She is supportive, efficient and coordinates care for my patients, right away.”

  • “SCOPE has provided me with a new and fresh approach to evaluate and manage patients with complex, chronic conditions.  It has provided a source of renewal for dealing with issues that otherwise become blurred over time due to hopelessness and frustration.”