Western York Region OHT SCOPE program
SCOPE: Seamless Care Optimizing the Patient Experience
SCOPE is a virtual, interdisciplinary program that connects registered primary care providers (PCPs) to a wide range of hospital and community care resources, all through a single access point.
By offering real-time access to interdisciplinary resources, SCOPE strengthens primary care and helps ensure patients receive equitable, team-based support and timely access to specialists. The program streamlines care co-ordination by:
- Delivering best practices and emerging standards of care
- Facilitating real-time consultations and collaborative care planning
- Creating meaningful opportunities for ongoing physician engagement
SCOPE helps PCPs manage complex patients more effectively in the community, reducing unnecessary emergency department visits and improving continuity of care.
Currently, SCOPE supports nearly 4,000 PCPs across 22 regional sites in Ontario.
SCOPE in Western York Region
The Western York Region OHT SCOPE program (SCOPE WYR-OHT) — launched in partnership with Mackenzie Health — offers registered PCPs in Western York Region direct access to timely specialist support, diagnostic services and service navigation in the region.
Our goal is to help you provide the best possible care for your patients, especially those with complex health needs or at risk of hospitalization.
With one easy point of contact, SCOPE WYR-OHT connects you to the right resources — quickly, efficiently and when you need them most.
Current SCOPE WYR-OHT pathways:
Nurse Navigator
The Nurse Navigator helps PCPs co-ordinate care and navigate available services across the health system. This dedicated support includes:
- Answering questions about community resources and how to access them
- Connecting providers to services within Western York Region
- When possible, linking providers to resources available through other SCOPE sites
Whether you’re looking for local supports or broader system navigation, the Nurse Navigator is here to help streamline care for your patients.
Diagnostic Imaging – Deep Vein Thrombosis
SCOPE supports PCPs by facilitating fast-track access to diagnostic imaging for suspected lower limb deep vein thrombosis (DVT) at Mackenzie Richmond Hill Hospital. This includes:
- Expedited imaging to confirm diagnosis
- Timely treatment and follow-up (as required) at Mackenzie Health’s Medical Urgent Care Clinic
This streamlined pathway helps PCPs manage DVT cases efficiently, ensuring patients receive prompt, co-ordinated care.
Ontario Health atHome
SCOPE supports PCPs in connecting patients to in-home and community-based care through Ontario Health atHome. This centralized referral process is co-ordinated in partnership with the SCOPE Nurse Navigator and a designated Care Co-ordinator, streamlined via a dedicated SCOPE phone line.
Palliative Care
Hospice partnerships
In collaboration with three local hospices, this pathway aims to ensure seamless, dignified end-of-life care — from initial diagnosis through to compassionate support for families after a loved one’s passing.
Mental Health
Centre for Behaviour Health Sciences
Mackenzie Health’s Centre for Behaviour Health Sciences provides comprehensive mental health assessments and interventions through its Behavioural Science team, focusing on:
- Behaviour management and aggression
- Self-injury and skill-building
- Social problem-solving for children and adults
Future SCOPE WYR-OHT pathways:
Palliative Care
Compassionate Care Clinic
Providing timely, patient-centered care for individuals with life-limiting illnesses, Mackenzie Health’s Compassionate Care Clinic offers:
- Palliative support
- Advance care planning
- Pain and symptom management
Seniors Wellness Clinic
Helping older adults maintain their independence and quality of life, Mackenzie Health’s Seniors Wellness Clinic focuses on:
- Supporting optimal function
- Preventing unnecessary hospital visits
- Promoting wellness and aging in place
Mental Health
Psychiatry
Through Mackenzie Health’s outpatient mental health services, primary care providers can access psychiatric consultations, outpatient programs and mental health services delivered by clinicians, including social workers and Registered Nurses, for adults experiencing mental health challenges.
Pregnancy Assessment Centre
Mackenzie Health’s Pregnancy Assessment Centre provides urgent and supportive care for individuals with confirmed or threatened pregnancy loss during early pregnancy, ensuring individuals have timely access to:
- Appropriate evaluation and assessment
- Clinical guidance
- Compassionate support
Accessing SCOPE services
If you are a primary care provider (family physician or nurse practitioner) and are interested in joining SCOPE, it's easy to get started.
Visit the SCOPE website
Visit scopehub.ca to learn more about the program and begin your registration.
Register
Complete and submit the registration form on scopehub.ca.
Onboard
Once your registration is submitted, a member of the SCOPE team will contact you to complete your onboarding.
Access services
Once registered, you can connect with SCOPE WYR-OHT through:
- Phone: 905-417-2000 ext. 2322
- Email: SCOPE@mackenziehealth.ca
- Fax: 905-417-3203
Our hours of operation are Monday to Friday, 8 a.m. to 4 p.m.
For questions about registration, email SCOPE@mackenziehealth.ca.
Meet the SCOPE WYR-OHT team
Rhea Villafuerte
Nurse Navigator
Zuleida Monroy
Manager, Community Integration
Dr. Lori DiSanto
Primary Care Lead
Pawan Khullar
Program Director, Community Integration
Share your feedback
Your insights help the SCOPE program grow and improve. Whether you’d like to share your experience with a SCOPE referral, suggest ways to improve access to care, propose ideas for future clinical pathways or offer feedback on how we can better support you — we want to hear from you.
