Building Bridges at Women’s College Hospital

When her family doctor diagnosed Karla with heart failure, he wanted advice from a medical specialist about the best management approach. Instead of waiting for the patient to see a specialist, the doctor picked up the phone and discussed the case with the internist on call at Women’s College Hospital.

Family doctors in solo practice – those who are not part of a family or community health team – have fewer resources and thus unique challenges in managing complicated medical patients. Ensuring patients in crisis have access to specialists, community resources and diagnostic tests is often difficult; sending the patient to a hospital emergency department is often seen as the only resort.

Supporting these family doctors in keeping their complicated medical patients well and out of hospital is what the University of Toronto BRIDGES program (Building Bridges to Integrate Care) is all about. Women’s College is uniquely positioned to partner with acute care hospitals and community providers to ensure safe transitioning of patients from hospital to home, and to ensure they stay well. So it makes sense that the SCOPE project (Seamless Care Optimizing the Patient Experience) – a partnership of Women’s College with University Health Network (UHN) and Toronto Central Community Care Access Centre (TC CCAC) – was granted funding from the Ministry of Health and Long-Term Care as a BRIDGES initiative.

Women’s College’s mandate is to create innovative health system solutions to keep complicated medical patients out of hospital, provide evidence to show that these innovations work, and then share these models with others across the country.

The SCOPE project is an excellent example of this model. It is a two-year quality improvement project that will evaluate the impact of providing a group of 25 solo practice, community-based family doctors with specific services at Women’s College, UHN and the TC CCAC to help them manage their complex medical patients. The aim is to avert exacerbations of chronic illness that often result in an emergency department visit or hospital admission.

The project has three key components:

• a navigation hub staffed by a nurse and a CCAC co-ordinator who can respond to calls from the physicians or their secretaries around urgent access to things like specialists, diagnostic testing and community resources

• doctor-to-doctor telephone access to a general internist at Women’s College Hospital

• access to the University Health Network’s electronic medical records system to enable fast, online access to things like test results, consult notes and discharge notes, which may otherwise take days or weeks

“As an ambulatory care hospital and home of the new Institute for Health System Solutions and Virtual Care, Women’s College Hospital is perfectly positioned to partner on the development and evaluation of innovative models of care that keep people out of hospital,” says Dr. Gillian Hawker, chief of medicine at Women’s College Hospital.

All components of the project are being evaluated. The result will be a scalable model for hospital, community and primary care integration that can be applied in other parts of the province to help reduce emergency room use within the system as a whole.

“It makes sense that the hospitals, CCAC and the primary care docs come together,” Heather McPherson, vice-president, patient care and ambulatory innovation, says. “It’s a beautiful example of how our Institute for Health Systems Solutions and Virtual Care is advancing primary care integration, and it’s an immediate and tangible way to improve the health outcomes for more complicated patients.”

Dr. Gillian Hawker
Chief of Medicine
Women’s College Hospital
Heather McPherson
Patient Care and Ambulatory
Women’s College Hospital


Ontario’s Action Plan for Health Care, Ministry of Health and Long-Term Care

“Family care providers are a natural anchor for patients in our health-care system… They need to be spending less time on the phone searching for a specialist to see their patient and more time with their patients.”

If family health-care providers are to have an even stronger role in our health-care system, they must be well integrated at a local level with all the other providers involved in the patient journey.”