​​​​​​​​​​​​​​​​​​​​​​We are pleased to share several case studies that demonstrate how SCOPE can help you manage your complex patients.

Diverting the ED through the Acute Ambulatory Care (AAC) Unit

Patient Assessment
  • Patient was a senior citizen who was living alone at home.
  • Patient had been unwell for the past month; suffering from significant weight loss, hand and leg edema and left shoulder pain. The patient was having trouble managing at home.
AAC Interventions
    The patient underwent blood work and an urgent CT of their chest and abdomen to look for the cause of the weight loss.
  • Patient was seen by rheumatology for inflammatory arthritis and placed on prednisone.
  • While at the AAC the patient was seen by an OT and PT; CCAC home support was arranged.
  • The patient was discharged from the AAC within 48 hours.
  • Upon follow-up one week later the patient was much improved and managing well at home.​

Managing Atrial Fibrillation in the Acute Ambulatory Care (AAC) Unit

Patient Assessment
  • Patient was a senior citizen with an initial diagnosis of new-onset atrial fibrillation.
AAC Interventions
  • Upon arrival at the AAC the patient was asymptomatic and underwent blood work and an EKG.
  • Patient was rate controlled with a beta blocker in combination with anticoagulation.
  • An echocardiograph revealed no evidence of structural heart disease.
  • Patient was discharged home from the AAC after 18 hours.​

Managing Renal Failure in the Acute Ambulatory Care (AAC) Unit

Patient Assessment
  • The patient was a senior citizen who was referred to the AAC with acute-on-chronic renal failure.
AAC Interventions
  • The patient underwent blood work, volume assessment and urinalysis to investigate for renal failure.
  • To rule out urinary tract obstruction an abdominal ultrasound was ordered.
  • An urgent nephrology appointment was scheduled and the patient was discharged home within several hours.​

Case Management through the Internist On-Call

Patient Assessment
  • The patient was a senior citizen with multiple medical problems and recent cardiac surgery for aortic valve replacement.
  • The patient’s post -operative course was complicated by atrial fibrillation, worsening renal function and volume management issues.
  • The patient had seen their GP after discharge and their weight had increased by 2kg but they were not short of breath. No changes to meds were made. The patient was brought back the next week and their weight had increased by 3-4 kg, the patient had increased edema and shortness of breath. The patient was also having hypoglycemia as insulin had been adjusted in hospital.
Internist On-Call Intervention
  • The internist sent the patient to the Clinical Decision Unit at Women’s College Hospital. The patient was diuresed over 2-3 days and their weight decreased by 5 kg. The patient was started on a beta blocker for their atrial fibrillation, and insulin doses were adjusted.
  • The patient will be followed up in the Centre for Ambulatory Care Education (CACE) complex care clinic to ensure their weight and creatinine are stable.​

Complex Care Coordination

Patient Assessment
Patient had sustained multiple fractures and a head injury while on vacation and was transferred back to Toronto once stable for rehabilitation.

Need for Support
The primary care physician contacted the SCOPE navigation hub for support with fragmented care as well as poor pain management. In addition, resources were needed to provide psychiatry, physical rehabilitation and support for caregiver burnout.

How SCOPE Helped

  • Identified existing members of the health care team (orthopedics, physiatry, psychiatry and the head injury clinic); coordinated compiling of patient records from the various providers.
  • Liaised with pain clinic intake coordinator to complete the patient intake form and process the clinic referral.
  • Completed CCAC referrals for PSW support, case management and connecting to community resources.
  • Consulted with the patient and their family regarding resources for pharmacy and nutrition support available through their assigned CCAC coordinator. The patient and family indicated that they were satisfied and felt well-supported.​

Urgent Obstetrics Referral

Patient Assessment
  • Pregnant patient had recently returned to Toronto from abroad and was due to deliver the 3rd week of August.
  • The pregnancy was low-risk but the patient was having difficulty finding an obstetrician.
  • The primary care physician had attempted several hospitals with no success and found that obstetricians were currently booking for December or January.
Nurse Navigator Intervention
  • The nurse navigator was aware of two additional OB offices affiliated with a different hospital; both were able to accept the patient referral.

Urgent Ophthalmology Referral

Patient Assessment

  • Patient was a young adult who had been suffering from ​a peri​orbital rash for more than two months.
  • The patient was initially seen in ED and was referred to Ophthalmology who prescribed eye drops and deferred care to local ophthalmologist
  • The rash had since been worsening and now extended from the patient’s brow to cheekbone.

Nurse Navigator Intervention

  • Reviewed patient chart and notes from ED visit as well as the ophthalmology notes.
  • Contacted the dermatology clinic for an urgent appointment, having provided Intake with a brief history and explanation of the situation
  • A dermatology appointment was obtained two days later.

Mental Health Case Management

Patient Assessment

  • Received referral for Psychiatry for a new patient with a history of bi-polar disorder who was presently struggling with a major depressive episode. The patient was recently discharged from CAMH with a referral to Community Mental Health.
  • The patient made frequent ED visits throughout the downtown hospitals.
Further Investigations by Nurse Navigator
  • Reviewed patient profile on PRO and hospital records.
  • Identified when patient came through the ED and was able to assess the patient as well as identify supports and concerns.
  • Discovered that patient had an active referral with CATCH-ED but was was difficult to connect with for an intake interview.
  • Identified members of the patient's care team (COSS and CCAC) to facilitate connection with primary care provider.
  • Determined that patient's sleep-wake patterns and signs of dependence on others were affected his ability to keep appointments.
  • Connected with Community Mental Health to inquire about referral status, obtained name of assigned clinician and date for first intake interview.

Nurse Navigator Intervention

  • Given patient's history of missing appointments, connected primary care office and mental  health clinician to phone patient regarding appointment date.
  • Primary care office phoned patient's primary contact who is known to bring him to appointments to help ensure the patient is seen by the clinician
  • Outcome: Patient was seen both at the initial intake visit and the second visit with the Psychiatrist.

Managing Patient Self-Referral to ED

Patient Assessment
  • The patient was a senior citizen with a history of severe osteoarthritis, macular degeneration, congestive heart failure and atherosclerotic heart disease.
  • Patient obtains the requisite number of homecare hours for bathing and basic housekeeping from the CCAC. They are unwilling to pay for extra services and would prefer to have live-in help in exchange for free room and board.
  • Patient avoids Tylenol 3 for pain control due to the gastrointestinal side effects. The patient prefers Ketorolac but refuses to pay for it. As a result, the patient visited the ED 27 times in 2012 for pain control, as ketorolac is covered during these visits.
  • The patient has also been seen in the ED for management of heart failure.

Need for Support
  • The patient is seen in the GP office approximately​ weekly but still ends up going to the ED. The physician contacted SCOPE for support in developing an integrated care plan for the patent.
  • Further assessment by the SCOPE hub team identified that some of the ED visits may have been to fulfil​ a social need and that the patient already has ready access to a community cardiologist.


How SCOPE Helped

The SCOPE hub team coordinated a case conference with the GP and CCAC pharmacist to develop recommendations:

  • Several pain management options were identified including 3-months of ketorolac coverage through the CCAC and prescribing dilaudid as alternative medication with fewer gastrointestinal side effects.
  • A day treatment program at St. Christopher’s House was suggested as a means of social interaction for the patient.
  • Social service agencies will be contacted to aid with leasing space in the patient’s house in exchange for personal care
  • A follow-up meeting was scheduled in one month to review patient progress.​

Coordinating Extensive Homecare Needs

Patient Assessment
  • The patient is a senior citizen who lives with their spouse who is also the primary caregiver.
  • The patient has multiple chronic illnesses including COPD, HTN, glaucoma, kyphosis, atrial fibrillation, hypothyroidism, and dyslipidemia.
  • GP was concerned as the patient hadn’t visited the office in nearly a year.
  • The SCOPE CCAC care coordinator was called to assess patient’s home situation and coordinate the appropriate community supports.


Need for Support
  • Patient presented as frail with a strong spirit.
  • The patient was finding it increasingly difficult to get out of the house. On most days the patient could only venture out to the front porch and around the house with assistance from their walker and spouse.
  • Patient was becoming increasingly cachectic; spouse purees their food as recommended during a previous hospital admission.
  • Patient spends most of their time on a well-worn bed in the living room.
  • Frequent visits by sons providing caregiver relief for spouse. The family felt it was unsafe to leave the patient alone for more than an hour due weakening physical condition and insight into self needs.


How SCOPE Helped

The CCAC coordinator made several initial recommendations:

  • OT consultation for pressure relief surface due to developing stage one ulcers.
  • Nursing education for ulcer prevention skin care.
  • SLP to assess swallowing as patient often coughs when eating.
  • Nutritionist to assess diet and advise on strategies to increase caloric intake.
  • In-home nurse practitioner services to complete a thorough medical assessment and provide treatment recommendations to GP.


As ongoing case management services were provided, supports were added based on patient needs:

  • Referral to the Telehomecare program to provide remote monitoring of vitals and telephone coaching for COPD management. This also provided the GP with regular data on the patient’s health status.
  • Advanced care directives were discussed in coordination with the patient, their spouse, sons, and GP. A DNR form was completed and left in the home. This provided peace of mind for the patient and family that their wishes would be understood in the event of an emergency.​

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