The code block below illustrates how one might use # and // as comments in your logic and calculations.

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Seamless Care Optimizing the Patient Experience (SCOPE) Primary Care Practitioner (PCP) Registration/Online Consent Form

We are inviting you to complete this questionnaire as a part of the registration for SCOPE. Your participation is completely voluntary, and you may choose to skip any questions you are not comfortable answering.

BACKGROUND

SCOPE (Seamless Care Optimizing the Patient Experience) is a free of charge program, funded by Ministry of Health. SCOPE offers Primary Care Providers (PCPs) a single access point to a comprehensive range of interdisciplinary supports, including a resource navigation hub, hospital internist on-call, and diagnostic imaging on-call. Health care providers enrolled in SCOPE are provided with a one-number to call with extensions to:
1. Local General Internal Medicine consultations - offers phone and email consultations between the health care provider and an Internal Medicine staff physician
2. Ontario Health Home and Community Care Coordination - provides in home assessments, case management, facilitates access to community-based resources and home care.
3. Nurse Navigator - facilitates access to specialist care, diagnostic testing, hospital and community resources.
4. Medical Imaging On-Call - facilitates access to services aimed at providing better access to medical imaging, both for urgent patient needs, and for informational and navigational support 5. Mental Health Program - a hub-based integrative case management and psychiatric care program supporting PCPs, providing patient resource navigation, social support, counselling, psychiatric consults and short-term follow-up.
6. Headache Neurology Program - facilitates access to a neurologist and nurse practitioner who interact with the patients and PCPs in a shared care model through the use of a bi-directional care plan and optimized communication.

The SCOPE Program is a quality improvement initiative. As part of program evaluation and improvement, we will be tracking the number, pattern and outcome of each contact made to SCOPE. No identifying patient information will be collected. We will use various techniques to elicit feedback and optimize the SCOPE platform to best meet the needs of you and your patients.

To better understand the association between SCOPE use and outcomes such as emergency departments, we will securely share your CPSO number and SCOPE-use data with ICES and/or the Ontario Medical Association (OMA) where it will be de-identified for analysis using administrative data. Analyses at ICES and OMA follow strict protocols to ensure confidentiality and are only performed on de-identified data. These anonymized analyses will allow us to understand how SCOPE is affecting health care and outcomes for the patients we all serve.

You may also be approached and asked to partake in a qualitative interview; further information and an additional consent form will be provided at that time.

By completing this questionnaire, you are providing consent for your answers to be used for quality improvement purposes. Thank you for considering participating.

You may choose to withdraw from participating in SCOPE by contacting the lead Research Assistant, Mona Emam (Mona.Emam@wchospital.ca).

First Name

* must provide value

Last Name

* must provide value

CPSO Number (or additional professional affiliation registration number)

* must provide value

What type of practice model do you work in?

* must provide value

Family Health Group (FHG)

Family Health Organization (FHO)/Family Health Network (FHN)/Family Health Team (FHT)

Community Health Centre (CHC)

Independent Practice

Other

Seamless Care Optimizing the Patient Experience (SCOPE) Primary Care Practitioner (PCP) Registration/Online Consent Form

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