Medical home and continuity OSCE — complex care discharge and transition counselling

Station objectives

1. Assess continuity domains and medical-home status. [1] [2]
2. Build a care-coordination plan with closed loops. [5] [6]
3. Avoid dumping unpaid coordination onto caregivers. [7]
4. Counsel structured transition steps. [8]
5. Link non-emergency acute care back to the medical home. [9]

Candidate brief

You are the paediatric doctor in a mixed clinic–ward interface. You have 12 minutes for Station A and 10 minutes for Station B. Examiners score systems thinking, safety and partnership language. [5] [7]

Station A — Complex care discharge

Setup: Caregiver of an 8-year-old with medical complexity, multiple specialties, recent ED visits, unsorted letters. [7]

Expected actions:

• Ask who the usual team is and how they are contacted. [2]
• Map network and outstanding results/medicines. [1] [5]
• Name relational, informational and management gaps explicitly. [1]
• Propose coordinator role, shared care plan and emergency information form. [5] [6]
• Set timed loop closure after ED/ward care. [9]
• Validate caregiver expertise without assigning unpaid full coordination. [7]

Station B — Transition counselling

Setup: Adolescent with chronic disease and parent; no adult service named. [8]

Expected actions:

• Explain transition as preparation, transfer and integration over time. [8]
• Start self-management and portable summary planning now. [8]
• Avoid birthday-only transfer. [8]
• Agree next medical-home review items and family questions. [8]

Marking anchors

Clear pass: defines continuity domains, builds coordination with loop closure, supports caregiver, outlines transition process. [1] [5] [8]
Borderline: correct labels but no concrete owners/times or still dumps labour on family. [7]
Fail: equates walk-in access with medical home; ignores open loops; birthday discharge as transition plan. [2] [9] [8]

Debrief pearls

• Access ≠ continuity. [1]
• Care coordination is infrastructure. [5]
• ED can be necessary; loop closure is mandatory. [9]
• Transition is a process inside the medical home. [8]