Continuity of care and the paediatric medical home — formative SAQs

SAQ 1 — Fragmented complex care (10 marks)

An 8-year-old with medical complexity attends after a second hospital admission in six weeks. Mother carries unsorted letters and coordinates all specialties alone. [7] [5]

Questions

1. Define continuity using Haggerty’s three domains and identify which domains are failing in this scenario. (4 marks) [1]
2. Outline the essential components of practice-based care coordination you would establish. (3 marks) [5] [6]
3. List concrete loop-closure actions after this discharge. (3 marks) [5] [9]

Model answer

Domains (4). Relational: ongoing relationship/being known. Informational: usable past information and results. Management: coherent cross-clinician plan. Here informational discontinuity (unsorted letters, missing reconciliation) and management discontinuity (no single plan/ownership) are clear; relational continuity may also be weak if no named home team exists. [1] [7]

Care coordination (3). Define coordinator/roles; family partnership; proactive tracking of referrals and results; shared care plan and emergency information form; scheduled review rather than crisis-only care. Do not leave unpaid full coordination to the caregiver alone. [5] [6] [7]

Loop closure (3). Name medical home and contact pathway; reconcile medicines/devices; assign owners and times for outstanding results and specialty feedback; timed primary/complex-care follow-up; communicate discharge plan in plain language with teach-back where possible. [5] [9]

SAQ 2 — Transition and foster-care continuity (10 marks)

A. A 16-year-old with chronic disease is still fully parent-managed with no adult service named. B. Separately, a newly placed foster child has unknown immunisations and no usual clinician. [8] [10]

Questions

1. Describe structured health care transition steps within the medical home for the adolescent. (4 marks) [8]
2. State immediate continuity priorities for the foster child. (3 marks) [10]
3. Explain why a usual source of care is not automatically a medical home. (3 marks) [2] [3]

Model answer

Transition (4). Preparation over years: teach self-management, create portable summary, discuss adult care needs. Transfer: identify adult team, share records, plan overlap. Integration: confirm first adult appointments, emergency plan and decision-making arrangements. Not a birthday letter alone. [8]

Foster care (3). Rapid medical-home assignment; reconstruct history and immunisations; address acute needs; lawful information-sharing with caregivers/child protection; catch-up preventive care. Do not wait for permanent placement. [10]

Usual source vs medical home (3). Usual source means the family can name where they usually go. A medical home requires continuous, comprehensive, family-centred, coordinated care attributes. Branding or a single clinic name without coordination and continuity is insufficient. [2] [3]