Shared-care planning across primary, secondary and tertiary care — branching viva · Paeds Vivas

Prompt

You are the paediatric registrar responsible for multi-level care design across clinic, ED and ward interfaces. The examiner will challenge definitions, co-management and disposition.

Stem

The examiner will move from definitions to a fragmented multi-specialty child, then to oncology shared care and transition. [2] [9]

Branch 1 — Definitions

Examiner: What is shared care? [2]

Strong answer: Deliberate co-management across primary, secondary and tertiary teams with named owners, one plan and closed loops. Not the same as a one-way referral or transfer of care. [2] [3]

Examiner: Is filing a specialty letter enough? [14]

Strong answer: No. Need return of plan, ownership and follow-through. Electronic filing without closed-loop human ownership is a trap. [2] [14]

Branch 2 — Parent intermediary

Examiner: Mother carries all letters between five clinics. [1]

Strong answer: Classic informational failure. Stille shows parents often become intermediaries when clinician communication fails. Redesign clinician-to-clinician routes; keep families informed without making them the messaging system. [1] [2]

Branch 3 — Complex care discharge

Examiner: Technology-dependent child, mother only coordinator after ward discharge. [9]

Strong answer: Named medical home and coordinator roles; shared plan and emergency thresholds; reconcilation; closed-loop specialty tracking; timed follow-up; caregiver support without unpaid labour dump. [9] [7] [6]

Branch 4 — Oncology model

Examiner: How can regional cancer care reduce travel safely? [5]

Strong answer: Hub-and-spoke shared care: tertiary protocol leadership, regional delivery where appropriate, organised communication and case management. Not ad hoc unlinked local care. [4] [5]

Branch 5 — Acute and transition

Examiner: Child crashes in ED; later a 16-year-old has no adult plan. [10]

Strong answer: ABCDE and emergency shared pathways first; then update multi-level plan. Transition is prepare–transfer–integrate across primary and specialty lanes, not a birthday letter. [13] [10]

Examiner extras

Primary/secondary/tertiary is capability and role, not prestige.
ADHD shared-care models need structure; do not over-claim universal effect sizes.
CCKO shows complex-care coordination can be trialled; local workforce still matters. [12]
Non-emergency acute care outside the medical home still needs loop closure. [11]

References

[1]Stille, Christopher J Parents as information intermediaries between primary care and specialty physicians Pediatrics, 2007.PMID 18055672
[2]Stille, Christopher J Determinants and impact of generalist-specialist communication about pediatric outpatient referrals Pediatrics, 2006.PMID 17015522
[3]Cooley, W Carl Redefining primary pediatric care for children with special health care needs: the primary care medical home Curr Opin Pediatr, 2004.PMID 15548933
[4]Seth, Rachna Children with Cancer: Shared Care and Transition of Care Indian J Pediatr, 2023.PMID 37368222
[5]Slater, Penelope Fifteen years of shared care for paediatric oncology, haematology and palliative patients across Queensland: The role of Regional Case Managers Aust J Rural Health, 2023.PMID 36577741
[6]Auger, Katherine A Summary of STARNet: Seamless Transitions and (Re)admissions Network Pediatrics, 2015.PMID 25489017
[7]Council on Children with Disabilities Patient- and family-centered care coordination: a framework for integrating care for children and youth across multiple systems Pediatrics, 2014.PMID 24777209
[8]McAllister, Jeanne W Practice-based care coordination: a medical home essential Pediatrics, 2007.PMID 17766512
[9]Kuo, Dennis Z Care Coordination for Children With Medical Complexity: Whose Care Is It, Anyway? Pediatrics, 2018.PMID 29496973
[10]White, Patience H Supporting the Health Care Transition From Adolescence to Adulthood in the Medical Home Pediatrics, 2018.PMID 30348754
[11]Conners, Gregory P Nonemergency Acute Care: When It's Not the Medical Home Pediatrics, 2017.PMID 28557775
[12]Cohen, Eyal Effectiveness of Structured Care Coordination for Children With Medical Complexity: The Complex Care for Kids Ontario (CCKO) Randomized Clinical Trial JAMA Pediatr, 2023.PMID 36939728
[13]Starmer, Amy J Changes in medical errors after implementation of a handoff program N Engl J Med, 2014.PMID 25372088
[14]Stille, Christopher J Building communication between professionals at children's specialty hospitals and the medical home Clin Pediatr (Phila), 2009.PMID 19286621

Branch 1 — Definitions

Examiner: What is shared care? [2]

Strong answer: Deliberate co-management across primary, secondary and tertiary teams with named owners, one plan and closed loops. Not the same as a one-way referral or transfer of care. [2] [3]

Examiner: Is filing a specialty letter enough? [14]

Strong answer: No. Need return of plan, ownership and follow-through. Electronic filing without closed-loop human ownership is a trap. [2] [14]

Branch 2 — Parent intermediary

Examiner: Mother carries all letters between five clinics. [1]

Branch 3 — Complex care discharge

Examiner: Technology-dependent child, mother only coordinator after ward discharge. [9]

Examiner extras

Primary/secondary/tertiary is capability and role, not prestige.

ADHD shared-care models need structure; do not over-claim universal effect sizes.

CCKO shows complex-care coordination can be trialled; local workforce still matters. [12]

Non-emergency acute care outside the medical home still needs loop closure. [11]

References

[1]Stille, Christopher J Parents as information intermediaries between primary care and specialty physicians Pediatrics, 2007.PMID 18055672
[2]Stille, Christopher J Determinants and impact of generalist-specialist communication about pediatric outpatient referrals Pediatrics, 2006.PMID 17015522
[3]Cooley, W Carl Redefining primary pediatric care for children with special health care needs: the primary care medical home Curr Opin Pediatr, 2004.PMID 15548933
[4]Seth, Rachna Children with Cancer: Shared Care and Transition of Care Indian J Pediatr, 2023.PMID 37368222
[5]Slater, Penelope Fifteen years of shared care for paediatric oncology, haematology and palliative patients across Queensland: The role of Regional Case Managers Aust J Rural Health, 2023.PMID 36577741
[6]Auger, Katherine A Summary of STARNet: Seamless Transitions and (Re)admissions Network Pediatrics, 2015.PMID 25489017
[7]Council on Children with Disabilities Patient- and family-centered care coordination: a framework for integrating care for children and youth across multiple systems Pediatrics, 2014.PMID 24777209
[8]McAllister, Jeanne W Practice-based care coordination: a medical home essential Pediatrics, 2007.PMID 17766512
[9]Kuo, Dennis Z Care Coordination for Children With Medical Complexity: Whose Care Is It, Anyway? Pediatrics, 2018.PMID 29496973
[10]White, Patience H Supporting the Health Care Transition From Adolescence to Adulthood in the Medical Home Pediatrics, 2018.PMID 30348754
[11]Conners, Gregory P Nonemergency Acute Care: When It's Not the Medical Home Pediatrics, 2017.PMID 28557775
[12]Cohen, Eyal Effectiveness of Structured Care Coordination for Children With Medical Complexity: The Complex Care for Kids Ontario (CCKO) Randomized Clinical Trial JAMA Pediatr, 2023.PMID 36939728
[13]Starmer, Amy J Changes in medical errors after implementation of a handoff program N Engl J Med, 2014.PMID 25372088
[14]Stille, Christopher J Building communication between professionals at children's specialty hospitals and the medical home Clin Pediatr (Phila), 2009.PMID 19286621