Prompt

Station A is discharge planning for a child with medical complexity and fragmented specialty care. Station B is counselling for adolescent transition within the medical home.

Station objectives

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

Paediatrics Fellowship Pro

You have read the opening of this case. The complete unit — every section and its primary-source references — is part of the Paediatrics Fellowship fellowship atlas.

References12Show ledger

[1]Haggerty JL, Reid RJ, Freeman GK, et al. Continuity of care: a multidisciplinary review. BMJ (Clinical research ed.), 2003.PMID 14630762
[2]Sia C, Tonniges TF, Osterhus E, et al. History of the medical home concept. Pediatrics, 2004.PMID 15121914
[3]Homer CJ, Klatka K, Romm D, et al. A review of the evidence for the medical home for children with special health care needs. Pediatrics, 2008.PMID 18829788
[4]Christakis DA, Mell L, Koepsell TD, et al. Association of lower continuity of care with greater risk of emergency department use and hospitalization in children. Pediatrics, 2001.PMID 11230593
[5]McAllister JW, Presler E, Cooley WC Practice-based care coordination: a medical home essential. Pediatrics, 2007.PMID 17766512
[6]Turchi, Renee M Patient- and family-centered care coordination: a framework for integrating care for children and youth across multiple systems. Pediatrics, 2014.PMID 24777209
[7]Kuo DZ, McAllister JW, Rossignol L, et al. Care Coordination for Children With Medical Complexity: Whose Care Is It, Anyway? Pediatrics, 2018.PMID 29496973
[8]White PH, Cooley WC Supporting the Health Care Transition From Adolescence to Adulthood in the Medical Home. Pediatrics, 2018.PMID 30348754
[9]Conners GP, Kressly SJ, Perrin JM, et al. Nonemergency Acute Care: When It's Not the Medical Home. Pediatrics, 2017.PMID 28557775
[10]Szilagyi, Moira A Health Care Issues for Children and Adolescents in Foster Care and Kinship Care. Pediatrics, 2015.PMID 26416941
[11]Cohen E, Quartarone S, Orkin J, et al. Effectiveness of Structured Care Coordination for Children With Medical Complexity: The Complex Care for Kids Ontario (CCKO) Randomized Clinical Trial. JAMA pediatrics, 2023.PMID 36939728
[12]Tschudy MM, Raphael JL, Nehal US, et al. Barriers to Care Coordination and Medical Home Implementation. Pediatrics, 2016.PMID 27507894

Station objectives

Assess continuity domains and medical-home status. [1] [2]

Build a care-coordination plan with closed loops. [5] [6]

Avoid dumping unpaid coordination onto caregivers. [7]

Counsel structured transition steps. [8]

Link non-emergency acute care back to the medical home. [9]

Paediatrics Fellowship Pro

You have read the opening of this case. The complete unit — every section and its primary-source references — is part of the Paediatrics Fellowship fellowship atlas.

References12Show ledger

[1]Haggerty JL, Reid RJ, Freeman GK, et al. Continuity of care: a multidisciplinary review. BMJ (Clinical research ed.), 2003.PMID 14630762
[2]Sia C, Tonniges TF, Osterhus E, et al. History of the medical home concept. Pediatrics, 2004.PMID 15121914
[3]Homer CJ, Klatka K, Romm D, et al. A review of the evidence for the medical home for children with special health care needs. Pediatrics, 2008.PMID 18829788
[4]Christakis DA, Mell L, Koepsell TD, et al. Association of lower continuity of care with greater risk of emergency department use and hospitalization in children. Pediatrics, 2001.PMID 11230593
[5]McAllister JW, Presler E, Cooley WC Practice-based care coordination: a medical home essential. Pediatrics, 2007.PMID 17766512
[6]Turchi, Renee M Patient- and family-centered care coordination: a framework for integrating care for children and youth across multiple systems. Pediatrics, 2014.PMID 24777209
[7]Kuo DZ, McAllister JW, Rossignol L, et al. Care Coordination for Children With Medical Complexity: Whose Care Is It, Anyway? Pediatrics, 2018.PMID 29496973
[8]White PH, Cooley WC Supporting the Health Care Transition From Adolescence to Adulthood in the Medical Home. Pediatrics, 2018.PMID 30348754
[9]Conners GP, Kressly SJ, Perrin JM, et al. Nonemergency Acute Care: When It's Not the Medical Home. Pediatrics, 2017.PMID 28557775
[10]Szilagyi, Moira A Health Care Issues for Children and Adolescents in Foster Care and Kinship Care. Pediatrics, 2015.PMID 26416941
[11]Cohen E, Quartarone S, Orkin J, et al. Effectiveness of Structured Care Coordination for Children With Medical Complexity: The Complex Care for Kids Ontario (CCKO) Randomized Clinical Trial. JAMA pediatrics, 2023.PMID 36939728
[12]Tschudy MM, Raphael JL, Nehal US, et al. Barriers to Care Coordination and Medical Home Implementation. Pediatrics, 2016.PMID 27507894

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

Station objectives

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

Station objectives