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]