Visiting Jack: Mixed methods evaluation of a virtual home visit curriculum with a child with medical complexity

Abstract

Background:

There are limited training opportunities for pediatricians in caring for children with medical complexity (CMC) in the home and community. Prior studies have described a lack of comfort caring for CMC among pediatric residents.

Objective:

1) To evaluate the impact of participation in a virtual home visit curriculum on pediatric residents’ confidence, knowledge, and application of knowledge in complex care; 2) to explore changes in perspectives relating to the care of CMC after participation in the curriculum.

Methods:

This was a prospective pre-post intervention study in 2019 with first-year pediatric residents, using quantitative and qualitative methods. The intervention, co-created with a family partner, was an online video-based curriculum followed by an in-person seminar. Pre- and post-assessments were compared using paired t-tests. Follow-up interviews and focus groups were performed 5–8 weeks after training. Transcripts were analyzed using inductive thematic analysis.

Results:

Twenty-four residents (100%) participated. Residents reported increased confidence in all aspects of complex care presented in the curriculum, with significant increase in knowledge and application of knowledge (all p<0.001). Twelve residents (50%) participated in a follow-up interview or focus group. Four themes were identified: 1) recognizing prior attitudes toward complexity, 2) new mental framework for complex care at home, 3) drivers of behavior change, 4) commitment to change practice.

Conclusions:

Participation in this curriculum was associated with increased confidence, knowledge, and application of knowledge in complex care outside of the hospital. Qualitative findings align with transformative learning theory, lending insight into effective approaches to complex care training.

Introduction

Children with medical complexity (CMC) are a growing population cared for by pediatricians in hospital and community settings. Characterized by medical fragility, functional limitations, and high healthcare utilization,¹ CMC are vulnerable to care fragmentation and medical error. CMC who require technology assistance have an increased risk of readmissions,² and residents have reported feeling ill-equipped to manage medical technology needs.³ Transitions between care settings occur frequently and post-discharge issues are common.⁴ CMC have a high incidence of polypharmacy,⁵ which is a recognized challenge for primary care pediatricians caring for CMC,⁶ and contributes to increased risk of medication errors.⁷

Both residents³ and practicing clinicians⁸ have described a lack of comfort providing comprehensive care for CMC; yet there is limited formal training in the care of CMC in the home and community settings, with most residents’ clinical exposure occurring in the context of acute hospitalizations.^9,10 In prior studies, residents described a lack of comfort identifying community services for children and youth with special healthcare needs,⁹ and challenges responding to psychosocial needs and identifying social supports for families of CMC.³ Identifying community supports to enhance participation has been recognized as an important area of competency for teams caring for CMC.¹¹ The Accreditation Council for Graduate Medical Education expects graduating pediatric residents to ensure families receive coordinated care; generate care plans through shared decision-making; and consider strengths and needs of the family as well as the social, educational, and cultural contexts of care.¹² These competencies are particularly critical in the care of CMC, highlighting a need for educational experiences that foster skills in these areas.

Home visit programs provide valuable learning opportunities in caring for CMC.^13–15 Families of CMC encounter tremendous challenges in caring for their children and managing their detailed treatment plans, including navigating competing demands on caregivers, difficulties with medication administration, support needs, and access issues.¹⁶ Home visits can help residents to recognize and address these challenges;¹³ however, logistical issues make offering this immersive learning experience difficult for many residency programs.¹⁷

Online modules are increasingly used in medical education to meet learner needs in ways that are engaging, accessible, and scaleable.¹⁸ A video-based online curriculum depicting day-to-day life of a CMC could reveal contextual factors that impact care outside of the hospital, while informing changes in clinical practice.

The aims of this study were to: 1) evaluate the impact of participation in a virtual home visit curriculum on pediatric residents’ confidence, knowledge, and application of knowledge in the care of CMC in the home and community; and 2) explore changes in perspectives relating to the care of CMC after participation in the curriculum. We hypothesized that residents would report increased confidence in performing essential care activities for CMC, and participation in the curriculum would be associated with knowledge gain and ability to apply knowledge in complex care. We drew on existing educational theory to situate our findings.

Methods:

Study Design and Participants

We performed a prospective, pre-post intervention study in 2019 with first-year pediatric residents in the Boston Combined Residency Program (BCRP), including Boston Children’s Hospital and Boston Medical Center. In this mixed-methods study with embedded design,¹⁹ quantitative data collection was followed by qualitative interviews to refine our understanding of the curriculum outcomes. BCRP residents are enrolled in quarterly advocacy seminars as a mandatory rotation in their first year. An email was sent to all residents enrolled in their advocacy seminar series from January-June 2019, inviting participation in the study, ensuring anonymity, and informing them of dissemination of results for publication. The study occurred over 2 rotations, for 24 eligible residents. We selected first-year residents as our target learners as we anticipated minimal prior exposure to complex care training. In addition, studies have identified the need for complex care training to occur early in residency, and recommend that certain competencies in complex care be achieved by second-year.^10,20 The Boston Children’s Hospital institutional review board deemed the study exempt.

Curriculum Development

We engaged in a systematic approach to curriculum development²¹ including a targeted needs assessment with members of the Complex Care Service Family Advisory Council and BCRP chief residents to identify educational gaps and inform effective educational strategies. The International Classification of Functioning, Disability and Health served as a guiding framework modified for curriculum development.¹¹ Mapping of educational gaps to learning objectives and curricular content is depicted in Figure 1. In collaboration with a patient/family partner, we developed a 90-minute online curriculum consisting of 9 concept videos and accompanying assessments.²² The curriculum was hosted on OPENPediatrics, an online, open-access educational platform.²³ The curriculum was piloted by 2 third-year residents and revised based on feedback.

Figure 1:

Educational needs mapped to the International Classification of Functioning, Disability and Health framework, learning objectives and video-based curriculum

Residents were given protected time to complete the online training and participate in a 2-hour seminar as part of their advocacy rotation. The seminar included: 1) facilitated reflection on the learning experience; 2) videoconference with the family partner to respond to residents’ questions; and 3) discussion with interprofessional clinicians about community resources for CMC.

Outcomes

Reactions and Confidence

A baseline survey included questions about prior experiences and attitudes in complex care. A post-intervention survey immediately after asked about reactions to the curriculum. Both surveys asked about confidence in addressing key aspects of complex care, using a 5-point Likert scale.

Knowledge and Application

Seven multiple-choice questions and 9 short-answer questions were asked before and after individual videos to assess knowledge and application to case-based scenarios. Topics included home accessibility, medication safety, enteral tube care, noninvasive ventilation, and post-discharge issues. Curriculum contributors (KH, LA, JP) created the questions to align with learning objectives 1–4. Two independent clinical experts reviewed and refined the questions to ensure content validity. Two third-year residents piloted the questions. Curriculum contributors (LA, JP), blinded to pre vs post status, scored short-answer questions using a standard rubric.

Changes in Perspectives and Practice

A study team member contacted residents who agreed to participate in a follow-up telephone interview or focus group. We used both methods for data collection as we anticipated that one-on-one interviews would allow participants to share challenging, personal experiences caring for CMC; whereas focus groups would provide an opportunity for shared exploration of perspectives. Residents participated in a 30–60 minute semi-structured interview via telephone or a focus group 5–8 weeks after the intervention. Participants were asked about key takeaways relating to the care of CMC in the home and community, experiences caring for CMC prior and subsequent to the curriculum, any changes or anticipated changes in approach to clinical care, and barriers to applying what they had learned. The interview and focus group guide was piloted and adapted for clarity (Appendix 1).

Data Analysis

Quantitative

We used descriptive statistics to summarize resident characteristics and reactions. Confidence level and mean overall scores for multiple-choice and short-answer questions pre- and post-intervention were compared using paired t-tests. Data were analyzed with JMP®, Version 14 Pro, SAS Institute Inc.

Qualitative

We used inductive thematic analysis to identify emerging themes from the interview and focus group data.²⁴ Interviews and focus groups were audio-recorded, transcribed, and de-identified. Data collection and analysis occurred iteratively. Two investigators (KH, LA) independently read the first 2 transcripts and generated a preliminary coding dictionary. They discussed how they applied codes to the data and refined definitions. They met with 2 other study team members (DL, LN) to discuss the coding framework and made minor revisions to the interview and focus group guide. KH and LA coded the subsequent transcripts and consolidated codes into themes and subthemes until consensus was achieved. Transcripts were re-analyzed and emerging themes and illustrative quotations were identified. Dedoose was used to facilitate data management (version 8.3.10, SocioCultural Research Consultants LLC, Los Angeles, California).²⁵ Once inductive analysis was complete, the study team reviewed the literature to identify educational theories related to emerging themes in order to develop a conceptual model.

Results:

Twenty-four residents (100%) participated in the study (Table 1). Most residents had no formal training in complex care (88%). They reported more frequent involvement in inpatient (83%) than outpatient (33%) care of CMC.

Table 1:

Resident characteristics (n=24)

	n (%)
Prior formal instruction in complex care
Yes	3 (12)
No	21 (88)
Prior home visit
Yes	11 (46)
No	13 (54)
Personal experience caring for a CMC
Yes	13 (54)
No	11 (46)
Active involvement in the care of CMC
Inpatient
Never	0 (0)
Rarely	0 (0)
Sometimes	4 (17)
Frequently	15 (62)
Very frequently	5 (21)
Outpatient
Never	0 (0)
Rarely	6 (25)
Sometimes	10 (42)
Frequently	8 (33)
Very frequently	0 (0)
Importance of learning about the approach to care of CMC to pediatrics training
Not at all important	0(0)
Slightly important	1(4)
Somewhat important	2(8)
Quite important	12 (50)
Extremely important	9 (38)

Reactions and Confidence

Most residents reported the training experience was very/extremely useful (88%), good/excellent quality (87%), appropriate length (79%), and appropriate level of difficulty (96%).

92% of residents indicated that learning about an approach to complex care at home was very/extremely important to their training as a pediatrician.

Residents reported increased confidence in all aspects of complex care presented in the curriculum (mean increase from 1.79 to 3.1 on 5-point Likert scale, all p<0.001).

Knowledge and Application

There was a significant increase in overall mean scores on multiple-choice questions (40% vs 82%, p<0.001) and short-answer questions (57% vs 73%, p<0.001) after the curriculum.

Changes in Perspectives and Practice

Twelve of 24 (50%) residents agreed to participate in a follow-up interview or focus group. Three interviews and 2 focus groups of 3–6 participants were performed. Residents described the curriculum’s strengths to be its interactivity, connection to the family, practical and relevant advice, and useful frameworks for complex care outside the hospital. Opportunities identified for further training included depicting different social contexts, revisiting concepts later in residency, depicting in-hospital clinical encounters, and developing a best practices checklist.

Four themes emerged across all interviews and focus groups related to the approach to complex care: recognizing prior attitudes toward complexity, new mental framework for complex care at home, drivers of behavior change, and commitment to change practice (Table 2).

Table 2:

Themes, subthemes and illustrative quotations

Subtheme	Illustrative quotation
Theme #1: Recognizing prior attitudes toward complexity
Challenges with holistic care	“[I]t’s easy to think of this as an individual just as a sort of a list of medical conditions, but I think always making sure to remember that it’s a person and interacting is really important so I think there can be some depersonalization that does happen.” (FG2, Resident 2)
Daunting nature of complex care	“I think that I, as a trainee… when faced with complex care patients, it can be very daunting, you know, at first, and I think that’s an inevitable feeling to have because ultimately, it’s like you want to help them to the best of your capabilities, and there’s always that subconscious kind of like, you know, ‘Am I doing the right thing?’, or ‘This is like beyond me.’” (FG1, Resident 3)
Need for time	“I think time is always the biggest barrier. You could very realistically on any given day be taking care of 12 to, depending on the service, 30 patients by yourself. If it’s a weekend day, you more often than not have multiple children with complex care needs, and so—and then you have children who are admitted to the hospital for a variety of reasons, some more acute than others. The ability to take up that mental space and take the time to really go through that I think is really challenging… when you add those layers it’s near impossible sometimes unfortunately.” (FG2, Resident 1)
Theme #2: New mental framework for the care of CMC
Quality of life at home	[S]eeing one child being well was so powerful. We don’t ever see complex care children in the hospital well…Sometimes, you just sense a feeling of hopelessness because it’s just a bad perspective… it gives you a goal to work on or work for, like, “Oh, they do do well.”… That was really heartening, he was like thriving in the home, with a loving family with community involvement, and that was really nice. (FG1, Resident 1)
Context and care coordination	“I think just overall the not really thinking about what it means to be a part of medically complex families, little things like thinking about how machines are going to fit through the door, and do you have enough outlets and those are things that I just don’t think about, and that’s just a lot of extra stress that families have to deal with. Besides, like, of course, actually having a child with complex needs. There’s just a lot that we don’t think about.” (Interview 3)
	“If a family has any burden, or struggle, or additional social factors, you can see how it can make it infinitely harder, and that kind of explains some of the things we see in our patients, like ‘Why won’t they just do these things?’ or ‘Why is it so hard?’ And then you see them at home, and then I go, ‘So this is why it’s so hard’… it was very informative. (FG1, Resident 1)
Implications of actions	I think it provided a lot more perspective… We prescribe all of these medications, but we don’t see what that means for the family when they go home. To give them medication four times a day, we’re casually like it’s fine, but realistically that’s not. It’s a huge pain to deal with and I think it was nice for me at least to see both sides of that. (FG2, Resident 4)
Theme #3: Drivers of behavior change
Empathy	“There’s a degree of thinking at the hospital… I think there could be frustrations with families… who are not adherent to their medication and who don’t know what medications they’re on, whose kids keep on coming back . . . who maybe, because they’re going under severe stress from the circumstances of their life. . . so that video served as a placeholder for me for how life is like. It also helped me – motivated me to empathize with that family. And I think when you go into peoples’ lives, you can do that for them, and that would be true to a family with a different circumstance too.” (FG1, Resident 2)
Seeing the whole person	“I think having the opportunity to see these kids in their elements and with their families kind of grounds you a little bit and it’ll help you realize that behind all of the medicalization, there is- there are people that love them… it makes you see how strong they are. And it just motivates you even more, I think, again, to help bond, to help you face the challenges in a way.” (FG1, Resident 3)
Reflective practice	“[Y]ou to start think like, “Oh, that medication needs to be four times a day,” and then, “This equipment should be used three times a day.” Like making sure to have the routine and the time, like the amount of family members or if they have nursing staff come up to help them do it. And then, if the child develops a new symptom or a disruption, like a power outage, how it has so many repercussions that any slight thing may not make that big of a difference for someone who isn’t as medically complex, like having more adjustments.” (FG2, Resident 3)
Self-teaching	“I think I could also do a better job of just like educating myself about routine care, if it’s a G tube if it’s a tracheostomy, that sort of thing so as to better be able to give families guidance with troubleshooting and who they should go to, that sort of thing.” (Interview 2)
Theme #4: Commitment to change practice
Asking about baseline	“I think it’s been useful for that context and instead of when you meet patients and families in clinic or in the hospital, you only see them in their hospital gown and when they’re actively sick or when they have, you know, active needs. But you don’t necessarily think about what life looks like outside of the hospital for them normally. So I think it’s been really helpful, like in remembering like to ask those questions about what life is like at home normally, and to remind myself this patient doesn’t always look like this, so let’s get some more information about what their baseline is and help them get back to that baseline.” (Interview 2)
Allying with caregivers	Well, I think it equips you to be an ally… hearing what parents’ concerns were, how this has affected their lives, how they integrate the kid socially in the community, how they adapted their home, what their day looks like, what the other things that are going on in their lives that get in the way of that… I think those are things that you can’t get as effectively, even when you’re just talking to a patient who’ve you’ve met multiple times, who you were trying to ally with in the clinical setting…it’s an opportunity to imagine, to have a placeholder(s) for when you ask those questions (FG1, Resident 2)
Checking in with caregivers	I’m trying to do it all the time now, rather than once in a while, is asking the parents how they’re doing…the parents had mentioned when we had the conversation afterwards that their life is so overwhelming and then they come to their kid’s appointments and often that it’s very kid centered…and so trying to ask, remembering to ask the parents every time like, “And how are you coping and are there any resources that I can help connect to you to what, what do you need?” (Interview 1)
Conscientious care	I think now when I’m doing a discharge for one of these, I tend to ask questions I didn’t used to ask…like if we’re adding a piece of equipment or something, like do you feel like this is doable at home maybe? A little bit more of that, but I definitely have started asking about like refills and things that aren’t more pertinent to the hospitalization. (FG2, Resident 6)
	And it seems really onerous and like, “Oh my gosh, I have so much to do today, and I don’t have time to read through all of this paperwork but realizing that if I don’t sign this form, and write down the exact needs of the family…to the best of my knowledge, then they might not get what they need.” And at the end of the day, that’s going to be way more important than anything else I’m able to do in clinic. (Interview 1)

Recognizing prior attitudes toward complexity

Residents described pre-existing feelings and attitudes toward the care of CMC, which were primarily based on inpatient and limited ambulatory care. Prior experiences focused on challenges of complex care. Several residents described difficulty maintaining a holistic view of the patient and family, particularly as they learned to care for CMC in the inpatient setting. One resident noted that “It is really hard to see the patient as a whole person and understand their quality of life and to understand ways they’re involved with their communities or with their families” (FG1, Resident 1).

Several residents described providing care as “overwhelming.” Residents viewed families as experts in their child’s care, and questioned their own role in the care team due to a lack of longitudinal relationship and expertise. Many felt they had insufficient time to explore concerns beyond acute issues, and thus, could not provide the thoughtful care they hoped to offer. They voiced their frustration that pressure to be efficient prevented them from giving families “the time that they deserve” (FG1, Resident 3) and to figure out “what would make their lives easier” (FG1, Resident 2).

New mental framework for complex care at home

Residents described gaining new insights into complex care at home, including patients’ quality of life, context and care coordination, and recognizing implications of their actions. Residents noted the impact of seeing a child’s baseline health status. Seeing a child with complex medical needs who is well at home helped learners to appreciate quality of life for CMC. Residents voiced a new understanding of hospitalizations as “a disruption in their typical schedule” (Interview 1).

After the curriculum, residents described having a new mental framework for life at home for CMC. This view into a family’s life provided context for previously “abstract content” (FG1, Resident 1), including medication administration, accessibility, equipment, and logistical issues. Residents described seeing “everything that goes behind the scenes” (FG2, Resident 1); “things I take for granted” (FG2, Resident 6). Residents expressed a new appreciation of the “moving parts and people involved” (FG2, Resident 5), requiring coordination in the community. They also described new insight into why management plans may not be implemented, and the impact of socioeconomic factors.

Residents noted a new awareness of “downstream effects” (Interview 1) of their actions. They attributed their prior lack of awareness to the fact that most of their interactions with CMC occur during hospitalizations, without having “a mental image of what you’re doing and how important it is” (Resident 1, FG1). Residents expressed that “every little change you make can make a big impact” (FG1, Resident 3). They discussed their role in discharge planning, with new insight that, “any tiny oversight or lack of clarity in putting in a consult or filling out a form” (Interview 1) or “a slight mistake in documentation or difficulties with a medication getting to a pharmacy” (Interview 2) could affect the child’s care at home.

Drivers of behavior change

As a result of insights gained after training, residents described having a deeper sense of empathy for families, more motivation to see the whole person, self-reflection on their approach to care, and interest in further learning about complex care. They reported that having additional context motivated them “even when things feel overwhelming” (Interview 1). The in-depth exposure to the home and subsequent dialogue with the family seemed integral to the behavior change process, with one resident noting the “intimate conversation” with the family was “not something you can forget” (FG1, Resident 3). Many residents reflected upon past interactions with caregivers of CMC and described feeling more compassion—for example, honoring specific requests made by a parent of a hospitalized child, and appreciating that the parent knows what works at home. Residents described a renewed interest in learning about clinical issues in complex care, particularly how to troubleshoot medical technology issues.

Commitment to change practice

Residents described changes in practice after the training, including inquiring about the child’s life at home and their baseline health, assessing caregiver needs, allying with families, and being more conscientious to prevent error. Residents felt they had new approaches to history-taking for CMC, including gathering details on patients’ daily lives when well. Some residents described feeling better equipped to provide relevant anticipatory guidance and develop contingency plans. Residents reported being more intentional about checking in with caregivers as a routine part of clinical care. They indicated their new knowledge enables them to “ally” with families, describing a commitment to “try to partner with them and think ahead with them” (Interview 2), “becoming more patient” (Interview 3), and “to bring more humanity to my interactions with them” (FG1, Resident 2).

Residents described being more thoughtful about management plans and conscientious about their actions, given their new awareness of logistical and safety concerns and potential for error. When adding a new medication or piece of equipment, residents considered whether it is “actually more of a burden than it is helpful” (FG2, Resident 1). They also identified possible safety concerns surrounding transitions in care for CMC. One resident noted that “helping accommodate a safe transition from the inpatient to outpatient setting is something I think I will just be more attentive to, given the module” (Interview 2). Residents described new appreciation for safe discharge planning, and their critical role in ensuring families receive the support they need to care for their child at home.

In the final stage of analysis, findings were compared to existing theories. Themes and subthemes closely aligned with elements of transformative learning theory. We situated these findings in a conceptual framework (Figure 2).

Figure 2:

Framework for qualitative themes and alignment with transformative learning theory

Discussion

In this mixed-methods evaluation of an educational intervention, we found residents gained increased confidence, knowledge, and ability to apply knowledge in the care of CMC. Moreover, we describe fundamental shifts in trainees’ attitudes and approach to caring for CMC. Our findings illuminate effective educational strategies in complex care that may be important for improving the quality of care for this vulnerable patient population.

Residents reported increased confidence in approaching all aspects of complex care addressed in the curriculum, which we interpret as a meaningful and credible change for first-year residents participating in an introductory training in complex care. We also found significant gains in knowledge and its application to case-based questions in important complex care domains, including medication safety, medical technology management, and preventing post-discharge issues. We believe the embedded assessments provide useful information for learners to check their own understanding of key concepts in complex care, as well as for educators to ensure the curriculum was delivered as intended.

Our qualitative analysis revealed fundamental changes in attitudes about the care of CMC in the home and community, a new mental framework, and changes in approach to complex care. Our findings align closely with transformative learning theory. Transformative learning describes the process by which learners’ pre-existing frames of reference evolve after experiencing a “disorienting dilemma,” or an experience that causes prior assumptions to be questioned.²⁶ Through critical reflection and discourse, learners can experience reframing and validation of new perspectives.^26,27 Finally, learners engage in new actions that fulfill a fundamental shift in their understanding.^26,28

Prior literature reveals educational strategies that foster transformative learning, with examples of multimodal curricula in gerontology, implicit bias, and professionalism.^29–31 Our findings offer insights into educational strategies that may foster transformative learning in complex care. Transformative learning can be facilitated by immersion in an unfamiliar context where prior beliefs may be challenged and there is freedom to explore issues outside of the traditional classroom.³² In our curriculum, concept videos provided a visual into a family’s daily activities with CMC, and caregivers offered their perspectives and lived experience via videoconference. These curricular elements may have served as a “disorienting dilemma” for learners who had relatively little exposure to complex care outside of acute hospitalizations. Using an online course to generate a disorienting dilemma has been previously described.²⁹ Critical reflection and discourse is necessary for learners to reconcile cognitive dissonance and processing new ideas through dialogue that result in personal meaning-making.³³ Educational strategies may include self-reflection exercise and large-group discussion, often with a social component to support norming of new ideas.^32,33 In our study, the in-person seminar incorporated structured debriefing that prompted self-reflection and sharing of new perspectives, as well as an opportunity for residents to engage with an interprofessional complex care team to help make sense of, and validate, their new worldview.

Our study provides insight into considerations for instructional design in complex care. We encourage development and implementation of educational interventions in complex care beginning early in residency, with reinforcing just-in-time training prior to clinical encounters to support learner confidence and application of new knowledge in caring for CMC. Other recommendations for complex care education garnered from our experience include: 1) partnering with a patient/family in curriculum development, including informing the needs assessment and incorporating authentic narrative in a case-based approach; 2) using home video to provide expanded views into different contexts; and 3) enabling residents to develop and validate new perspectives by providing opportunities for self-reflection and discussion with interprofessional clinicians and patients/family members. These strategies can illuminate a child’s daily life and participation in school and community services.

Home visit programs for pediatric residents have been shown to generate a greater appreciation of the child’s environment and community resources, and to change perspectives on the care of children with disabilities outside of the hospital.³⁴ Pediatricians who participated in a home visit curriculum led by parents of children with chronic conditions during residency reported a more family-centered approach to care.³⁵ While our findings suggest that a “virtual home visit” model may contribute to similar outcomes, we would advocate for pediatric resident participation in a home visit with a CMC if this opportunity is available. An online curriculum is not intended to replace the authentic experience of engaging in a home visit with a CMC with specific educational and clinical care goals, but this modality may complement the home visit experience by priming learners with key concepts and considerations.

This study has some important limitations. The curriculum highlighted one family; future initiatives should provide an opportunity for residents to encounter families with different psychosocial contexts. Quantitative outcomes were studied in a small sample of learners using assessment questions with limited validity evidence; thus, we would encourage further development of high-quality assessments in complex care. Residents skipped some short-answer questions, so it is unclear whether a missing response indicated lack of knowledge or questionnaire fatigue. Our analysis underestimates knowledge application as missing responses were counted as incorrect. Only 12 residents agreed to participate in a follow-up interview or focus group. While this represents half of all participants, we cannot be certain that their perceptions and experiences are similar to those who did not agree to participate. However, our use of both interviews and focus groups is a strength, as both data collection methods allowed us to explore in-depth perceptions about complex care. Though we examined residents’ perspectives and anticipated practice changes, we did not assess actual changes in practice or the extent to which changes were sustained. We anticipate next steps in evaluating this complex care training will include direct observation of clinical encounters and assessing patient/family experience.

Conclusions

A multimodal curriculum highlighting the care of CMC in the home and community was associated with increased resident confidence, knowledge, and application of knowledge in complex care. Our qualitative findings aligned with transformative learning theory, offering a framework for developing new perspectives in the care of CMC and commitment to change practice. Co-creation of training opportunities in complex care with a family partner supports the goal of empowering future pediatricians to provide thoughtful and informed care for CMC.

What’s New.

Residents had increased confidence, knowledge, and ability to apply knowledge in complex care after participating in a virtual home visit curriculum. Qualitative findings reveal new perspectives and approaches to caring for children with medical complexity outside of the hospital.