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Pediatrics. 2018 Mar;141(Suppl 3):S224-S232. doi: 10.1542/peds.2017-1284G.

Care Coordination for Children With Medical Complexity: Whose Care Is It, Anyway?

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Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York;
Department of Pediatrics, School of Medicine, Indiana University, Indianapolis, Indiana.
The New Mexico Disability Story, Albuquerque, New Mexico.
Department of Pediatrics, St. Christopher's Hospital for Children and Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania; and.
Department of Pediatrics, School of Medicine, University of Colorado Denver, Denver, Colorado.


Children with medical complexity (CMC) have multiple chronic conditions and require an array of medical- and community-based providers. Dedicated care coordination is increasingly seen as key to addressing the fragmented care that CMC often encounter. Often conceptually misunderstood, care coordination is a team-driven activity that organizes and drives service integration. In this article, we examine models of care coordination and clarify related terms such as care integration and case management. The location of care coordination resources for CMC may range from direct practice provision to external organizations such as hospitals and accountable care organizations. We discuss the need for infrastructure building, design and implementation leadership, use of care coordination tools and training modules, and appropriate resource allocation under new payment models.

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