Care Coordination for Children With Medical Complexity: Whose Care Is It, Anyway?
Abstract
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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A key component of care coordination for children with complex health care needs is coordination and collaboration between school systems and health and behavioral health care providers.
“A key component of care coordination for children with complex health care needs is coordination and collaboration between school systems and health and behavioral health care providers (Kuo et al., 2018).”
From Adequate Care Coordination is Associated with Reduced Unmet Mental Health Needs for Children (2026) · cites this paper as Kuo et al., 2018
CSHCN, especially those with mental health needs, often receive care from multiple service sectors.
“CSHCN, especially those with mental health needs, also often receive care from multiple service sectors (e.g., public health, schools, health systems) to address their complex health or behavioral health concerns”
From Adequate Care Coordination is Associated with Reduced Unmet Mental Health Needs for Children (2026) · cites this paper as Kuo et al., 2018
Social worker activities such as participating on child and family care teams, ensuring fidelity to family-centered planning, facilitating communication across sectors, and helping to establish and implement multi-stakeholder care plans are essential for effective cross-system collaboration and consistent care planning and implementation.
“All of these activities are essential for effective cross-system collaboration and consistent care planning and implementation (Bruns et al., 2008; Kuo et al., 2018).”
From Adequate Care Coordination is Associated with Reduced Unmet Mental Health Needs for Children (2026) · cites this paper as Kuo et al., 2018
Cites
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A New Definition of Children With Special Health Care Needs
McPherson, M., Arango, P., Fox, H., Lauver, C., McManus, M., Newacheck, P. W., Perrin, J. M., Shonkoff, J. P., & Strickland, B. (1998) · Pediatrics · doi:10.1542/peds.102.1.137 · Cited by 1,487 · see citing works
Structuring payment to medical homes after the Affordable Care Act
Edwards, S. T., Abrams, M. K., Baron, R. J., Berenson, R. A., Rich, E. C., Rosenthal, G. E., Rosenthal, M. B., & Landon, B. E. (2014) · Journal of General Internal Medicine · doi:10.1007/s11606-014-2848-3 · Cited by 46 · see citing works
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SEIPS 3.0: human-centered design of the patient journey for patient safety
Carayon, P., Wooldridge, A., Hoonakker, P., Hundt, A. S., & Kelly, M. M. (2020) · Applied Ergonomics · doi:10.1016/j.apergo.2019.103033 · Cited by 493 · see citing works
Increasing mental health engagement from primary care: The potential role of family navigation
Godoy, L., Hodgkinson, S., Robertson, H. A., Sham, E., Druskin, L., Wambach, C. G., Beers, L. S., & Long, M. (2019) · PEDIATRICS · doi:10.1542/peds.2018-2418 · Cited by 60 · see citing works
Children with Cerebral Palsy and Unmet Need for Care Coordination
Casseus, M., & Cheng, J. (2021) · Journal of Developmental & Behavioral Pediatrics · doi:10.1097/dbp.0000000000000950 · Cited by 16 · see citing works
Adequate Care Coordination is Associated with Reduced Unmet Mental Health Needs for Children
Graaf, G., Gigli, K., Hughes, P., & Thomas, K. C. (2026) · Child and Adolescent Social Work Journal · doi:10.1007/s10560-026-01101-w
- Authors
- Kuo, D. Z., McAllister, J. W., Rossignol, L., Turchi, R. M., & Stille, C. J.
- Affiliations
- University at Buffalo, State University of New York (US)
- Indiana University Indianapolis (US)
- The New Mexico Disability Story, Albuquerque, New Mexico;
- St. Christopher's Hospital for Children (US)
- University of Colorado Denver (US)
- Corresponding author
- Kuo, Dennis Z.
- Venue
- Pediatrics
- Publisher
- American Academy of Pediatrics (AAP)
- Published
- 2018-03-01
- Volume
- 141
- Issue
- Supplement_3
- Pages
- S224-S232
- ISSN
- 0031-4005 (ISSN-L)
- 1098-4275
- OpenAlex
- W2792138892
- Cited by
- 182
- References
- 3
- Citations by year
- 2026: 23 · 2025: 16 · 2024: 22 · 2023: 27 · 2022: 24 · 2021: 27 · 2020: 23 · 2019: 14 · 2018: 6
- FWCI
- 4.09
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- PEDIATRICS (publishedVersion)
- PubMed (publishedVersion)
- IUScholarWorks (Indiana University) (submittedVersion)
- Author eBooks
- Topics
- Health Sciences › Health Professions › Speech and Hearing › Adolescent and Pediatric Healthcare
- Health Sciences › Medicine › Epidemiology › Chronic Disease Management Strategies
- Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Healthcare Policy and Management
- Keywords
- care coordination, children with medical complexity, integrated care, case management, chronic disease, care fragmentation, accountable care organizations, payment models, resource allocation, team-based care
- MeSH terms
- Child Health, Intersectoral Collaboration, Child, Child Health Services, Chronic Disease, Humans, Patient Care Planning
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