The Impact of Telehealth and Care Coordination on the Number and Type of Clinical Visits for Children With Medical Complexity

Holly D. McKissick, BS; Rhonda G. Cady, PhD, RN; Wendy S. Looman, PhD, APRN, PNP; Stanley M. Finkelstein, PhD


J Pediatr Health Care. 2017;31(4):452-458. 

In This Article

Abstract and Introduction


Introduction: The purpose of this analysis was to evaluate the effects of an advanced practice nurse–delivered telehealth intervention on health care use by children with medical complexity (CMC). Because CMC account for a large share of health care use costs, finding effective ways to care for them is an important challenge requiring exploration.

Method: This was a secondary analysis of data from a randomized clinical trial with a control group and two intervention groups. The focus of the analysis was planned and unplanned clinical and therapy visits by CMC over a 30-month data collection period. Nonparametric tests were used to compare visit counts among and within the three groups.

Results: The number of unplanned visits decreased over time across all groups, with the greatest decrease in the video telehealth intervention group. Planned visits were higher in the video telehealth group across all time periods.

Discussion: Advanced practice registered nurse–delivered telehealth care coordination may support a shift from unplanned to planned health care service use among CMC.


Children with medical complexity (CMC) are an important clinical population to study given their high health care use patterns. Common conditions affecting CMC include congenital or acquired multisystem conditions, cancer, or cancer in remission, with ongoing disability in multiple areas and severe neurologic conditions with marked functional impairment (Cohen et al., 2011). Children with certain chronic conditions have been shown to incur medical care costs 2.5 to 20 times higher than children in general in the United States, and in 2009 CMC accounted for $9.2 billion of U.S. hospital charges (Berry, Agrawal, Cohen, & Kuo, 2013; Ireys, Anderson, Shaffer, & Neff, 1997). In fact, 20% of all U.S. children who use medical services have been shown to incur about 80% of all children's health care expenditures (Simon, Berry, Feudtner, & Stone, 2010). CMC tend to have the most intensive health care needs and to be the most medically fragile (Hudson, 2013). Advances in health care have led to an increasing number of CMC surviving longer, so the relative medical complexity of hospitalized pediatric patients has increased over the past 15 years (Burns et al., 2010). Therefore, finding efficient ways to deliver the highest quality care to this high-need population is an important challenge in health care today.

The pediatric health care home model of care is advocated for children and youth with special health care needs, of which CMC are a subset; in this model, each family has an ongoing relationship with a primary health care provider, and care is coordinated using a team-based model (Turchi, et al., 2014). Although there are no current standards for the educational preparation or core functions of the care coordinator in the health care home (McAllister, Presler, & Cooley, 2007; Wise, Huffman, & Brat, 2007), improved outcomes for children have been shown in studies of advanced practice registered nurse (APRN)–delivered care coordination within the health care home (Cady et al., 2015; Looman, et al., 2015; National Association of Pediatric Nurse Practitioners, 2015). The TeleFamilies study examined the effectiveness of an APRN in an established health care home setting coordinating the care of CMC using telehealth technology compared with usual care and telephone triage. The primary goal of this analysis was to determine whether the intervention decreased the number of unplanned clinical visits and whether the availability of video telehealth technology was more effective than telephone-only telehealth technology.