Description/Overview: Emerging models of health care delivery require rigorous research to establish effectiveness. Nursing must define its unique contributions to these models. Integrating care coordination (CC) and telehealth into patient-centered medical / health care homes is a key strategy for improving patient access and outcomes. However, clarification regarding the focus and effectiveness of comprehensive CC, the tools to support it and the required scope of practice are lacking. This presentation discusses matching telehealth and user scope of practice, defining the value-added features of advanced practice nurse (APRN) care coordination and implementing comprehensive data collection strategies to demonstrate outcomes. • Telehealth includes telephone, remote monitoring, online decision support systems / virtual clinics and video. The depth and breadth of the information available with the tool must match the depth and breadth of information needed by the user to provide care. • Care coordination intensity is dependent on the complexity of physical and psychosocial conditions. Children with complex special health care needs (CCSHCN) present challenges to CC due to multiple, complex conditions that do not fit treatment algorithms. These children challenge the scope of practice required for effective CC. The APRNs advanced training and autonomous scope of practice positions this clinician to provide comprehensive CC for CCSHCN within the health care home. • High-quality quantitative and qualitative data lend validity to findings and recommendations. Comprehensive data collection strategies and effort ensure reliable data for analysis. Collecting data from family members caring for CCSHCN requires multi-faceted and labor-intensive collection strategies to yield high rates of return. The exemplar for this presentation is TeleFamilies, a randomized controlled trial (NIH R01NR010883), integrating APRN CC into a pediatric health care home for CCSHCN. Two intervention groups receiving APRN-delivered CC via telephone or telephone supplemented with video telehealth are compared to a control group receiving physician-delivered CC during clinic visits.

Learner Objective #1: The learner will be able to describe the role and value of APRN care coordination for children with complex special health needs

Learner Objective #2: The learner will be able to evaluate effective APRN care coordination that matches technology to work processes and ensures comprehensive data collection