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care coordination, care fragmentation, children with medical complexity (CMC), chronic conditions, goal planning, Iowa Model, Triple Aim



  1. Lindstrom, Kathy DNP, APRN, FNP-BC
  2. Cady, Rhonda PhD, RN
  3. Bushaw, Andrea PhD, RN, CPNP


Abstract: NPs piloted a family-centered goal-planning tool with a medically complex pediatric population during outpatient clinic visits. The tool was an effective reminder to discuss goals after trust and rapport are established between provider and family.