Major Health Issues in Nova Scotia: An Environmental Scan

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ongoing care and follow-up, CM can facilitate guideline-concordant
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Coordination of care is an essential function of pediatric primary care,
needed most by children with special health care needs (CSHCN).
Coordination is highly dependent on effective communication within
the health care system and between the health care system and the
larger community. While coordination may best be undertaken at the
level of the physician practice, a team approach involving
nonphysician staff and families as primary participants may be the
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The Chronic Care Model (CCM) is an influential and accepted guide
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the role of chronic care coordination assistance and disease