Learning Health for Pediatric Complex Care Integration (PCCI)

* Inclusion criteria for children and parents/caregivers: * Patients up to 20 years old or under at the time of the monthly data pull or clinical team recommendation (for participation in the PCCI clinical program; no minors under 18 years old will be directly surveyed) * Adult parents/caregivers of participating children (for participation in interviews and quantitative parent-reported surveys) \*For human-centered design interviews, PCCI program participation is not required * Primary care attributed to Duke Pediatrics Primary Care - Roxboro Road clinic * High level of medical complexity: CSHCN (level 2 PMCA) or CMC (level 3 PMCA) * High risk for future healthcare utilization - may be defined by provider/care team determination, EHR data-based risk prediction model (exempt IRB Pro00104983, Developing a Model to Predict Risk for Healthcare Utilization by Children with Chronic Conditions), or any other way in which the clinical team determines a patient is "high risk" as part of their standard practice/care. * Exclusion criteria for children and parents/caregivers: children/parents will be excluded if they meet the below criteria: * Unable to provide informed consent * Non-English or Spanish speaking parent/caregiver or young adult patient * Inclusion criteria for clinical staff and providers (participation in interviews and quantitative staff/provider-reported surveys): * Currently employed by Duke Health * Primary site of work at participating primary c…