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Many families of children with special health care needs piece together their care, often depending on their pediatric subspecialist as their primary source of health care services. As a result, their care is not adequately coordinated or integrated. Further, subspecialists are not optimally using their expertise when they function as a de facto medical home, limiting their ability to care for other children who need their services and increasing the costs of the health care system. This study explores gaps in residency training, knowledge and skills, and proposes a model to explore whether changes in residency training might improve the quality of care for children with complex needs and reduce costs.