10/5/2018
MANAGING MEDICALLY COMPLEX STUDENTS AT SCHOOL
MaryAnn Strawhacker MPH, BSN, RN Special Education Nurse Consultant Heartland AEA 1
Course Objectives ◦15. Examine the state and federal laws that insure school safety, confidentiality, and accessibility for students with complex medical needs
◦16. Discuss the roles and responsibilities of the school nurse when a 1:1 agency nurse accompanies a student to school
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Common Terms
◦Medically fragile refers to children whose complex medical conditions require professional nursing monitoring and supervision on a 24-hour basis to prevent life-threatening complications, prevent deterioration of health status, and/or maintain health status. Such children may or may not be dependent on technology assistive devices.
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Technology Dependent
◦ Children considered technology-dependent have chronic respiratory insufficiency or failure and require specialized medical equipment to support their lives.
◦ Common conditions to require this care include: ◦ Neuromuscular disease ◦ Conditions as a result of extreme premature birth ◦ Congenital abnormalities of the lungs or airways ◦ Complications from serious illness, injury, or surgery
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Medically Complex
◦Medical condition(s) that lasts for >12 months and involves several different organ systems or 1 organ system requiring a high level of specialty care and hospitalization. ◦ Examples include brain and spinal cord malformations, metabolic disorders, cardiac and respiratory malformations, and
malignancies 5
Special Health Services
“Services for eligible individuals whose health status requires interpretation or intervention, administration of health procedures and health care, or use of a health device to compensate for the reduction or loss of a body function”
Department of Education
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Review of Rules
Board Policy
AEA Chapter 14 Manual
State Rules of SPED Nurse Practice Education Law
Special Education FERPA Section 504
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Early Access to IEP
◦ If the team determines that an evaluation is needed for special education services, consent is signed, and medical records are shared from the AEA ◦Once parental consent is obtained, the team has 60 days to evaluate. Eligibility must be determined prior to the child’s 3rd birthday
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Apply the Nursing Process
◦Assessment ◦Nursing Diagnosis ◦Planning ◦Outcome Identification ◦Implementation ◦Evaluation
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Purpose of Assessment ◦To determine child’s health status ◦To determine response to medical and nursing therapy ◦To determine strengths and limitations ◦To identify actual or potential need for accommodations at school ◦To collect educationally relevant data
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Health Evaluation
◦ Seven different domains including health ◦ Must determine what services the student needs while transported and during school ◦ Reflect these needs in the Education Evaluation Report paperwork.
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First Visit at School
◦ Interview parents for Hx ◦ Get signed releases to obtain medical records from ◦ Primary care provider ◦ Specialists relevant to school care ◦ Home nursing agency
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When is a nurse needed?
◦ Need for immediate complex intervention • Tracheal suctioning • Trach changes • Maintenance of ventilator ◦ Need for nursing judgement more frequently or more quickly that the school nurse can respond
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LPN vs. RN
◦Iowa Administrative Code 655, Chapter 6, Section 6.2(5)" c", which states that, "Activities and functions which are beyond the scope of practice of the licensed practical nurse may not be delegated to unlicensed assistive personnel.
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According to the IBON an LPN may:
◦ May insert NG tubes and feeding tubes ◦ May receive telephone, verbal and which do not require guide wires for written physician orders and process the insertion. same according to institution policy. ◦ May reinsert a gastrostomy tube in an ◦ May perform glucometer readings. established tract. ◦ May irrigate and remove a suprapubic ◦ May participate in the nursing process, catheter and reinsert a suprapubic consistent with accepted and prevailing catheter in a well-established tract. practice. The RN is responsible for the initial ◦ May irrigate a urethral catheter assessment. ◦ May perform a patient history. ◦ May monitor clients receiving mechanical ventilation with assessments verified by RN ◦ May monitor the patient receiving total parenteral nutrition. ◦ May perform tracheal suctioning. (List is not complete.)
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655—6.5 (152) Additional acts which may be performed by licensed practical nurses.
◦6.6(2) The licensed practical nurse shall be permitted to provide supportive and restorative care to a specific student in the school setting in accordance with the student’s health plan when under the supervision of and as delegated by the registered nurse employed by the school district.
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Nursing Supervision
655—6.2 (152) 281—14.2(256) IAC Nursing Chapter 6 IAC Education
d. Supervising, among other things, includes “Supervision” is the assessment, delegation, any or all of the following: monitoring, and frequency of evaluation and documentation of special health services by ◦ (1) Direct observation of a function or licensed health personnel. Levels of activity. supervision include situations in which: ◦ (2) Assumption of overall responsibility for 1. Licensed health personnel are physically assessing, planning, implementing, and ◦ present. evaluating nursing care. ◦ 2. Licensed health personnel are available ◦ (3) Delegation of nursing tasks while retaining accountability. at the same site. ◦ 3. Licensed health personnel are available ◦ (4) Determination that nursing care being on call. provided is adequate and delivered appropriately
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IAC 655—6.2(5) Accountability a) Performing or supervising those activities and functions which require the knowledge and skill level currently ascribed to the registered nurse and seeking assistance when activities and functions are beyond the licensee’s scope of preparation. b) Assigning and supervising persons performing those activities and functions which do not require the knowledge and skill level currently ascribed to the registered nurse. c) Using professional judgment in assigning and delegating activities and functions to unlicensed assistive personnel.
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Agency Nurses
◦ If a nurse is needed at home it does not automatically mean a nurse is needed at school
◦ Must evaluate care needs at school
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8/17/18 DHS Memo “While the IEP might order nursing services, the school is not obligated to use the private duty nursing agency that provides services in the student’s home before and/or after school. In addition, an IEP might require health paraprofessional services supervised by the school nurse if private duty nursing services are not medically necessary. If rejected by the IEP team, the private duty nursing agency cannot fail to provide services at the other authorized times of day.” 21
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Role of the PCP with IEP
◦ Under 34 CFR §300.304(b)(1), in conducting the evaluation, the public agency must use a variety of assessment tools and strategies to gather relevant functional, developmental, and academic information about the child that may assist in determining whether the child is a child with a disability and the educational needs of the child. That information could include information from a physician, if determined appropriate, to assess the effect of the child’s medical condition on the child’s eligibility and educational needs
◦ Under 34 CFR §300.304(b)(2), no single measure or assessment may be used as the sole criterion for determining whether the child is a child with a disability and for determining an appropriate educational program for the child 22
IAC Chapter 14.2(2) b.
b. Prior to the provision of special health services, the following shall be on file: (1) A written statement by the prescriber detailing the specific method and schedule of the special health service, when indicated. (2) A written statement by the individual’s parent requesting the provision of the special health service. (3) A written report of the preplanning staffing or meeting of the education team. (4) A written individual health plan available in the health record and integrated into the IEP or 504 plan, if applicable.
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IAC Chapter 14.2(2) c.
◦c. Licensed health personnel, in collaboration with the education team, shall determine the special health services to be provided and the qualifications of the individuals performing the special health services.
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Writing the Draft IEP
◦Nursing Diagnosis ◦Planning ◦Outcome Identification
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IAC Chapter 14.2(2) b. b. Prior to the provision of special health services, the following shall be on file: (1) A written statement by the prescriber detailing the specific method and schedule of the special health service, when indicated. (2) A written statement by the individual’s parent requesting the provision of the special health service. (3) A written report of the preplanning staffing or meeting of the education team. (4) A written individual health plan available in the health record and integrated into the IEP or 504 plan, if applicable.
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Services Page F 1:1 LPN
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Services Page F 1:1 LPN
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Writing SN Health Services
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Page F Activities
◦ Alternate emergency evacuation plan ◦ Training for teacher and any associate needed ◦ Accommodations based on health needs ◦ Interagency linkages
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Alternate Emergency Evacuation Plan
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Support for School Personnel
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Accommodation
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Interagency Linkages
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Nursing Treatment Plan vs IHP
IHP Agency Treatment Plan Author School nurse Agency driven/ PCP signed Driving Focus Nursing process Medical orders Outcomes Student focus moves to a Focus on keeping out of the higher level of health status hospital or maintaining or to maintain health Purpose Reimbursement, details Reimbursement, details health services required and actual and potential health training for staff services | Updates At least yearly and for Based on prior authorization changes in health status time, varies with company delivering privatized care
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Nurse Roles: Depends on Contract Agency Nurse School Nurse ◦ Writes the health evaluation ◦ Provide direct care to the child ◦ Writes the IHP ( if LPN) ◦ Collaborate with the school ◦ Writes the emergency plan and nurse trains agency nurse and staff in its ◦ May assist child in classroom use depending on payment ◦ Writes the emergency evacuation ◦ Implement the child’s IHP and EP plan and trains agency nurse and ◦ Follow all district policies and staff in its use procedures ◦ May provide on site assistance or supervision 41
Rational for Writing an IHP ◦Communicates/documents what nurses and others do to provide health services for individual students
◦Details systematic nursing process ◦Documents student health needs ◦Potential documentation for reimbursement of nursing services
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Planning for Emergencies
◦Emergencies may result from: ◦ Changes in medical condition ◦ Accidents or injuries ◦ Equipment malfunction ◦ Staff or student error ◦ Disaster situations
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Planning for Emergencies ◦Coordinate with all care providers ◦ Ask for written orders where applicable ◦ Send a written copy of the IHP and emergency plan to the physician for review (optional)
◦Coordinate with local EMS system ◦ Obtain a current emergency form and have on file with EMS personnel and at school ◦ Plan for emergency response (drills) ◦ Know what you get when you call 911
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Emergency Health Plan
◦Required for students with a condition that has potential to develop predictable signs/symptoms that may lead to a life- threatening situation
◦Emergency plan may be separate from or incorporated into the intervention section of the IHP.
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Planning for School Emergencies ◦ Review all building evacuation plans and lock down in light of a student’s disability
◦ Adjust plan to accommodate individual needs
◦ Identify potential environmental hazards
◦ Seek team and administrative input
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What to do when student is well but 1:1 nurse is ill? ◦ IF agency, they should replace ◦ IF private, hire need back up ◦ Can call a sub for school nurse (SN) and SN becomes 1:1 ◦ May allow parent to sub
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IHP Evaluation ◦ Measures student response to intervention and progress toward identified student goals
◦ Use collected data to determine what IHP revisions are needed
◦ IHP should be reviewed at least annually or whenever the student’s health status changes
◦ Collaborate with the team to update the IHP as needed
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Questions?
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