New w Me Mexico xico Pu Public blic Ed Educat ucation ion De - - PowerPoint PPT Presentation

1190 S. St. Francis Drive • Santa Fe, NM 87505 • Phone: 505-827-2613 • Fax: 505-827-2530 • nmhealth.org

New w Me Mexico xico Pu Public blic Ed Educat ucation ion De Depar artme tment nt Schoo hool l He Healt alth h Ed Education ucation In Inst stitut itute November ember 20 2019 19

1190 S. St. Francis Drive • Santa Fe, NM 87505 • Phone: 505-827-2613 • Fax: 505-827-2530 • nmhealth.org

1190 S. St. Francis Drive • Santa Fe, NM 87505 • Phone: 505-827-2613 • Fax: 505-827-2530 • nmhealth.org

Chronic Disease Management and Care Coordination in Schools

Susan n Aco Acosta, a, B. B.S. RN State e Sch choo

• ol Health

lth/St /Stat ate e Sch choo

• ol Nu

Nurse Con

• nsul

ultant tant New ew Mexi xico co Depar artme tment nt of

• f H

Health th Office ce of

• f Sch

choo

• ol and Ad

Adol

• lesc

scent ent Health lth

1190 S. St. Francis Drive • Santa Fe, NM 87505 • Phone: 505-827-2613 • Fax: 505-827-2530 • nmhealth.org

CA CARE RE CO COORD RDIN INATION TION

INDIVIDUAL CASE MANAG AGEMENT

1190 S. St. Francis Drive • Santa Fe, NM 87505 • Phone: 505-827-2613 • Fax: 505-827-2530 • nmhealth.org

WORDS MATTER

1190 S. St. Francis Drive • Santa Fe, NM 87505 • Phone: 505-827-2613 • Fax: 505-827-2530 • nmhealth.org

CDC C definition nition of care coordin dination ation Care coordination is the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient's care to facilitate the appropriate delivery of health care services

www.ahrq.gov/research/findings/evidence-based-reports/caregaptp.html

1190 S. St. Francis Drive • Santa Fe, NM 87505 • Phone: 505-827-2613 • Fax: 505-827-2530 • nmhealth.org

CDC de defin init itio ion of care e coor

• rdi

dinati tion

• n in

in Schoo

• ols

Care coordination in schools involves sch choo

• ol

l nurses es organizing the care of students by sharing information and maintaining communication among those concerned with the needs and care of students with chronic health conditions

1190 S. St. Francis Drive • Santa Fe, NM 87505 • Phone: 505-827-2613 • Fax: 505-827-2530 • nmhealth.org

Resources for Care Coordination

• https://www.cdc.gov/healthyschools/chronic_conditions/pdfs/2017_02_15-How-Schools-

Can-Students-with-CHC_Final_508.pdf

• https://www.cdc.gov/healthyschools/chronic_conditions/pdfs/2017_02_15-CHC-and-

Academic-Achievement_Final_508.pdf

• https://www.cdc.gov/healthyschools/chronic_conditions/pdfs/2017_02_15-FactSheet-

RoleOfSchoolNurses_FINAL_508.pdf

• https://medicalhomeinfo.aap.org/tools-resources/Pages/Care-Coordination.aspx
• https://schoolhealthteams.aap.org/public/content.cfm?m=11&id=11&startRow=1&mm=0

&parentMenuID=0

• https://www.pathlms.com/nasn/courses/11191

CHRONIC CONDITIONS IN SCHOOLS

SHEI 2019

CHRONIC CONDITIONS IN SCHOOLS- 18-19 SY

• 43

43% of students had an identified medical diagnosis (N=138,996).

• Top

4 medical diagnoses were: allergic disorders, asthma, ADD/ADHD, and eye disorders*.

• 920

920 students had a diabetes diagnosis (Type I=708, Type II= 212)

• 6,308

08 students had a mental health diagnosis.

Source: 2018-19 Annual School Health Services Report Data

0.00 20.00 40.00 60.00 80.00 100.00 120.00 140.00 160.00

2014-2015 2015-2016 2016-2017 2017-2018 2018-2019 Rate per 1,000 Students

Top Four Diagnoses by School Year

Allergic disorders Asthma ADD/ADHD Eye disorders

Source: 2018-19 Annual School Health Services Report Data

CHRONIC CONDITIONS IN SCHOOLS

• 23% of all student visits were for care of chronic

conditions during the 18-19 school year.

• Asthma and diabetes care accounted for 55% of all

medically complex procedures.

• Top 3 prescription medications prescribed for

students were asthma medications (42%), %), epinephrine (14%), %), and allergy medication (12%). %).

Source: 2018-19 Annual School Health Services Report Data

Prescription Medications

Asthma medication (41.5%) Epinephrine (13.6%) Allergy medication (12.4%) ADD/ADHD (10.7%) Diabetes (6.2%)* Other (5.9%)** Analgesics (4.7%) Antibiotics (2.0%) Mental health (1.8%)*** Cardiovascular (0.1%)

* Diabetes includes insulin, glucagon, and oral diabetes medications. ** Other includes migraine includes medications, digestive aids and anticonvulsants. *** Mental health includes antidepressants and psychotropics.

Source: 2018-19 Annual School Health Services Report Data

LEGISLATIVE UPDATES

SHEI 2019

MEDICAL CANNABIS IN SCHOOLS

• New Mexico joins Colorado, Delaware, Florida, Illinois, Maine,

New Jersey, Pennsylvania, Washington and California (California’s law effective 1/1/2020) in having passed legislation allowing medical cannabis in the school setting.

• There are variances in how each of these states has

implemented their laws and rules regarding medical cannabis in schools.

MEDICAL CANNABIS: POLICIES & PROCEDURES

Must allow the administration of medical cannabis, in accordance with the qualified student’s required treatment plan, by primary caregivers and/or designated school personnel. Must address the requirement that the administration

• f medical cannabis not disrupt the education

environment and not cause medical cannabis exposure to other students

• Schools may wish to designate a specific location for the safe administration of

medical cannabis

MEDICAL CANNABIS: POLICIES & PROCEDURES

Established by local school boards or governing bodies and shall establish the responsibilities of the qualified student’s primary caregiver in order for a qualified student to be administered medical cannabis in the school setting.

• These responsibilities include providing:

A copy of the qualified student’s written certification signed by a certifying practitioner A copy of the patient’s New Mexico Department of Health’s (NMDOH) issued ID card, which includes the name of the primary caregiver A written treatment plan including dosage allotment and frequency

MEDICAL CANNABIS IN SCHOOLS

• Medical cannabis in schools may only be in the form
• f a capsule, extract, or concentrate that may be safely

divided into measurable doses and ingested through the mouth.

• Individuals authorized to possess, store and

administer medical cannabis to a qualified student may be primary caregivers (parents/legal guardians) and/or designated school personnel, excluding school nurses under current law.

MEDICAL CANNABIS: POLICIES & PROCEDURES

The NMPED Safe and Healthy Schools Bureau website regularly updates training opportunities and other resources related to medical cannabis in the school setting.

• Resources include:
• Final Rule (6.12.10)
• Medical Cannabis Policy Framework
• Guidance for School Nurses Regarding Medical Cannabis
• Sample Medical Cannabis Treatment Plan
• HIPAA Authorization Form

https://webnew.ped.state.nm.us/bureaus/safe-healthy-schools/medical-cannabis-in-schools/

STUDENT DIABETES MANAGEMENT ACT

Rule Hearing for NMAC 6.12.11 held on October 25, 2019 Goal date for adoption: November 12, 2019 Requires annual comprehensive diabetes training for all school nurses and diabetes care personnel. A minimum of two school employees must be trained at each school attended by a student with diabetes. At least one diabetes care personnel must be available at the school in which a student with diabetes is attending. Requires annual training of staff with supervisory role during the school day, including bus drivers, in relation to recognition of symptoms and emergency response. End of year reporting to the NMPED is required by October 15 each year starting 2020.

1190 S. St. Francis Drive • Santa Fe, NM 87505 • Phone: 505-827-2613 • Fax: 505-827-2530 • nmhealth.org

Care Coordination in Schools for Students with Chronic Diseases

Presented by NM School Health Advocates: Leslie Berry, BSN, RN Jennifer Downey, MPH, BSN, RN Marisa Pisana, BSN, RN Lynn Wheeler, MSN, RN, NCSN

1190 S. St. Francis Drive • Santa Fe, NM 87505 • Phone: 505-827-2613 • Fax: 505-827-2530 • nmhealth.org

1190 S. St. Francis Drive • Santa Fe, NM 87505 • Phone: 505-827-2613 • Fax: 505-827-2530 • nmhealth.org

Case Study

Considering your role in the school, how would you manage the following?

1190 S. St. Francis Drive • Santa Fe, NM 87505 • Phone: 505-827-2613 • Fax: 505-827-2530 • nmhealth.org

Background

It is mid-October and a 5th grade student is enrolling in your school. His mother is in the office registering her son and tells the registrar he was recently diagnosed with type 1 diabetes.

1190 S. St. Francis Drive • Santa Fe, NM 87505 • Phone: 505-827-2613 • Fax: 505-827-2530 • nmhealth.org

Background

A.J. knows how to do his finger-sticks to check his blood sugar. But he does not understand how to calculate his carbohydrates and insulin. He is on a sliding-scale for insulin and uses syringes. He is afraid to give himself the injections. A.J.’s parents are not very involved in his care. He is the first student with diabetes in your school since the new law has passed.

1190 S. St. Francis Drive • Santa Fe, NM 87505 • Phone: 505-827-2613 • Fax: 505-827-2530 • nmhealth.org

Questions?

• What else do you want to know?
• What are your concerns and why?
• What do you want to do first?

1190 S. St. Francis Drive • Santa Fe, NM 87505 • Phone: 505-827-2613 • Fax: 505-827-2530 • nmhealth.org

Initial Plan

• Make a plan for when child is safe to start school
• Identify two staff members to be “diabetes care

personnel”

1190 S. St. Francis Drive • Santa Fe, NM 87505 • Phone: 505-827-2613 • Fax: 505-827-2530 • nmhealth.org

Initial Plan Continued

• Seek diabetes educator from community to train:
• All staff and bus driver on hypoglycemia,

hyperglycemia, and what do to for emergencies

• After school program personnel
• Student’s teacher, PE teacher, and elective teachers

with advanced diabetes training/plan of care

• The diabetes care personnel with in-depth training

including insulin administration by syringe, carbohydrate calculations, and emergency glucagon administration.

1190 S. St. Francis Drive • Santa Fe, NM 87505 • Phone: 505-827-2613 • Fax: 505-827-2530 • nmhealth.org

Initial Plan Continued

• Coordinate diabetes care personnel for AM bus

and after school program

• Notify cafeteria/get carb count
• Need supplies/snacks from parents
• Need written evacuation/lockdown plan
• Need written Individualized Health Care Plan

1190 S. St. Francis Drive • Santa Fe, NM 87505 • Phone: 505-827-2613 • Fax: 505-827-2530 • nmhealth.org

A.J. Starts School

• The community diabetes educator provided

all staff training and wrote the IHP.

• Your school secretary and principal

volunteered as the diabetes care personnel and are providing coverage on the bus, afterschool activities, and during the school day.

• You still do not have juice and snacks

1190 S. St. Francis Drive • Santa Fe, NM 87505 • Phone: 505-827-2613 • Fax: 505-827-2530 • nmhealth.org

Field Trip

A.J.’s class is going to the pumpkin patch. It is an all day trip. The parent cannot go but the teacher said she “can handle it”.

1190 S. St. Francis Drive • Santa Fe, NM 87505 • Phone: 505-827-2613 • Fax: 505-827-2530 • nmhealth.org

Field Trip

What else do you want to know? What concerns you and why? What is your plan?

1190 S. St. Francis Drive • Santa Fe, NM 87505 • Phone: 505-827-2613 • Fax: 505-827-2530 • nmhealth.org

Field Trip Plan

• Need to bring all supplies:

Juice/snacks/glucagon/insulin/glucometer

• Cell phone available at all times
• Bringing lunch: need to take carb count list
• Take Medical Management Plan and emergency

contact phone numbers

• One of your diabetes care personnel has agreed

to go

1190 S. St. Francis Drive • Santa Fe, NM 87505 • Phone: 505-827-2613 • Fax: 505-827-2530 • nmhealth.org

A few months later…

• A.J. tells his parents that he doesn’t like going to

the office every day before lunch to check his blood sugar and administer his insulin.

• He says he is always at the back of the line in the

cafeteria and has to hurry to eat.

• Because of this, he misses some of his recess

time.

1190 S. St. Francis Drive • Santa Fe, NM 87505 • Phone: 505-827-2613 • Fax: 505-827-2530 • nmhealth.org

A few months later…

• He has learned to give his own insulin and has

asked his parents if he can begin to manage his diabetes at school without the care personnel and they agree.

• A.J. also reports to his parents that his

classmates are picking on him because he is always late to lunch.

1190 S. St. Francis Drive • Santa Fe, NM 87505 • Phone: 505-827-2613 • Fax: 505-827-2530 • nmhealth.org

Questions?

• What else do you want to know?
• What concerns you and why?
• What is your plan?

1190 S. St. Francis Drive • Santa Fe, NM 87505 • Phone: 505-827-2613 • Fax: 505-827-2530 • nmhealth.org

Plan for self-management

• Amend Medical Management Plan
• Parent written authorization/release of liability
• Student evaluation by diabetes community

educator

• Community educator updates IHP

1190 S. St. Francis Drive • Santa Fe, NM 87505 • Phone: 505-827-2613 • Fax: 505-827-2530 • nmhealth.org

Plan for self-management cont.

• Bring in school mental health professionals
• Back-up medications and supplies in school
• Update bus driver, all student’s teachers, after

school program personnel, diabetes care personnel of change in plan

• Ensure student has access to carb counts

1190 S. St. Francis Drive • Santa Fe, NM 87505 • Phone: 505-827-2613 • Fax: 505-827-2530 • nmhealth.org

Two weeks later…

• A.J.’s parents call the school and inform the

principal that he was admitted to the hospital

• ver the weekend.
• You learn from his parents that he was not

checking his blood sugar or administering insulin at school or at home. They feel very guilty that they assumed he was managing it without their

• versight.

1190 S. St. Francis Drive • Santa Fe, NM 87505 • Phone: 505-827-2613 • Fax: 505-827-2530 • nmhealth.org

Two weeks later continued…

• They report the reason he was not caring for

himself was because he “feels different” from his peers because of his diagnosis of diabetes.

• He also stated that he didn’t want diabetes

anymore, so he just wanted to ignore it.

• He is going to be in the hospital for at least 5

school days.

1190 S. St. Francis Drive • Santa Fe, NM 87505 • Phone: 505-827-2613 • Fax: 505-827-2530 • nmhealth.org

Questions?

• What else do you want to know?
• What are your concerns and why?
• What is your plan?

1190 S. St. Francis Drive • Santa Fe, NM 87505 • Phone: 505-827-2613 • Fax: 505-827-2530 • nmhealth.org

Plan

• Get updated Medical Management plan from the Dr.
• Work with community diabetes educator to refresh staff

training

• Re-address 504 with parents; they agree
• Accommodations: leave for lunch 10 minutes early
• Counselor visit with student- consider anti bullying presentation
• Update all pertinent staff
• Develop plan for missed school work

1190 S. St. Francis Drive • Santa Fe, NM 87505 • Phone: 505-827-2613 • Fax: 505-827-2530 • nmhealth.org

Congratulations!

• A.J. has successfully returned to school after his

hospitalization

• He is thriving by meeting with the counselor and

his new 504 accommodations

• His diabetes is well controlled
• His parents are happy with how the school has

managed his care

1190 S. St. Francis Drive • Santa Fe, NM 87505 • Phone: 505-827-2613 • Fax: 505-827-2530 • nmhealth.org

Reflection

• How does this scenario make you think

differently?

• What did you learn that you could apply to your

role at the school?

• What is the importance of teamwork in this

scenario?

1190 S. St. Francis Drive • Santa Fe, NM 87505 • Phone: 505-827-2613 • Fax: 505-827-2530 • nmhealth.org

Now a school nurse has been hired

How is this scenario different with a school nurse?

1190 S. St. Francis Drive • Santa Fe, NM 87505 • Phone: 505-827-2613 • Fax: 505-827-2530 • nmhealth.org

This is what your school nurse would have done at time of registration:

• Reviewed Medical Management Plan
• Contacted parent and requested supplies
• Written Individual Health Plan for student
• Worked with parents to get needed supplies

1190 S. St. Francis Drive • Santa Fe, NM 87505 • Phone: 505-827-2613 • Fax: 505-827-2530 • nmhealth.org

Registration Continued:

• Provided training to all staff, bus driver, after

school program personnel and one other diabetes care person

• Written evacuation plan/lockdown plan
• Worked with cafeteria to obtain nutritional

guidelines for meals

1190 S. St. Francis Drive • Santa Fe, NM 87505 • Phone: 505-827-2613 • Fax: 505-827-2530 • nmhealth.org

This is what your school nurse would have done daily:

• Supervised student’s blood sugar checks
• Calculated carbohydrates
• Drawn up insulin in syringe
• Administered insulin to student
• Documented his care

1190 S. St. Francis Drive • Santa Fe, NM 87505 • Phone: 505-827-2613 • Fax: 505-827-2530 • nmhealth.org

This is what your school nurse would have done daily:

• Managed low and high blood sugars
• Handled any emergencies
• Developed therapeutic relationship with student
• Educated parents on student's care
• Worked for physician for any insulin adjustments
• Educated student on how to administer injections

1190 S. St. Francis Drive • Santa Fe, NM 87505 • Phone: 505-827-2613 • Fax: 505-827-2530 • nmhealth.org

This is what your school nurse would have done for self-managed care:

• Worked with physician to get amended orders for

self-management

• Would have evaluated student for self-

administration

• Would have ensured parents signed release of

liability for self-management

• Updated all staff with changes

1190 S. St. Francis Drive • Santa Fe, NM 87505 • Phone: 505-827-2613 • Fax: 505-827-2530 • nmhealth.org

Self-managed care continued:

• Continued to monitor health status of student
• Would have ensured that back up supplies were

located in health office

• Amended the IHP
• Collaborated with school social worker/counselor

regarding mental health concerns

• Ensured student had access to nutritional

information for meals

1190 S. St. Francis Drive • Santa Fe, NM 87505 • Phone: 505-827-2613 • Fax: 505-827-2530 • nmhealth.org

This is what your school nurse would have done after discharge:

• Worked with counselor and administration to get

504 plan in place and recommend appropriate accommodations

• Provide integrated care with the school counselor
• r mental health professional to address his

mental health and psycho-social concerns

1190 S. St. Francis Drive • Santa Fe, NM 87505 • Phone: 505-827-2613 • Fax: 505-827-2530 • nmhealth.org

This is what the school nurse would have done after discharge:

• Worked with the physician to get updated orders
• Communicated to all staff the change in the

students care plan

• Provided refresher training to school staff for

diabetes care

• Amend the IHP (3rd time)

1190 S. St. Francis Drive • Santa Fe, NM 87505 • Phone: 505-827-2613 • Fax: 505-827-2530 • nmhealth.org

Benefits of a school nurse

• School nurses caring for children with diabetes is

related to better blood glucose control and management

• School nurses positively affect academic success

and well-being of students with diabetes

• In teens, school nurse case management

improves quality of life, particularly the ability to communicate with health professionals

The Case for School Nursing (2012). National Association of School Nurses [White Paper]. Retrieved from https://higherlogicdownload.s3.amazonaws.com/NASN/3870c72d-fff9-4ed7-833f- 215de278d256/UploadedImages/PDFs/Advocacy/advocacy_The_Case_for_School_Nursing.pdf

1190 S. St. Francis Drive • Santa Fe, NM 87505 • Phone: 505-827-2613 • Fax: 505-827-2530 • nmhealth.org

In Conclusion

• Care Coordination for students with a chronic

medical condition is a complex task

• It requires ongoing communication and

evaluation of the process

• The school nurse has the education, professional

licensure, and experience to care for students with chronic conditions

• It involves a team approach by school personnel
• Promotes student safety, health, and well-being