Implementation of a Diabetic Resource School Nurse for Marion County, FL Public Schools

State: FL Type: Model Practice Year: 2011

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"Our target population is all of the diabetic students attending public schools in Marion County, Florida. The number fluctuates from 105 to 110 students. We reached 100% of them. The public health issue addressed is effective medical management of Type 1 and Type 2 diabetes in school-aged children, at school and school-related events.

Our goal is to identify and meet the complex medical needs of diabetic students attending public school in Marion County, Florida; and prepare to meet the needs of greater numbers, as the diabetic population increases. Objective #1. Create, implement, and maintain a position entitled “Diabetic Resource School Nurse” to centralize medical management for diabetic public school children. The School Health program at the Marion County Health Department provides health services to over 42,000 public school students. Although diabetic students represent a small percent of the total, medical management is complex. The number of diabetic students requiring medical management is increasing. Over the last 20-30 years, diabetes in American children has increased by 40%. Providing safe care at school presents difficult challenges to school nurses and non-medical school personnel. The Marion County Health Department created a specialized Diabetic Resource School Nurse position to address diabetic issues. The position provides a greater degree of safety for students by improving medical management.

Anticipated accomplishments were: 1.Improved medical management of diabetic students, including improved glucose monitoring and/or insulin coverage; 2.Improved training of non-professional school staff, enabling them to better serve diabetic students; 3.Improved confidence level of parents in the school’s diabetic services; 4.To provide assistance to newly diagnosed students and families, to help them navigate the complex world of diabetes management; 5.Increased level of participation by diabetic students in their own care; 6.Improved communication between medical providers and school staff; 7.Reduction of medical errors.

Our practice was implemented in November 2008.Steps taken to implement our practice: 1) Recognized the need for better diabetic medical management for students. 2) Discussed solutions for improvement and chose to implement the Diabetic Resource School Nurse position. 3) Marketed a proposal to the School District, which included a request for funding. 4) Obtained approval for the 2008-2009 school year. 5) Recruited and hired the best person for the job. 6) Activated the position in November of 2008.

After position activation, we took additional implementation steps: A) Improved diabetic training of school staff, by making it shorter, more interesting, and providing for one-on-one training where appropriate. B) Reviewed insulin logs with greater frequency and accuracy. C) Channeled diabetic-related communication from school personnel to one “point person,” the Diabetic Resource School Nurse. D) Established communication between school personnel, the Diabetic Resource School Nurse, University of Florida Pediatric Endocrine and other providers. E) Improved communication between all entities involved in diabetic management. 

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Marion County Health Department
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Implementation of a Diabetic Resource School Nurse for Marion County, FL Public Schools
"Our target population is all of the diabetic students attending public schools in Marion County, Florida. The number fluctuates from 105 to 110 students. We reached 100% of them. The public health issue addressed is effective medical management of Type 1 and Type 2 diabetes in school-aged children, at school and school-related events. Our goal is to identify and meet the complex medical needs of diabetic students attending public school in Marion County, Florida; and prepare to meet the needs of greater numbers, as the diabetic population increases. Objective #1. Create, implement, and maintain a position entitled “Diabetic Resource School Nurse” to centralize medical management for diabetic public school children. The School Health program at the Marion County Health Department provides health services to over 42,000 public school students. Although diabetic students represent a small percent of the total, medical management is complex. The number of diabetic students requiring medical management is increasing. Over the last 20-30 years, diabetes in American children has increased by 40%. Providing safe care at school presents difficult challenges to school nurses and non-medical school personnel. The Marion County Health Department created a specialized Diabetic Resource School Nurse position to address diabetic issues. The position provides a greater degree of safety for students by improving medical management. Anticipated accomplishments were: 1.Improved medical management of diabetic students, including improved glucose monitoring and/or insulin coverage; 2.Improved training of non-professional school staff, enabling them to better serve diabetic students; 3.Improved confidence level of parents in the school’s diabetic services; 4.To provide assistance to newly diagnosed students and families, to help them navigate the complex world of diabetes management; 5.Increased level of participation by diabetic students in their own care; 6.Improved communication between medical providers and school staff; 7.Reduction of medical errors. Our practice was implemented in November 2008.Steps taken to implement our practice: 1) Recognized the need for better diabetic medical management for students. 2) Discussed solutions for improvement and chose to implement the Diabetic Resource School Nurse position. 3) Marketed a proposal to the School District, which included a request for funding. 4) Obtained approval for the 2008-2009 school year. 5) Recruited and hired the best person for the job. 6) Activated the position in November of 2008. After position activation, we took additional implementation steps: A) Improved diabetic training of school staff, by making it shorter, more interesting, and providing for one-on-one training where appropriate. B) Reviewed insulin logs with greater frequency and accuracy. C) Channeled diabetic-related communication from school personnel to one “point person,” the Diabetic Resource School Nurse. D) Established communication between school personnel, the Diabetic Resource School Nurse, University of Florida Pediatric Endocrine and other providers. E) Improved communication between all entities involved in diabetic management. 
This practice addresses the management of Type 1 and Type 2 diabetes in public school children. Over the last 20-30 years, diabetes in American children has increased by 40%. Public health issues such as childhood obesity and possibly environmental factors play a role in the increase of Type I and Type II diabetes. Providing safe care at school and school-related events presents difficult challenges to school nurses and non-medical school personnel. It is estimated that 9,000 Floridians die each year due to complications of diabetes. According to the Centers for Disease Control’s Fact Sheet entitled “SEARCH for Diabetes in Youth,” about one in every 400 to 500 persons under 18 years of age have diabetes, and more than 13,000 young people are diagnosed with Type 1 diabetes each year. They further state that health care providers are finding more children with Type 2 diabetes, a disease usually diagnosed in adults 40 years or older. Optimum medical care and self-management, as outlined in the Florida Diabetes Medical Practice Guidelines, can improve health outcomes for people with diabetes. People who can control their diabetes by maintaining normal or close-to-normal blood sugar levels will lower their risk for complications, and gain, on average: 5 extra years of life; 5 more years of eyesight; 6 years free from kidney disease; and 6 years free from amputations and nerve damage. According to the American Diabetes Association, health care costs directly related to diagnosed and undiagnosed diabetes was 218 billion dollars in 2007. Without effectively addressing this increasing epidemic, costs will continue to rise.
Agency Community RolesThe Marion County Health Department’s School Health program formulated the plan needed to provide better continuity of care and oversight of diabetic management in the schools. Since the Health Department employs and supervises all the school health staff that provides medical services in Marion County Public Schools, it was logical that the Diabetic Resource School Nurse position would also be created, maintained and supervised by the Health Department. Furthermore, by basing this nurse at the Health Department, rather than in a school, she is centrally located to serve all personnel in all schools as needed. The Diabetic Resource School Nurse provides day-to-day management by guiding and assisting non-licensed and non-medical caregivers and students, by communicating with providers and parents as necessary, and by providing improved and enhanced diabetic training to existing school staff. The training may be group training for several staff, or “one-on-one” as appropriate for the given situation and the learner involved. The Health Department, through the Diabetic Resource School Nurse, also improved and shortened the diabetes training used, by obtaining for all schools “Diabetes Care Tasks at School – What Key Personnel Need to Know,” from the American Diabetic Association. This 23 minute DVD has replaced the previous training, which was a 90 minute power point presentation. Trainees demonstrated improved learner knowledge and ability to perform diabetic management services with greater accuracy, faster reverse demonstration and verbalization of the correct performance of the management plan. This nurse is also an excellent resource for educating students and family members. The required quarterly retraining/review has also been revised. The previous one hour session has been reduced to approximately 20 minutes, by using target questions and scenarios. Time spent may be less or more depending on individual learners.   Costs and ExpendituresOur target population is all of the diabetic students attending public schools in Marion County, Florida. The number fluctuates from 105 to 110 students. We reached 100% of them. The public health issue addressed is effective medical management of Type 1 and Type 2 diabetes in school-aged children, at school and school-related events. Our goal is to identify and meet the complex medical needs of diabetic students attending public school in Marion County, Florida; and prepare to meet the needs of greater numbers, as the diabetic population increases. Objective #1. Create, implement, and maintain a position entitled “Diabetic Resource School Nurse” to centralize medical management for diabetic public school children. The School Health program at the Marion County Health Department provides health services to over 42,000 public school students. Although diabetic students represent a small percent of the total, medical management is complex. The number of diabetic students requiring medical management is increasing. Over the last 20-30 years, diabetes in American children has increased by 40%. Providing safe care at school presents difficult challenges to school nurses and non-medical school personnel. The Marion County Health Department created a specialized Diabetic Resource School Nurse position to address diabetic issues. The position provides a greater degree of safety for students by improving medical management. Anticipated accomplishments were: 1.Improved medical management of diabetic students, including improved glucose monitoring and/or insulin coverage; 2.Improved training of non-professional school staff, enabling them to better serve diabetic students; 3.Improved confidence level of parents in the school’s diabetic services; 4.To provide assistance to newly diagnosed students and families, to help them navigate the complex world of diabetes management; 5.Increased level of participation by diabetic students in their own care; 6.Improved communication between medical providers and school staff; 7.Reduction of medical errors. Our practice was implemented in November 2008. Steps taken to implement our practice: 1) Recognized the need for better diabetic medical management for students. 2) Discussed solutions for improvement and chose to implement the Diabetic Resource School Nurse position. 3) Marketed a proposal to the School District, which included a request for funding. 4) Obtained approval for the 2008-2009 school year. 5) Recruited and hired the best person for the job. 6) Activated the position in November of 2008. After position activation, we took additional implementation steps: A) Improved diabetic training of school staff, by making it shorter, more interesting, and providing for one-on-one training where appropriate. B) Reviewed insulin logs with greater frequency and accuracy. C) Channeled diabetic-related communication from school personnel to one “point person,” the Diabetic Resource School Nurse. D) Established communication between school personnel, the Diabetic Resource School Nurse, University of Florida Pediatric Endocrine and other providers. E) Improved communication between all entities involved in diabetic management. All objectives were met. Factors for success were: 1.We were supported by our Public Policy Institute, Health Department, School District, and school staff. 2.We found the right person for the job. 3.We earned the support of parents. 4.We had the support of medical providers, who favored centralized communication. ImplementationNeed Recognition - The Marion County Health Department’s school nurses recognized the need for improved diabetic management of school children. Planning – The school nurses discussed diabetic management issues to determine possible solutions. The consensus was that a school nurse position dedicated to diabetic care was the best solution. Proposal Preparation - The School Health Supervisor prepared a proposal for the Marion County School District, for discussion with the Marion County Public Schools’ Executive Director of Student Services, to request funding for the position. Approval – The proposed additional school nurse position was added to the 2008-2009 Marion County Health Department/Marion County School District contract. The contract was approved by the Health Department Medical Director and the School Board. Recruitment/Hiring – Position requirements were: extensive diabetic knowledge including technical skill and experience; ability to interact positively with children and adults; and ability to educate all levels of learners. The ideal candidate was hired. Position Activation – This nurse shadowed other school nurses, researching and compiling information pertaining to diabetic management. She was supplied with a lap-top computer, a cell phone, and a desk at the Health Department. Improvement of Training for School Staff- The previously mandated diabetes training utilized a 90 minute power point presentation. The Diabetic Resource School Nurse researched and implemented the American Diabetes Association’s 23 minute DVD, “Diabetes Care Tasks at School—What Key Personnel Need to Know.” The previous three month review/retraining, lasting 1 hour, was revised to approximately 20 minutes, using target questions and scenarios. Optional training for all school personnel is available. Quality Assurance including Review of Insulin Logs – Insulin logs are reviewed every three months, and when new orders are obtained. Changes in student status, or interactions with families and school personnel are documented in the Student Health Record. Communication between students, school personnel, parents, and medical providers was enhanced by designating a “point” person for diabetic issues. Performance Review – Verbal and written reports to the School Health Supervisor are ongoing. Parents verbalize confidence in improved medical management. Communication with medical providers is simplified. Oversight quality assurance is ongoing. Medical errors are reduced. In the fall of 2007, a School Nurse’s review of a student’s insulin log revealed a large number of documented insulin administration errors and evidence of unsafe practice by the School District’s Health Clinic Assistant. This discovery was the wake-up call to action. Problem solving dialogue began immediately. In the spring of 2008, the proposed plan was discussed with School District Directors and added to the 2008-2009 MCHD/MCSD contract. Due to financial constraints, this position was not filled until November 2008. Performance review and evaluation will continue for the life of the program.
Objective: Create, implement, and maintain a specialized Diabetic Resource School Nurse position to provide comprehensive oversight of diabetic medical management at school and school related activities in Marion County public schools. Performance measures used: 1. Number of school staff trained. 2. Number of phone calls from school personnel to the School Health Department requesting help with student’s diabetic management issues. 3. Number of 504 and IEP meetings attended by the Diabetic Resource School Nurse. 4. Number of insulin administration errors. 5. Number of contacts with University of Florida Pediatric Endocrine and other medical providers. 6. Number of parents expressing increased confidence in the school’s diabetic management ability. Data collection: 1. At the beginning of the program, 57 school staff were trained in diabetic management issues. (per the Diabetic Resource School Nurse) 2. In the first 3 days of school in the fall of 2009, the Marion County Health Department’s School Health Department received 117 phone inquiries from school personnel regarding diabetic management issues. (per the Diabetic Resource School Nurse) 3. In the 2009-2010 school year the Diabetic Resource Nurse was invited to one 504, and one 504/IEP meeting. (per the Diabetic Resource School Nurse) 4. In the 2007-2008 school year, there were 65 documented insulin administration errors. (per the Marion County Public Schools Risk Management Office) 5. The number of calls for help to University of Florida Pediatric Endocrine and other providers is not known for certain, because any school personnel could and did make them. 6. Some parents expressed some doubt about the school’s ability to handle diabetic management.   These comments were not gathered in a statistical manner, but we feel that #3 above, number of invitations to 504 and IEP meetings, is an indicator of how the parents felt about engaging school personnel on their child’s health management team. Evaluation results: 1. Number of school staff trained in diabetic management has risen, from 57 to 226, and continues to rise as trainings continue. 2. In the first 3 days of school in 2010, the school health department received approximately 40 calls from school personnel regarding diabetic management issues, down from 117 the previous year. 
The stakeholders involved in this practice are the Marion County Health Department and Marion County Public Schools. Both entities have committed to this project from the beginning, and after two years, both see the rewards of this practice. Funding for the Diabetic Resource School Nurse position now comes exclusively from The Marion County Health Department. However, the School District funds and supports many other aspects of the school nurse program. It is in both parties’ best interest to perpetuate the practice, not only to maintain compliance with current legislation and possible future legislation; but also to be prepared to meet the needs of what is likely to become a growing population of diabetic school aged children. By dedicating a Diabetic Resource School Nurse position, County Health Departments or Local Health Departments can enable the limited number of school nurses to complete other mandated school health duties. The implementation of the Diabetic Resource School Nurse position as a model practice to improve the health of Marion County school students could be replicated in other counties by working with supportive community partners and local school districts. The Marion County Health Department is committed to having this position as long as we have the funding to support it. We will continue to partner with Marion County Public Schools to improve medical management for diabetics in our public school system. The School Health Supervisor has reviewed the outstanding decrease in medication errors in one year’s time with the School District’s Risk Management office. The Risk Management Supervisor verbalized amazement over the decreased numbers. She suggested that the improved oversight provided by the specialized nurse was a reason for the decrease in errors. This dramatic improvement may be in part due to less anxiety of school personnel in administering diabetic management services. This information was shared with the Marion County Public School’s Executive Director of Student Services, the originator of the MCHD/MCSD contract, to substantiate the need for continued funding of this position. This nursing position also generates a small amount of Medicaid Certified Match revenue for eligible services rendered
 
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