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Filling the Nurse’s Tool Box in Constructing a Well Built IEP
CommunicationSystem /Protocol
Nursing
Evaluations
Care Planning
IHP and ECP
Care Evaluation
Present Levels of Performance
Goals and Objectives
Reimbursement
PED Licensed School Nurses
Susan Acosta, B.S. RNState of New Mexico, Human Services DepartmentMedical Assistance Division, Quality Bureau
505- 476-7113
Presentation BY…..
Disclosures
All planning committee members and presenter(s) author(s), and content reviewer(s) participating in this educational activity do not have any financial relationships they or an immediate family member may have with any commercial interest in any amount occurring within the past 12 months that create a conflict of interest.
Disclosures
• This presentation is to assist the participant in delivering services that meet New Mexico Medicaid School Based Service Program
• The specific focus is for Nursing Service
• Best practices to integrate or link nursing services into special education service to enhance communication and notification of student need for Related Health and Nursing Service
• Nursing Evaluation as a best practice to determine need for Related Health and Nursing Service
• Best practice on how to place Related Health and Nursing services on the written IEP to meet New Mexico Medicaid School Based Service Program
• Care planning, care coordination, and care evaluation as a claimable service under New Mexico Medicaid School Based Service Program
Presentation Focus
• The steps in creating an Individualized Educational Plan from student referral to placement on written IEP
• What are Related Services and Support Services
• How Related Services are used in the IEP process
• Distinction between Related Health and Nursing Service and why distinction is important
Learning Objectives
• Best practice on how to document nursing service justification in a written IEP for MSBS program purpose
• How to use the Independent Care Plan in the IEP process and how to make it claimable under the MSBS program
• Making Care Evaluation claimable for Medicaid School Based Program requirements
Learning Objectives
Where to begin
IDEA describe students with health issuesand the health service they require within two categories:
• Other Health Impaired – 504 services and plans• Special Education – IEP special education services and
related services
Special Education and Health Issues
• IDEA-97 emphasizes a collaborative approach.
• The IEP requirements under IDEA emphasize the importance of working cooperatively as a team.
Working Together
•Think of the Individual Educational Program (IEP) as if you were constructing a house for the special education student
• The request to begin the construction of the IEP may come by way of a request or referral from a Child Find Program, Early Intervention Program, SAT team evaluation, diagnostician, school registrar office of a transfer student with existing special education services, teacher or parent referral.
• The IEP process starts at this point and an evaluation is done by an eligibility team or case manager to determine if the student meets special education requirements for eligibility and related service need(s).
Construction of the IEP
Case Management model
Multidisciplinary Team Model
IEP Models
The team has integrated activities to manage. Each activity is of equal importance and interdependent on the quality of the other.
• Eligibility determination
• Evaluation of disabilities needs and impact
• Determine the need for related and support services and refer for evaluations
Multidisciplinary Team Model
• In order to ensure the integrated delivery of services, some school systems use a case management approach
• a team leader coordinates and oversees services on behalf of the student. In some schools, this person might be the child's special education teacher. In other schools, supervisory school district personnel may assume this responsibility.
Case Management Model
It is an Individualized Educational Program for the a special education student
– The IEP is a collaborative process and product
– The product of the IEP is the written document which reflects that the student is receiving a Free Appropriate Public Education (FAPE) consistent with all federal and state requirements.
– The written IEP specifies the services to be provided, how often the services will be provided, the student’s present level of performance, specific accommodations and modifications that will be provided and how the student’s disabilities may affect their academic performance
– The IEP is the foundation for a student achieving an individualized educational experience.
– It captures the special education student’s and the family’s vision for how to educate to the extent appropriate with individuals who do not require special education (Least restrictive environment).
What is IEP?
• IDEA 2004 requires all related services to be considered (evaluated) and specifically defines health related services
• Since related health services can be provided by qualified individuals other than a nurse, it is recommended for MSBS billing purposes that the NM PED licensed school nurse be the professional who evaluates, delegates, trains, monitors and provides the ongoing assessment for all health related services provided to a student in special education.
Considerations and Suggestions
A key component of this multidisciplinary evaluation for a child with ahealth related condition is a health assessment that may be conducted bythe school nurse. Based on this assessment, the school nurse identifiesthose health issues that are relevant to the child's educational progress.
If a child with health related disabilities is determined eligible forspecial education and related services an individualizedhealth care plan (IHCP) with specific health and medical related objectives, interventions and evaluation criteria should be initiated by the school nurse as part ofthe child's individual education program (IEP) or the individual familyservices plan (IFSP) team process, and incorporated into the IEP or IFSP.
Recommend Nurse Evaluation
Related services are the supports needed for a child to benefit from special education. Transportation and such developmental, corrective and other supportive services are required to assist a child with a disability to benefit from special education
• Includes speech-language pathology • Audiology services• Interpreting services• Psychological services• Physical and occupational therapy• Counseling Services• Rehabilitation Counseling• Orientation and Mobility Services• Recreation - including therapeutic recreation• Early identification and assessment of disabilities in children• Medical services for diagnostic or evaluation purposes• Social work services in schools and parent counseling and training• Health and Nursing services
What Are Related Services
Construction Process
STEP THREEIndividual Education Plan Meeting
STEP TWO
Special Education Evaluation
STEP ONE
Identification
IEP PROCESS
Step Six
IEP Written
Step Five
IEP MeetingStep Four
Related Service Evaluation
Related Health vs. Related Nursing Service
• A related health service can be provided by either a qualified licensed provider or non licensed provider, such as a resource aid. Examples would be providing assistance with ADLs, providing delegated care indicated in the Independent Care Plan.
• A Nursing service requires a qualified licensed skilled nurse to provide the service. Examples of this service would be medication administration, skilled nursing procedures, assessment, care planning and care evaluating.
Notification and Awareness…..
Who needs nursing services that receive special education ???
Which special education students are Medicaid Participants or eligible?
Best Practices to link nursing services to special education
Create formal communication systems which consistently link the school nurse to the special education student
Best practices for linkage:• Each month obtain a roster of special education students and review for health
related needs or medical conditions that may impact the student education –• Ensure that the school nurse is on the notification list distributed by the
school’s registrar for incoming students –• Be a standing member of the SAT team: The school nurse will not attend every
meeting but will be linked in to be notified of students who have been determined to qualify for special education-
• Develop a campus protocol- only the school nurse is to complete page 13 of IEP to be completed by nurse.
• Establish a procedure that all special education students with a medical or health related condition must have a evaluation to determine the need for health related and nursing services
How to Determine if the student has a need for Related Health or Nursing Service?
Conduct a Related Health and Nursing Evaluation
As evaluation proceeds, the team or case manager will be responsible demonstrating an understanding of the impact of the health condition and the needs for care during the school day.
– Schools nurse acts as health professional consultant
– School nurse can determine Related Health and Nursing Service needed
– School nurse develops the individualized health
– care plan that becomes the blue print to care for health related needs
– School nurse provides direct care and indirect care
– School nurse makes the decision to delegate care
– School nurse determines competency of unlicensed personnel to provide delegated care.
Identifying Related ServiceRole of School Nurse
• Assesses the student’s health or medical conditions which may impact the student’s ability to learn or achieve special education goals and objectives
• Assesses of need for direct nursing service and health related service necessary to enable a student with a disability to receive FAPE
• Assesses the educationally relevant medical or health related conditions that are likely to adversely impact the student’s educational performance
• If related health and or nursing services are needed
• To assess the type of care, amount of care, and which environment to deliver health and nursing care in a safe and effective manor to promote optimal student outcomes.
Skilled Nursing Evaluation
Nursing Evaluation Continued
• The assessment or evaluation information is to be used in the development of the student’s individualized health care plan (IHCP).
• The care planning for the IHCP and ECP is a collaborative process that includes the student’s parent or guardian, the student (when appropriate), the student’s physician, other school staff, community health providers, and medical specialists, if applicable.
• Students health history
• Physical Assessment
• School and medical record review
• Consultation with health care providers, teachers, parents
• Student observation
• Determine if health condition impacts student’s ability to learn
• Assessment of needed accommodations & other related services.
Components of Nursing Evaluation
Assessment of Health/Physical Status is recommended when: •Medications or health care procedures are necessary at school for the student to be able to receive FAPE
•A student has a physical or mental Health Condition (past or present) that may be impacting learning
•A student has a sensory deficit (i.e. fluctuating hearing loss) which requires ongoing monitoring and/or case management by the School Nurse
• A student has a complex health/medical history requiring Individual and/or Emergency Health Care Plan
• The Licensed School Nurse is involved in care coordination and/or case management for a student who has physical and/or mental health conditions
Assessment and Evaluation Tools
Log into the internetClick on nmschoolhealthmanual.orgEnter Special Education
What Happens After the Nursing Evaluation?
Case Manager Construct the
written IEP
School Nurse Develops the
Independent Health Care Plans
The written IEP is developed by the case manager and Independent Care Plan is developed and written by the School Nurse
• All related services must provide evaluation results and recommendations
• Nursing service is unique –traditionally special education staff write in information regarding services
• It is imperative the school nurse collaborates and provides results of the nursing evaluation and provides service justification, scope, and service time
•The Federal special education law tells us what information must be included in the IEP
• The Federal special education law does not specify we use particular form
• Each state may decide what form to use – The Public Education Department has a recommended IEP form for use
•Each school district in New Mexico may use own form or written IEP design – Most likely when districts use Electronic Student Records or documentation systems
•Most important is that each written IEP form used must be clear and useful to parents, educators, related service providers, and administrators.
IEP Form
Next Step in Constructing Building the Written IEP
The IEP is written by the Case Manager/team leader with evaluation information entered by each related service provider, except nursing.
The school nurse is to participate in the development of the IEP by providing the case manager (written) information as to why related health and nursing services are needed for the student. This reason or justification is to be incorporated in to the Present Level of Performance area of the written IEP.
The type of related health and nursing service are needed, the amount of service, and frequency of service to include on the service page of the written IEP.
The related health services can be placed in multiple area of the written IEP. Such as, medical supplemental page, or accommodation section
Next Steps in Constructing IEP
For a school to bill Medicaid for covered IEP services the followingrequirements must be met:
1. The student receiving the service must be enrolled in the Medicaid program.
2. The student must qualify for services under the IDEA.
3. The student must have an IEP or FSP.
4. The services must be specified in the IEP or FSP.
5. The services must be furnished by a practitioner who meets Medicaid qualifiedprovider criteria and who is qualified to provide the service underapplicable NM State licensure requirements.
6. The school must obtain a signed parental consent to bill Medicaid for covered IEP services provided to the student.*
Medicaid Reimbursement Program for the Schools
Components of the Written IEP for Related Health and Nursing Service for
MSBS Program
Present Level of Performance
Medical Considerations Service Page
Service Justification
Service need for Related Health and
Nursing ServiceService Time and
Place
Schedule of Service Requirements for Medicaid School Based Service
Program
Nursing services rendered must be listed in the written IEP in the following areas:
• Justification listed in the Present Level of Performance section• Medical Considerations page• Schedule of Service page either in the direct service grid or supplemental area of
the service page
SN Services must be considered medically necessary under MSBS regulations
SN services are provided by practitioners who meet MSBS qualifications and who are acting within the scope of their license.
For the MSBS program serves as the written justification for services to be claimed and billed under the MSBS program
• The PLP according to Special Education in Plain Language, “The IEP must provide information on the child's present level of performance, addressing each area of need. The present level of performance is a clear, descriptive statement of how the child is performing. Any health issues, limitations, or needs can be incorporated into PLP if it describes how the student’s disability affects the student’s involvement and progress in the general curriculum and also how the disability affects the child’s participation in school and recreational activities. (20 U.S.C. Section 1414 (d) (1) (A) of IDEA).
• Other needs for supports, adaptations, accommodations, equipment and other issues related to the student’s health concerns also can be recorded in the present level of performance.
What is a Present Level of Performance?
Jane missed 10 days of school last year due to pressure sores. So that Jane does not miss school, Health related and nursing services are needed to for assessment of care needs and plans, health related classroom interventions to prevent skin breakdown, needed direct nursing services for skin breakdown if needed. Student unable to move self due to physical and cognitive inability
Danny requires nursing services for medication management and administration since her medications are taken mid day and Sarah is not developmentally able to self administer. Danny also has “as needed” medication for her asthma. She is beginning to recognize her symptoms that indicate the need for her to use her inhaler, but needs more instruction and practice therefore related nursing services are needed.
Examples of Present Level of Performance Statements for Nursing
Service
Identified Area of Need: Health Maintained Student/Parent Input:Student has difficulty remembering to take oral medication each morning for ADHD. Student has missed 4 out of 5 doses of ADHD medication in the past 3 weeks, which has affected his cognitive ability and ability to maintain attention to participate in instructional interventions and the meeting of educational goals. The missing of oral medication for his ADHD also affects his ability to control impulses, which create behavioral issues. The student has had 7 behavior/disciplinary referrals in 3 weeks in which affects instructional time. Parent is not able to provide daily supervision for medication or able to administer daily oral medication.
Intermittent skilled nursing for development of IHP related to ADHD, and daily skilled nursing for medication administration for ADHD. Student’s cognitive ability and participation in special education interventions dependent on daily compliance of prescribed ADHD medication, Student and family not able to be consistent in prescribe daily administration regime.
Student reports he does not remember, and does not remember to set alarm to use as an aid.
Mother reports she is a single mother and due to her work schedule is unable to be present to supervise or to administer medication administration.
PRESENT LEVELS OF FUNCTIONAL PERFORMANCE Please document the student’s present levels of functional performance for identified areas of need (eg. social/emotional,
behavior, life skills, energy level, sustained attention, memory function, impulse, processing speed, and motor skills).
•Symbol indicates information that goes into the Student Teacher Accountability Recording System (STARS).
• IEP Page 7 of 31 IEP for ___________________________________________________ Date: _________________________
Medical Consideration Page
• School Nurse to collaborate with the case manager or provide written information to the case manager for scribing purposes
• Medical Consideration Page is where the student’s medical needs are communicated and where specific related health and nursing service can be documented
• Important to check whether student has IHCP and or ECP
MEDICAL/SIGNIFICANT HEALTH INFORMATION
MEDICATION: Twice a day oral medication for ADHD. Intermittent Skilled nurse to assessments for medication effectiveness and medical management needs
SIGNIFICANT HEALTH INFORMATION: Student has diagnosis of severe ADHD, and struggles with medication compliance.
Student can self monitor blood glucose, but does not have hand dexterity to conduct finger prick, and use glucose monitoring device. Intermittent SN assessment to evaluate the delegation of interventions in IHCP/ECP, training of Interventions in IHCP and ECP, and provided re-assessment of effectiveness of IHCP and ECP. .Direct Skilled nursing care to respond and deliver nursing interventions for diabetic emergency care per ECP Does the student require an individualized health plan or school health services as a related service? YES NO: If YES, attach the health plan to the IEP and/or indicate on the Schedule of Services.Does the student require an emergency evacuation plan? X YES If YES, attach the emergency evacuation plan, including the person(s) responsible to the IEP.Physical Education: Regular with accommodations Adapted
MOBILITYDoes the student require assistance to move in and around the school? YES NO:If YES, describe the assistance to be provided:
TRANSPORTATIONDoes the student require transportation as a related service? YES NO:If YES, what accommodations and supports are required in order for the student to be transported with typically developing peers in the Least Restrictive Environment (LRE)?
•- Symbol indicates information that goes into the Student Teacher Accountability Recording System (STARS).• IEP Page 20 of 31 IEP for ___________________________________________________ Date: ____________________
While it is likely that most covered services appear in the related services grid, the federal regulations simply require that the covered services be ordered in the child’s IEP.
Ultimately the service must be included in the IEP, but the required location of the service is not designated in the federal regulation.
Schedule of Service
Schedule of Service
The amount of a special education or related service to be provided to a child may be stated in the IEP as a range (e.g., speech therapy to be provided three times a week for 30-45 minutes per session) only if the IEP team determines that stating the amount of the services as a range is necessary to meet the unique needs of the child.
For example, it would be appropriate for the IEP to specify, based upon the IEP team's determination of the student's unique needs, that particular services are needed only under specific circumstances, such as the occurrence of a seizure or of a particular behavior. A range may not be used because of personnel shortages or uncertainty regarding the availability of staff. [Appendix A, Response to Question 35, 64 Federal Register, page 12479 (March 12, 1999).]
• Document Skilled Nursing Services directly in the service grid area if services are usual and predictable• Usual and predicable are those services that you provide routinely and can estimate time
• examples: Medication administration, procedures, assessessment if routine
• Document Skilled Nursing Service in Supplemental or Support Area if not routine and predictable • Non routine would be PRN services, or intermittent that cannot be predicted routinely
• examples: Intermittent assessment for evaluation of care in IHCP or ECP. Intermittent SN service to implement Emergency Care Plan for seizure, or low blood glucose
• Always use language to document related SN services, “as per medical order/ medical plan or IHCP/ECP” to prevent the need for frequent IEP amendment. If changes in the medical order or plan required extensive changes in the IHCP or ECP it is recommended the SN discuss with the case manager, for an IEP amendment may be required.
• Related health services are to be placed on the supplemental area of the Service Page of the IEP. Examples of supplemental services and accommodations would be: examples:
• Skilled nurse to assess ability of resource aide to provide care RN delegated interventions outlined within the IHP/ECP.
• SN to teach delegated interventions to resource aide outlined in IHP for health related services provided in the classroom. Resource aide to provide daily interventions outlined in the IHP in classroom- not a reimbursable direct service but should be on the IEP.
Schedule of ServiceHow to document SN and Health
Related Services
Schedule of ServiceHow to document SN and Health
Related Services
The amount of a special education or related service to be provided to a child may be stated in the IEP as a range (e.g., speech therapy to be provided three times a week for 30-45 minutes per session) only if the IEP team determines that stating the amount of the services as a range is necessary to meet the unique needs of the child.
For example, it would be appropriate for the IEP to specify, based upon the IEP team's determination of the student's unique needs, that particular services are needed only under specific circumstances, such as the occurrence of a seizure or of a particular behavior. A range may not be used because of personnel shortages or uncertainty regarding the availability of staff. [Appendix A, Response to Question 35, 64 Federal Register, page 12479 (March 12, 1999).]
SCHEDULE OF SERVICESIf this IEP spans between two school years, please complete this page twice, separating the services to be delivered in each school year.
Special Education & Related Services Minutes per Day/
Week/Month/
Semester/Year
Start
Date
Ending Date Service Provider (s) Location
Time in RegularSetting
Time in Special Education Setting
Speech-Language Therapy 1 hr/wk 8/1/2013 8/1/2014 SLP 30 min/wk 30 min/wk
Occupational Therapy 1 hr/wk 8/1/2013 8/1/2014 OT 1 hr/wk
Direct Skilled Nursing Service 15 min/day or per medical orders
8/1/2013 8/14/2014 SN School Health Office
Direct Skilled Nursing Service 1 hr/day 08/01/2013 08/01/2014 SN School Health Office
Time Totals
Supplementary Aids andServices
Minutes per Day/Week/Month/Semester/Year
Start Date Ending Date Service Provider (s)
Location
Time in Regular
Setting
Time in Special Education Setting
Related Skilled Nursing Intermittent SN for Evaluation and Assessments
8/1/2013 8/1/2014 SN School Health OfficeEducational Classrooms
Related Health Services 1.5 hrs/week for assistance with blood glucose monitoring in classroom.
8/1/2013 8/1/2014 Resource Aide ClassroomsCafeteriaPlayground
Related Skilled Nursing Intermittent to implement Diabetic ECP
08/01/2013 08/13/2014 SN ClassroomsCafeteriaPlayground
The school nurse (RN) is responsible for planning, coordinating and developing the IHP. As the Case Manager develops the written IEP the School Nurse develops the Care Plans. The IHP is a document or the blueprint of care that is needed for the student to be safe in a school setting and care that is needed to keep the student in school to receive FAPE or to achieve special education goals and objectives.
The IHCP provides direction to staff that implement all or a portion of the plan. The care plans are to correlate with information found in the Present Level of Performance section of the written IEP.
Every student with an IEP who requires direct nursing care, or health related intervention in the classroom, or care supervision must have a written Health Care Plan and if applicable an Emergency Care Plan (ECP)
Care Planning for Related Health and Nursing services
The IHP is a document or the blueprint of care that is needed for the student to be safe in a school setting and care that is needed to keep the student in school to receive FAPE or to achieve special education goals and objectives. The IHCP provides direction to staff that implement all or a portion of the plan.
The Individual Health Plan should detail the nursing services that will be required in the school environment. There are a variety of options for nursing care, ranging from using an on-site school nurse for intermittent needs to assigning a dedicated one-to-one nurse for the entire school day.
Student’s goals for health and nursing related services are to be documented in the IHCP and ECP and do not need to be written in the actual written IEP
IHP is to be signed by the school nurse (RN) who wrote the plan, the student’s parents or guardian, and the student’s primary health care provider
The IHP and ECP is to be retained in the student health record, and a statement placed in the written IEP as to where to access or locate the IHP and ECP.
Care Planning for Related Health and Nursing services Continued
Health Assessment:
The collection, documentation and analysis of information or data about a student's health situation leading to the development and initiation of an individualized health care plan to determine the student's state of health, patterns of functioning and need for health services, counseling and education.
The health assessment is on going and as-needed basis evaluating the student's current health status, reviewing medical diagnoses, treatments, or orders and requesting a change in a physician’s order if necessary, reviewing nursing diagnoses and collaborative health problems, assessing routine and emergency health care needs, confirming health procedures, equipment and supplies.
The Health Assessment Development of the IHCP/ECP
Independent Health Care Plan Components
• IHPs are individualized to each student’s medical, nursing, and educational needs.
• The IHP is to identify health services the child will need during the school day and contain interventions to meet those needs.
•The IHP is to contain interventions which support the student’s participation in school activities both inside and outside of the classroom and is to be written with consideration of minimal disruption of the student’s school day.
•The IHP should also contain an Emergency Care Plan (ECP) for each student to include care instructions on how to address the child's specific medical or care needs during an fire drills, power failures, and school lockdowns. Access to building exits, the need for additional staff support and emergency response time by school nursing and /or local ambulance service should be considered
Independent Health Care Plans
Individualized Health Care Planconsiderations
Written for a broad audience: the multidisciplinary team and must correlate with what is written in the IEP and is to detail the health related and nursing services that will be required in the school
environment
When planning for nursing in the school environment it is important to consider:
• Type of skilled medical needs • Level and frequency of skilled medical needs • Proximity of the nurse to the child • Type of nursing skill and / or licensure required to provide the care • How providing the required care impacts student participation in a typical school schedule Hours of
care required during the school day• Qualified/ designated personnel• Location of the IHP and ECP • Is updated whenever necessary• Uses language appropriate for the broad audience• Can be ”sectioned” as needed- e.g. emergency info to take on• field trips
• The school nurse is to evaluate care provided by licensed or unlicensed staff contained in the care plan on a routine basis or as dictated by the student’s needs or staff needs.
• The school nurse is to revised the care plan if the student’s health related, nursing, or medical needs change, but at least yearly.
• The maintenance of an ongoing, collaborative plan of care can be facilitated by the school nurse attending and being an active participant in all student evaluation and planning meetings.
• The evaluation of the effectiveness of the IHCP and ECP is reimbursable service within the MSBS program (Medicaid School Based Services program).
EvaluationIHCP/ECP
References
http://idea.ed.gov ED. Gov, U.S. Department of Education
WWW.ped.state.nm.usNew Mexico Public Education Department
www.hsd.state.nm.us/madOffice of School Health
http://nmschoolhealthmanual.org
The End
Questions and Answer session
