57: Filling the Nurse`s Toolbox PowerPoint

Filling the Nurse’s Tool Box in
Constructing a Well Built IEP
Presentation BY…..
Susan Acosta, B.S. RN
State of New Mexico, Human Services Department
Medical Assistance Division, Quality Bureau
[email protected]
505- 476-7113
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
Presentation Focus
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
Learning Objectives
• 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
• How to use the Independent Care Plan in the IEP
process and how to make it claimable under the MSBS
• Making Care Evaluation claimable for Medicaid School
Based Program requirements
Where to begin
Special Education and Health
IDEA describe students with health issues
and the health service they require within two
• Other Health Impaired – 504 services and plans
• Special Education – IEP special education services and
related services
Working Together
• IDEA-97 emphasizes a collaborative
• The IEP requirements under IDEA emphasize
the importance of working cooperatively as a
Construction of the
•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).
IEP Models
Case Management model
Multidisciplinary Team Model
Multidisciplinary Team Model
The team has integrated activities to manage. Each activity is of
equal importance and interdependent on the quality of the
• Eligibility determination
• Evaluation of disabilities needs and impact
• Determine the need for related and support
services and refer for evaluations
Case Management Model
• In order to ensure the integrated delivery of services,
some school systems use a case management
• 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.
What is IEP?
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
– 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).
Considerations and
• 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.
Recommend Nurse Evaluation
A key component of this multidisciplinary evaluation for a child with a
health related condition is a health assessment that may be conducted by
the school nurse. Based on this assessment, the school nurse identifies
those health issues that are relevant to the child's educational progress.
If a child with health related disabilities is determined eligible for
special education and related services an individualized
health care plan (IHCP) with specific health and medical related objectives,
interventions and evaluation criteria should be initiated by the school nurse as part of
the child's individual education program (IEP) or the individual family
services plan (IFSP) team process, and incorporated into the IEP or IFSP.
What Are Related Services
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
Construction Process
Special Education Evaluation
Individual Education Plan Meeting
Step Four
Related Service Evaluation
Step Five
IEP Meeting
Step Six
IEP Written
Related Health vs. Related Nursing
• 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
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 educationDevelop 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
Identifying Related Service
Role of School Nurse
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.
Skilled Nursing Evaluation
• 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.
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.
Components of Nursing
• 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.
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 internet
Click on nmschoolhealthmanual.org
Enter Special Education
What Happens After the Nursing
Case Manager
Construct the
written IEP
School Nurse
Develops the
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
• 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
IEP Form
•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.
in in
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
Medicaid Reimbursement Program
for the Schools
For a school to bill Medicaid for covered IEP services the following
requirements 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 qualified
provider criteria and who is qualified to provide the service under
applicable NM State licensure requirements.
6. The school must obtain a signed parental consent to bill Medicaid for covered IEP
services provided to the student.*
Components of the Written IEP for
Related Health and Nursing Service for
MSBS Program
Present Level of
Service Page
Service need for
Related Health and
Nursing Service
Service Time and
Schedule of Service Requirements for
Medicaid School Based Service
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.
What is a Present Level
of Performance?
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.
Examples of Present Level of
Performance Statements for Nursing
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.
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).
Identified Area of Need: Health Maintained
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.
Student/Parent Input
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
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.
•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
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
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?
If YES, attach the emergency evacuation plan, including the person(s) responsible to the IEP.
Physical Education: Regular with accommodations Adapted
Does the student require assistance to move in and around the school?
If YES, describe the assistance to be provided:
Does the student require transportation as a related service?
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: ____________________
Schedule of Service
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
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 Service
How to document SN and Health
Related Services
• 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 Service
How 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).]
If 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/
Date Service
Provider (s)
Time in Regular
Time in Special
Education Setting
30 min/wk
Speech-Language Therapy
1 hr/wk
30 min/wk
Occupational Therapy
1 hr/wk
1 hr/wk
Direct Skilled Nursing Service
15 min/day or per
medical orders
School Health Office
Direct Skilled Nursing Service
1 hr/day
School Health Office
Minutes per Day/
Start Date
Ending Date
Provider (s)
Time Totals
Supplementary Aids and
Time in Regular
Related Skilled Nursing
Intermittent SN for 8/1/2013
Evaluation and
School Health Office
Related Health Services
1.5 hrs/week for
assistance with
blood glucose
monitoring in
Resource Aide
Related Skilled Nursing
Intermittent to
implement Diabetic
Time in Special
Education Setting
Care Planning for Related
Health and Nursing services
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 Continued
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.
The Health Assessment
Development of the IHCP/ECP
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.
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
Individualized Health Care Plan
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
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).
ED. Gov, U.S. Department of Education
New Mexico Public Education Department
Office of School Health
The End
Questions and Answer session

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