Rebecca King RN, CSN, MSN, MEd School Nurse Liaison WVDE-Office of Healthy Schools Changing the Way We Do Business: Working SMARTER not HARDER?

Objective #1: Participants will be knowledgeable of the vision for school health service initiatives at a national, state and local level.

WV Department of Education WV State Board of Education (Promulgate educational rule for PreK-12, adult vocational, institutional education facilities and the school for the deaf and blind) State Superintendent of Schools WVDE Offices Deputy Superint endent RESA OEPA

Coordinated-School Public Health Partnership

The West Virginia Story… Coordinated School-Public Health Structure

2011 RESA-RSWS Focus Work Plan – Local Wellness – Bullying (S3 high schools) – Substance Abuse (SBIRT) – Suicide Prevention (ASPEN) – Teen Pregnancy (HEAP, PREP grants) – Physical Activity (Let’s Move) – Nutrition (current WVDE-OCN initiatives) – Tobacco Prevention (Quit Kits)

What’s on the books? SN ratio of 1:1500 K-7 (W.Va. Code § ) WVBE Policy Standards for Basic and Specialized Health Care Procedures in the School Setting WVBE Policy Medication Administration (Prescribed and OTC) WVBE Policy 2423-Communicable Disease Control (HIV & Comm. Dx Inservices)

What’s on the books? WVBE Policy Certification…Authorization, Permit, Full Certification, Short or Long-Term Substitute and PPST Asthma laws-W.Va. Code § b Diabetes laws- W.Va. Code §18-2K-1 High Acuity Funding-W.Va. Code § School Nurse National Certification- W.Va. Code §18A-4-2b

Top 5 Medical Diagnoses/Procedures 2010/11 School Nurse Needs Assessment Medical DiagnosesIn-School Specialized Health Care Procedures AsthmaInhalers for Asthma Behavioral DisordersEmergency Medications Anaphylactic ReactionLong-Term Medications ObesitySpecial Diets per Federal Form Mental Disorders (Depression, Bipolar, Schizophrenic, Suicidal) Seizure Management Close 5 th places….. Ear, Nose and Throat/ Migraine or Severe Headache/Seizures

School Health Efficiency Multidisciplinary Team (SN, LPN, Aides, Health Clerk/Secretary) Utilization HealthCheck examination for new school enterers…No mass school screenings Evidence-based practices and policies (BMI, Scoliosis, Screenings, Lice, Prevention Programs, etc.) SBHC with full array medical, dental and mental Model YOUR County WVDE-Healthy Schools at

National School Nurses to Student Ratio 1:750 Well child 1:225 Chronic conditions 1:125 Complex conditions 1:1 as needed for multiple disabilities

What does the Student to School Nurse ratio look like on paper? = = 5.28 nurses

Multidisciplinary Approach = = 2 RNs 1 P/T LPN 1 clerk

NASN Research Priority Identify school nurse delivery models (school nurse caseloads, credentials, experience, etc.) necessary for quality nursing care School nurses must identify and measure outcomes expected as a result of quality school nursing care

School nurse sensitive outcomes Identify factors that measure the impact of nursing care over and above other factors Outcomes “sensitive” enough to distinguish between the effects of family and community and the effects of the quality and the quantity school nursing interventions on child, family and school community outcomes

Health Care Reform WV children with increased insurance coverage Expansion of Primary Care Center services and funding (currently serving 1 in 5 West Virginians) – School-Based Health Services Dental Mental Health Family Planning Helping us move to full-service communities/schools

Objective #2: Participants will be familiar with evidence- based practice recommendations in school health and challenged to fully utilize them in daily practice.

WHY EBIs…so students can get safe, quality standardized care

Prioritize Immunizations, Immunizations, Immunizations HealthCheck, Parent and Provider Education, HealthCheck, Common language, HealthCheck, Medical home concept Evidence-based Practice and Programs

Talk the Talk and Walk the Walk Know the data and the research, STOP the routines and start utilizing the facts to make school health programming and procedure decisions!

BMI… USPSTF recommends Medical provider screening for year old with comprehensive weight management program. Inclusive of counseling, diet, physical activity and behavioral interventions which are beyond our scope as nurses.

BMI… CDC (2007) recommends surveillance only not census or population-based screening by school personnel. Health and physical education including modeling school meals and physical activity for schools. Medical home management.

Acanthosis nigricans (AN) Markers… CDC is aware that some groups are interested in AN screening of children in school settings to identify those at high risk to develop type 2 diabetes. Although some studies have observed that half the children with type 2 diabetes had AN, insufficient evidence exists for us to conclude that having AN will lead to type 2 diabetes. Therefore, at this time, CDC scientists strongly discourage AN screening of children in school or community settings.

Acanthosis nigricans (AN) Markers… While AN is a reliable and independent marker of hyperinsulinemia, the extent to which AN predicts the development of type 2 diabetes is unclear. In this study, none of the 233 students screened had hyperglycemia. CDC scientists are not aware of any systematic guidelines for clinical detection of AN or a uniform AN case definition. The repeatability, reliability, and validity of AN screening, relative to expert diagnosis (gold standard), is unknown. This makes it impossible to meaningfully interpret AN screening results. Therefore, the utility of using AN as a screening tool for diabetes prevalence or as a predictor of developing diabetes is currently unknown.

Acanthosis nigricans (AN) Markers… Those adolescents who have AN can be stigmatized by the screening process and subsequent identification. We are also concerned that if AN status becomes a part of adolescents' medical records, it might jeopardize their future insurance benefits. Most importantly, there are now no known interventions or protocols to treat those who have AN. There is some evidence that those with AN might benefit from physical activity. Because improved physical activity benefits everyone in school or communities, it makes sense to encourage physical activity for all children, regardless of AN status. Medical home screening.

Acanthosis nigricans (AN) Markers… Given the absence of a uniform case definition and intervention protocols for those with AN and considering the risk of stigmatization for those with AN, CDC scientists believe that it is not ethical or cost-effective to mass screen children for AN. CDC recommends that state diabetes control programs consider an alternative primary prevention approach and use available resources to improve physical activity and nutrition in schools and communities.

Scoliosis Screenings... Affects only 2-3% of entire US Population. Do the math. USPSTF did not find GOOD evidence to support this screening for early detection. Accuracy of current screening test (forward bending or scoliometer) is VARIABLE. Only a small amount (minute) of the nationally 2-3 % cases actually have health benefits more cases are not clinically significant.

Scoliosis Screenings... USPSTF found idiopathic scoliosis detected through screening leads to MODERATE HARM…concluding that harms of screening out weigh the potential benefits.

Dental Screening… By West Virginia Dental Laws, this is outside of the scope of a nurse. We do individual “oral health assessments” based on an individual complaint NOT massive screenings.

Massive Screenings Are massive screening conducive to accurate screenings? Do they detect a high population of needs? Can you do a diagnosis, treat or referral to a specialist? Is the medical home an unneeded entity in a child’s life? Do you coordinate health services and share health information with them?

Massive Screenings Outdated Lack of supportive research to show need or true gaps in birth up to three year old screenings and medical home care. The concept of surveillance and screening in a medical home is continuity of care.

WHY? PreK is the new enterer with approximately 15, 000 (71%)students entering last year leaving only 6,000 new enterers in kindergarten. Follow PreK rule under WVBE…HealthCheck and now Superintendent’s Interpretation from 2007 which is rule for 6,000 kindergarten enterers. Prioritize your time stop rescreening!

Objective #3: Participants will be provided with the current status of school nursing and school health services in the state of West Virginia (changing of the guards, current data and trends, national certification and continued recruitment, working toward full-service schools, etc.).

Retirements School Nurses Principals Health Services Directors Superintendents Offsite PreK collaboratives

WV Data Lack of preventive care. Adolescents without well-child visits and immunizations. Poor oral hygiene and health. 17% increase in teen pregnancy population. Below proficiency on HEAP scores throughout the state. Leading in Asthma, Obesity, Hepatitis B and C, prescription drug abuse, etc.

Developing a Collaborative Team Completing Electronic Data Entry (Immunizations required on WVEIS, Ipad Grant requires HealthCheck data, High Acuity funds require HCP for certain specialized health procedures, medication logs, sick bay). PreK Child Accomplishment Summaries. Increasing the use of WV Statewide Immunization Information System (WVSIIS)…feeding into WVEIS.

Developing a Collaborative Team Capitalization of funding sources…what are they? Training of staff to recognize early signs and symptoms of communicable diseases, provide fluoride rinse programs, health promotion programs, enhancing health and physical education, physical activity, nutritional programs, relationships with hospitals, programming to assist school health, filling in the resource gaps, etc.

Developing a Collaborative Team Ensuring children receive annual Well Child visit and Dental exam for continued health promotion and prevention practices Incorporation of nursing students (LPN to NP and Doctorate in the school setting) and others. Developing MOUs/Contracts for a county medical director (Primary Care Centers, School-Based Health Centers, Private) or Medical Advisory Board

Developing a Collaborative Team Ensuring children receive annual Well Child visit and Dental exam for continued health promotion and prevention practices. Developing and maintaining working relationships. Developing supports at the RESA Developing a seamless health and medical record with the most influential people working together for the best of each student.

Full Service School School which provides for the whole child with integration of the eight components of school health through medical, behavioral and dental services, parent supports and services in the school, community supports…Making your school friendly with a whole child, family and community focus.

Become Nationally Certified Ensures leadership skills, quality care, efficiency, annual professional development and evidence-based practice.

How do we get there?

Strategies Know legislative rule, state rules and county policy. Know your nursing practice act and the role of LPN and UAPs. Support the Medical and Dental Home concept to move West Virginia towards preventive health. Validate immunization records and follow provisional enrollments through to completion. Make adolescent vaccinations and well-child visits YOUR priority NOT an AFTER THOUGHT!

Strategies Follow and implement evidence-based practice. Obtain a medical consultant or form medical advisory board for your county’s school health services program. Form collaborative teams/ relationships with public health. Form collaborative teams/initiatives with medical, dental and behavioral health providers/communities.

Together we serve the WHOLE CHILD

THANK YOU! Have a WONDERFUL Thanksgiving!

Rebecca King WVDE-Coordinator School Health and Coordinated School-Public Health