540215
research-article2014
NASXXX10.1177/1942602X14540215NASN School NurseNASN School Nurse
School Health Partners
The Student Health Collaboration An Innovative Approach to Enhancing Communication and Improving Student Health Patricia Guilday, MSN, RN, NCSN Students, families, school staff, and school nurses all benefit from successful community partnerships. School nurses requested improved communication with local clinicians and access to the health information of their students. School nurses were not routinely recognized as part of the care team and therefore were not able to access protected health information found in the medical record, which would improve health outcomes for their students. With a goal of improving student health outcomes, a local pediatric health care delivery system partnered with school nurses to share student health information. School nurses were included as part of the health care team, with access to electronic health records. This is an innovative coordinated care team approach with parents, nurses, and community clinicians able to communicate, plan, intervene, and evaluate student health. Keywords: electronic medical records; collaboration; partnership; health care team
W
hat makes school nursing different from any other type of nursing? For the most part, school nurses function independently and as the only
244 NASN School Nurse | September 2014
health care provider in a non-health care setting. This isolation is a challenge for most school nurses. School nurses can experience frustration in making their role and function within the school understood by administration, faculty, community health care providers, families, and sometimes, even the students. Simply stated, school nurses assume the responsibility for student health care during the school day. Multiple health factors can impact a child during the school day. To provide care for children with chronic, complex, post-operative, or post-emergency health care needs, school nurses need the cooperation and support of families and community providers. Most of all, school nurses need information. School nurses not only serve as care-givers but are often the “middleman,” providing and clarifying health information among families, school staff, and physician offices (Murray et al., 2008). School nurses are in a position to identify health care concerns and barriers to care and work with families, school staff, and students to achieve the best outcomes (Foley, Dunbar, & Clancy, 2013). School nurses recognize that successful partnerships offer the opportunity for community
providers and school nurses to recognize and appreciate the contribution each makes to the student health care team. School nurses are able to communicate the student’s school health status to providers, assist parents with health literacy issues, and advocate for student health care needs. Partnerships can also support and promote school health practice from the nurse perspective. It has been noted in the literature that school nursing and agency partnerships can provide opportunities for growth and development of school nurse practice (Kreulen, Bednarz, Wehrwein, & Davis, 2008). With the aim of optimizing health outcomes for children and seeking collaboration and care coordination across the health care community, the Nemours Health Care System partnered with Delaware school nurses through the Delaware School Nurse Association and the Department of Education to establish the Student Health Collaboration (SHC). Delaware school children have the advantage of having a school nurse in every school, all day, every day. Initially instituted in the public schools, the project has expanded to include all school nurses in Delaware: public, private, charter, and parochial. It also includes in-patient care at the AI DuPont
DOI: 10.1177/1942602X14540215 For reprints and permission queries visit SAGE’s Web site, http://www.sagepub.com/journalsPermissions.nav. Downloaded from nas.sagepub.com at Uni of Southern Queensland on June 22, 2015 © 2014 The Author(s)
Hospital for Children, 11 primary care pediatric offices, pediatric sub-specialties, and the Nemours Emergency Department. The Nemours Health Care System is a major provider of pediatric health care in the state. The SHC facilitates the exchange of medical/education information between school nurses, clinicians, and families. Nemours has allowed school nurses, with proper authorization, to access their system’s electronic health record known as NemoursLink® (EMR; based on EpicCare Link, which is licensed from Epic Systems Corporation). Individual student records can be viewed by the nurse on an as-needed basis. Informed consent from the parent is needed to access an individual student’s health record. Obtaining this parental consent has fostered communication between the school nurse and the parent concerning confidentiality and information sharing. School nurses and school health records and student health information from providers fall under the joint domain of the Health Insurance Portability and Accountability Act (HIPAA) and the Family Educational Rights and Privacy Act (FERPA). Participation in the SHC project is not intended for all students who are also Nemours Health Care patients. The nurse is able to view the health care records for those students with complex health care needs, who need ongoing care, who may be in poor control or non-compliant with their treatment plan, or who need post-discharge short-term accommodations. Participation in the project requires informed consent from families, training and enrollment of school nurses, and the agreement of school district administrators. Students (who are also Nemours patients) without the need for specialized intervention for acute health care needs or monitoring of chronic conditions are not routinely included in the project. Permission to access routine well child care records is usually not requested of parents. The project began as a collaborative process with the Delaware School Nurse Association, the Delaware Department of
Education, and local Nemours representatives from Nursing Administration, Health and Prevention Services, Privacy/Legal, Health Informatics, and Primary and Specialty Care. The initial request to Nemours Health and Prevention services came from school nurses and a Nemours physician in 2009. The project got under way with workgroups forming in late 2011. Students and nurses began to enroll in a limited rollout in late 2012. Each school district or administrative office is required to sign a partner agreement; each school nurse also signs a user agreement for access to the EMR. Each nurse is assigned a unique user ID and password. Trainings in the use of NemoursLink® were conducted at multiple sites and at multiple times since the project was instituted in the 20122013 school year. The use of the EMR is monitored by Nemours Health Informatics. Prior to implementation, this project was vetted in a series of interviews and meetings with Nemours nurses and physicians, school nurses, and the Nemours Family Advisory Council (parent group). Informational sessions and care team meetings with clinicians and school nurses ensure engagement and promote an understanding of the role they both provide in the integration and care coordination of patient/student health. The authorization form (parent informed consent) can be initiated by the school nurse or a Nemours clinician. Once parental consent is obtained, the school nurse’s access to NemoursLink® includes immunizations, physical exams, lab tests and medical imaging, care and treatment plans, medication lists, discharge instructions, notes made during clinician encounters, as well as notes related to school participation (e.g., physical education excuses). Consent is renewed on a yearly, as needed, basis. The only information that school nurses do not have access to is Behavioral Health and Adolescent Medicine. Data are being collected on an ongoing basis by Nemours evaluators. During the first year of full
implementation (2013-2014), changes in care coordination, efficiency, and access were evaluated using a pre-post online survey sent to school nurses. In analyzing the results of the surveys, findings suggest that there are significant pre-post differences in the amount of time spent trying to get medical information on Nemours patients/ students. Nurses report that after implementation of the program, they are spending less time looking for information. There was also a statistically significant pre-post difference reported for accessing information (p = .018), with nurses more likely to report that it is easy to get needed medical and treatment information after program implementation. In addition, there are significant differences overall for Nemours patients/students, with school nurses reporting that it is easier and less time-consuming to get necessary medical and treatment information as compared to non-Nemours patients/ students. In the post-implementation data, nurses reported an increase in the “feeling of being part of the health care team.” It was important to the project that nurses become a more integrated part of student health care and feel that they are part of the health care team. Data are currently being collected from families to measure perceived changes in health-related quality of life, parent opinions about the project and their child’s health, as well as days of work missed due to child illness. In addition, data on health care utilization and school-related behaviors (academic achievement and attendance) are being tracked longitudinally using the EMR and school electronic records data (Kaplan & Zhao, 2013). Data have not been collected from the providers in the Nemours Health Care System. School nurses, however, have anecdotally noted that communication is easier between schools and providers. One comment from the survey reflects the general impression of the partnership: “I really appreciate having the Link and wish we could do this with all our doctors—not just Nemours.”
Downloaded from nas.sagepub.com at Uni of Southern Queensland on June 22, 2015
September 2014 | NASN School Nurse 245
Conclusion Nurses are natural advocates for their students. School nurses want to collaborate and be recognized as part of the health care team. This is a groundbreaking program in community partnerships. The goals of the SHC are to enhance quality of care, improve student health, and reduce cost of care. The project provides school nurses with access to medical information, opens lines of communication, and changes the perception of what a school health care team looks like. In initiating this project, the implementation team was unable to identify any research articles in the literature to use for guidance. The team relied heavily on the compliance officer at Nemours and the Delaware Department of Education laws that
246 NASN School Nurse | September 2014
define the scope of practice for Delaware public school nurses. The benefits of opening and sharing electronic health records include improved communication across the continuum of care as well as fewer miscommunications among providers, families, and school. The Nemours provider has access to the school nurses’ clinical input and assessment of the patient/student in the school setting. The school nurse is better able to make assessments and interventions with full access to related health care information. Access to the NemoursLink® is on a read-only basis for nurses. Notes from the school nurse cannot be added into the Nemours EMR. However, parent consent to have their child and school nurse participate in this project is also permission for the school nurse to communicate verbally with the Nemours provider. These conversations
Downloaded from nas.sagepub.com at Uni of Southern Queensland on June 22, 2015
are happening and are contributing to a true team approach to student health care. School nurses no longer need to discuss last night’s emergency department visit with an 8-year-old student because that is the only available source of information. The nurse can access the notes and discharge instructions related to that visit. The school nurse and the community care provider can discuss and plan for any interventions needed in the school setting. Accessing that student medical information allows nurses to provide appropriate care as well as gives them the ability to reinforce instructions to families. Families no longer have to contact their provider for clarification of health care instructions or to obtain routine information. They can have conversations with their child’s school
nurse, who now has the input of the community health care provider as well as information on how the child is functioning in school. This is a new program, with only 1 full year of implementation. Better coordination of care and recognition of the school nurse as part of the care team should provide improved health outcomes for students. School nurses spend nearly 200 days a year with their students, seeing them much more than primary care and specialty group providers. Having access to information and the ability to collaborate and plan with other health care providers maximizes the potential of the school nurse as an integral part of the health care team. ■
Acknowledgments This project would not have been possible without the foresight of Aguida Atkinson, MD, Linda C. Wolfe, EdD, RN, the Delaware School Nurse Association,
and the Nemours Health and Prevention Services team of Claudia Kane, MS, David Nichols, and Shari Thomassen, MSN, APRN; Vicki Sanders; Jamie Hart; as well as data collection by Marina Kaplan.
References Foley, M., Dunbar, N., & Clancy, J. (2013). Collaborative care for children: A grand rounds presentation. Journal of School Nursing. doi:10.1177/1059840513484364
Patricia Guilday, MSN, RN, NCSN Lead Nurse Brandywine School District Wilmington, DE Patricia has been a school nurse in Delaware for the past 20 years. She is immediate past president of the Delaware School Nurse Association.
Kaplan, M., & Zhao, J. (2013, September 12). Improving care coordination and quality: Findings from the School Nurse Survey. Nemours Health and Prevention Services Technical Report, Newark, DE. Kreulen, G. J., Bednarz, P. K., Wehrwein, T., & Davis, J. (2008). Clinical education partnership: A model for school district and college of nursing collaboration. Journal of School Nursing, 24(6), 360-369. Murray, R., Devore, C. D., Gereige, R. S., Grant, L. M., Roland, M. M., Lamont, J. H., . . . Mazyck, D. (2008). Role of the school nurse providing health services. Pediatrics, 121, 1052-1056.
Downloaded from nas.sagepub.com at Uni of Southern Queensland on June 22, 2015
September 2014 | NASN School Nurse 247
research-article2014
NASXXX10.1177/1942602X14540215NASN School NurseNASN School Nurse
School Health Partners
The Student Health Collaboration An Innovative Approach to Enhancing Communication and Improving Student Health Patricia Guilday, MSN, RN, NCSN Students, families, school staff, and school nurses all benefit from successful community partnerships. School nurses requested improved communication with local clinicians and access to the health information of their students. School nurses were not routinely recognized as part of the care team and therefore were not able to access protected health information found in the medical record, which would improve health outcomes for their students. With a goal of improving student health outcomes, a local pediatric health care delivery system partnered with school nurses to share student health information. School nurses were included as part of the health care team, with access to electronic health records. This is an innovative coordinated care team approach with parents, nurses, and community clinicians able to communicate, plan, intervene, and evaluate student health. Keywords: electronic medical records; collaboration; partnership; health care team
W
hat makes school nursing different from any other type of nursing? For the most part, school nurses function independently and as the only
244 NASN School Nurse | September 2014
health care provider in a non-health care setting. This isolation is a challenge for most school nurses. School nurses can experience frustration in making their role and function within the school understood by administration, faculty, community health care providers, families, and sometimes, even the students. Simply stated, school nurses assume the responsibility for student health care during the school day. Multiple health factors can impact a child during the school day. To provide care for children with chronic, complex, post-operative, or post-emergency health care needs, school nurses need the cooperation and support of families and community providers. Most of all, school nurses need information. School nurses not only serve as care-givers but are often the “middleman,” providing and clarifying health information among families, school staff, and physician offices (Murray et al., 2008). School nurses are in a position to identify health care concerns and barriers to care and work with families, school staff, and students to achieve the best outcomes (Foley, Dunbar, & Clancy, 2013). School nurses recognize that successful partnerships offer the opportunity for community
providers and school nurses to recognize and appreciate the contribution each makes to the student health care team. School nurses are able to communicate the student’s school health status to providers, assist parents with health literacy issues, and advocate for student health care needs. Partnerships can also support and promote school health practice from the nurse perspective. It has been noted in the literature that school nursing and agency partnerships can provide opportunities for growth and development of school nurse practice (Kreulen, Bednarz, Wehrwein, & Davis, 2008). With the aim of optimizing health outcomes for children and seeking collaboration and care coordination across the health care community, the Nemours Health Care System partnered with Delaware school nurses through the Delaware School Nurse Association and the Department of Education to establish the Student Health Collaboration (SHC). Delaware school children have the advantage of having a school nurse in every school, all day, every day. Initially instituted in the public schools, the project has expanded to include all school nurses in Delaware: public, private, charter, and parochial. It also includes in-patient care at the AI DuPont
DOI: 10.1177/1942602X14540215 For reprints and permission queries visit SAGE’s Web site, http://www.sagepub.com/journalsPermissions.nav. Downloaded from nas.sagepub.com at Uni of Southern Queensland on June 22, 2015 © 2014 The Author(s)
Hospital for Children, 11 primary care pediatric offices, pediatric sub-specialties, and the Nemours Emergency Department. The Nemours Health Care System is a major provider of pediatric health care in the state. The SHC facilitates the exchange of medical/education information between school nurses, clinicians, and families. Nemours has allowed school nurses, with proper authorization, to access their system’s electronic health record known as NemoursLink® (EMR; based on EpicCare Link, which is licensed from Epic Systems Corporation). Individual student records can be viewed by the nurse on an as-needed basis. Informed consent from the parent is needed to access an individual student’s health record. Obtaining this parental consent has fostered communication between the school nurse and the parent concerning confidentiality and information sharing. School nurses and school health records and student health information from providers fall under the joint domain of the Health Insurance Portability and Accountability Act (HIPAA) and the Family Educational Rights and Privacy Act (FERPA). Participation in the SHC project is not intended for all students who are also Nemours Health Care patients. The nurse is able to view the health care records for those students with complex health care needs, who need ongoing care, who may be in poor control or non-compliant with their treatment plan, or who need post-discharge short-term accommodations. Participation in the project requires informed consent from families, training and enrollment of school nurses, and the agreement of school district administrators. Students (who are also Nemours patients) without the need for specialized intervention for acute health care needs or monitoring of chronic conditions are not routinely included in the project. Permission to access routine well child care records is usually not requested of parents. The project began as a collaborative process with the Delaware School Nurse Association, the Delaware Department of
Education, and local Nemours representatives from Nursing Administration, Health and Prevention Services, Privacy/Legal, Health Informatics, and Primary and Specialty Care. The initial request to Nemours Health and Prevention services came from school nurses and a Nemours physician in 2009. The project got under way with workgroups forming in late 2011. Students and nurses began to enroll in a limited rollout in late 2012. Each school district or administrative office is required to sign a partner agreement; each school nurse also signs a user agreement for access to the EMR. Each nurse is assigned a unique user ID and password. Trainings in the use of NemoursLink® were conducted at multiple sites and at multiple times since the project was instituted in the 20122013 school year. The use of the EMR is monitored by Nemours Health Informatics. Prior to implementation, this project was vetted in a series of interviews and meetings with Nemours nurses and physicians, school nurses, and the Nemours Family Advisory Council (parent group). Informational sessions and care team meetings with clinicians and school nurses ensure engagement and promote an understanding of the role they both provide in the integration and care coordination of patient/student health. The authorization form (parent informed consent) can be initiated by the school nurse or a Nemours clinician. Once parental consent is obtained, the school nurse’s access to NemoursLink® includes immunizations, physical exams, lab tests and medical imaging, care and treatment plans, medication lists, discharge instructions, notes made during clinician encounters, as well as notes related to school participation (e.g., physical education excuses). Consent is renewed on a yearly, as needed, basis. The only information that school nurses do not have access to is Behavioral Health and Adolescent Medicine. Data are being collected on an ongoing basis by Nemours evaluators. During the first year of full
implementation (2013-2014), changes in care coordination, efficiency, and access were evaluated using a pre-post online survey sent to school nurses. In analyzing the results of the surveys, findings suggest that there are significant pre-post differences in the amount of time spent trying to get medical information on Nemours patients/ students. Nurses report that after implementation of the program, they are spending less time looking for information. There was also a statistically significant pre-post difference reported for accessing information (p = .018), with nurses more likely to report that it is easy to get needed medical and treatment information after program implementation. In addition, there are significant differences overall for Nemours patients/students, with school nurses reporting that it is easier and less time-consuming to get necessary medical and treatment information as compared to non-Nemours patients/ students. In the post-implementation data, nurses reported an increase in the “feeling of being part of the health care team.” It was important to the project that nurses become a more integrated part of student health care and feel that they are part of the health care team. Data are currently being collected from families to measure perceived changes in health-related quality of life, parent opinions about the project and their child’s health, as well as days of work missed due to child illness. In addition, data on health care utilization and school-related behaviors (academic achievement and attendance) are being tracked longitudinally using the EMR and school electronic records data (Kaplan & Zhao, 2013). Data have not been collected from the providers in the Nemours Health Care System. School nurses, however, have anecdotally noted that communication is easier between schools and providers. One comment from the survey reflects the general impression of the partnership: “I really appreciate having the Link and wish we could do this with all our doctors—not just Nemours.”
Downloaded from nas.sagepub.com at Uni of Southern Queensland on June 22, 2015
September 2014 | NASN School Nurse 245
Conclusion Nurses are natural advocates for their students. School nurses want to collaborate and be recognized as part of the health care team. This is a groundbreaking program in community partnerships. The goals of the SHC are to enhance quality of care, improve student health, and reduce cost of care. The project provides school nurses with access to medical information, opens lines of communication, and changes the perception of what a school health care team looks like. In initiating this project, the implementation team was unable to identify any research articles in the literature to use for guidance. The team relied heavily on the compliance officer at Nemours and the Delaware Department of Education laws that
246 NASN School Nurse | September 2014
define the scope of practice for Delaware public school nurses. The benefits of opening and sharing electronic health records include improved communication across the continuum of care as well as fewer miscommunications among providers, families, and school. The Nemours provider has access to the school nurses’ clinical input and assessment of the patient/student in the school setting. The school nurse is better able to make assessments and interventions with full access to related health care information. Access to the NemoursLink® is on a read-only basis for nurses. Notes from the school nurse cannot be added into the Nemours EMR. However, parent consent to have their child and school nurse participate in this project is also permission for the school nurse to communicate verbally with the Nemours provider. These conversations
Downloaded from nas.sagepub.com at Uni of Southern Queensland on June 22, 2015
are happening and are contributing to a true team approach to student health care. School nurses no longer need to discuss last night’s emergency department visit with an 8-year-old student because that is the only available source of information. The nurse can access the notes and discharge instructions related to that visit. The school nurse and the community care provider can discuss and plan for any interventions needed in the school setting. Accessing that student medical information allows nurses to provide appropriate care as well as gives them the ability to reinforce instructions to families. Families no longer have to contact their provider for clarification of health care instructions or to obtain routine information. They can have conversations with their child’s school
nurse, who now has the input of the community health care provider as well as information on how the child is functioning in school. This is a new program, with only 1 full year of implementation. Better coordination of care and recognition of the school nurse as part of the care team should provide improved health outcomes for students. School nurses spend nearly 200 days a year with their students, seeing them much more than primary care and specialty group providers. Having access to information and the ability to collaborate and plan with other health care providers maximizes the potential of the school nurse as an integral part of the health care team. ■
Acknowledgments This project would not have been possible without the foresight of Aguida Atkinson, MD, Linda C. Wolfe, EdD, RN, the Delaware School Nurse Association,
and the Nemours Health and Prevention Services team of Claudia Kane, MS, David Nichols, and Shari Thomassen, MSN, APRN; Vicki Sanders; Jamie Hart; as well as data collection by Marina Kaplan.
References Foley, M., Dunbar, N., & Clancy, J. (2013). Collaborative care for children: A grand rounds presentation. Journal of School Nursing. doi:10.1177/1059840513484364
Patricia Guilday, MSN, RN, NCSN Lead Nurse Brandywine School District Wilmington, DE Patricia has been a school nurse in Delaware for the past 20 years. She is immediate past president of the Delaware School Nurse Association.
Kaplan, M., & Zhao, J. (2013, September 12). Improving care coordination and quality: Findings from the School Nurse Survey. Nemours Health and Prevention Services Technical Report, Newark, DE. Kreulen, G. J., Bednarz, P. K., Wehrwein, T., & Davis, J. (2008). Clinical education partnership: A model for school district and college of nursing collaboration. Journal of School Nursing, 24(6), 360-369. Murray, R., Devore, C. D., Gereige, R. S., Grant, L. M., Roland, M. M., Lamont, J. H., . . . Mazyck, D. (2008). Role of the school nurse providing health services. Pediatrics, 121, 1052-1056.
Downloaded from nas.sagepub.com at Uni of Southern Queensland on June 22, 2015
September 2014 | NASN School Nurse 247
