How to Create and Use Meaningful IHPs for Students

with Chronic Conditions Teresa DuChateau, DNP, RN, CPNP

WISHeS Project CoordinatorWASN District 6

2015

The learner will be able to explain how to develop outcome measures (indicators) as part of the student’s individual health plan

The learner will be able to identify ways to use outcome measures to guide case management/care activities

The learner will be able to articulate ways to

use outcome measures to evaluate the care provided to students

Objectives

Measuring Outcomes Why Does it Matter?

Determine the impact school nurses have on students managing their chronic conditions (particularly diabetes and asthma)

Example: Follow a standard, evidence-based practice of care/case management and measure the impact on:◦ A1C ◦ Decreased time out of class ◦ Decreased emergencies ◦ Absenteeism (NASN, 2014)

Why Do Outcomes Matter?

The Nursing Process

It is the responsibility of the school nurse to implement and evaluate the IHP at least yearly and as changes in health status occur to determine the need for revision and evidence of desired student outcomes (NASN, 2013)

Integral Part of IHP

Where do you Start?

?

Assessment Developing Goals

Examples of Goals For a student with Asthma

◦ Student participates fully in all school activities

For a student with Diabetes◦ Student increases understanding of pathophysiology of diabetes

& develop or improve the skill necessary for management

For a student with ADHD◦ Student improves interactions with classmates and have at least

one friend in class

For a student with Cerebral Palsy◦ Student maintains adequate nutrition and fluid intake

For a student with Sickle Cell◦ Student participates in regular school/class activities, including

P.E., with modifications as necessary

Six categories of goals: ◦ Safe school environment◦ Symptom management◦ Self-care◦ Academic success◦ Supportive family/peer relationships◦ Health care coordination

(Keehner Engelke, et al, 2009)

Case management is goal oriented based on the specific needs of the child and evaluated based on the impact on the child

Developing Goals

Example of Goals

(Keehner Engelke, et al, 2009)

School nurse needs to gather data from:◦ Student◦ Academic record◦ Health record◦ Parents◦ Teachers

(Keehner Engelke, et al, 2009)

Assessment-Developing Goals

The academic record is important in identifying those children whose illness is affecting their school performance

Problems related to:◦ Grades◦ Attendance◦ Time out of class◦ End-of-grade (EOG) testing◦ Participation in school activities

are possible indicators for case management

(Keehner Engelke, et al, 2009)

Attendance and Grades

Outcome Measurements

Start with the end in mind◦ What are you trying to evaluate?◦ Do you have a baseline measurement to evaluate

the effectiveness of the intervention?

End in Mind

For a student with Asthma◦ Student participates fully in all school activities

Outcome Measurement:

◦ Number of absences from physical education class

◦ Number of absences from school related to asthma

◦ Asthma Control Test score◦ Number of times prn albuterol was administered

each month

Asthma

Asthma Control Test

GSK, 2015

Significant reduction in specific symptoms such as:◦ Chest tightness ◦ Wheezing ◦ Asthma attacks

◦ Students reported fewer problems with using their inhaler, being responsible for the medications, and controlling their asthma

(Keehner Engelke, 2014)

Reduction in Symptoms

For a student with Diabetes◦ Student increases understanding of

pathophysiology of diabetes◦ Student develops or improves the skill necessary

for management

Outcome Measurement:◦ Student verbalization of diabetes pathophysiology ◦ Demonstration of diabetes management skills

Diabetes

(American Diabetes Association, 2014)

Diabetes

IHP

Diabetes

IHP

(American Diabetes Association, 2014)

Outcome Data

(Bonaiuto, 2007)

For a student with ADHD◦ Student improves interactions with classmates◦ Student reports having at least one friend in class

Outcome Measurements:◦ Verbalization of improved interactions with

classmates◦ Evidence of successful friendship

ADHD

(Varni, 2015)

PEDS QL

4.0

(Varni, 2015)

PEDS QL

4.0

For a student with Cerebral Palsy◦ Student maintains adequate nutrition intake◦ Student maintains adequate fluid intake

Outcome Measurements:◦ Height and Weight ◦ Daily fluid intake ◦ Daily dietary intake

Cerebral Palsy

For a student with Sickle Cell◦ Student participates in regular school/class

activities, including P.E., with modifications as necessary

Outcome Measurements:◦ Student verbalization of precautions that should

be taken in physical education◦ Student verbalization of warning signs and when

student should stop activity◦ Student verbalization of how he will signal the

physical education teacher that he needs a break

Sickle Cell

Working SMART

SMART ◦ Specific◦ Measurable◦ Action-oriented◦ Realistic◦ Time-limited

Make Your Goals SMART

For a student with Diabetes◦ Student increases understanding of

pathophysiology of diabetes◦ Student develops or improves the skill necessary

for self-management

Outcome Measurement:◦ Student verbalization of diabetes pathophysiology ◦ Demonstration of diabetes management skills

Diabetes

Semone

• 8 year-old girl who has had diabetes since she was three years-old

• She is very confident testing blood sugar and adjusting insulin dose

• Just started using an insulin pump a couple months ago

Outcome Measurement:◦ By the completion of the first semester Semone

will demonstrate an increase in competence completing the following skills related to her diabetes management Review the basal rate on insulin pump to ensure it is

accurate Set insulin pump to give prescribed bolus Reconnect pump to infusion set

SMART Goals and Outcomes

(American Diabetes Association, 2014)

Diabetes

IHP

At every blood glucose testing and insulin administration demonstrate or review the following:◦ Set insulin pump to give prescribed bolus◦ Review the basal rate on insulin pump to ensure it

is accurate◦ Reconnect pump to infusion set

Intervention

Interventions and Outcomes

How will you measure this?How will you know you are

successful?

(Texas School Nurse Association, 2011)

Outcome Measures:◦ Student verbalization of precautions that should

be taken in physical education◦ Student verbalization of warning signs and when

student should stop activity◦ Physical education attendance◦ Student report of participation in physical

education class◦ Teacher report of student participation in physical

education class

Sickle Cell

Rodger

• 14 year-old with Sickle Cell Disease• He wants to fit in with his friends

and has in the past participated too hard in physical education class and resulted in a pain crisis

• Requires modifications that don’t signal him out from his classmates

• Needs to have a “system” in place so he can take a break in physical education class and not draw attention to himself

For a student with Sickle Cell◦ Student participates in regular school/class

activities, including P.E., with modifications as necessary

Outcome Measurements:◦ Student verbalization of precautions that should

be taken in physical education◦ Student verbalization of warning signs and when

student should stop activity◦ Student verbalization of how he will signal the

physical education teacher that he needs a break

Sickle Cell

Outcome Measurement:◦ Prior to the start of physical education class at

second semester, Rodger will: Verbalize the precautions that need to be taken in

physical education class Verbalize the warning signs that indicate he needs to

stop exercising Verbalize how he will signal the physical education

teacher that he needs a break Student will have no pain crisis as a result of

overexertion in physical education class

SMART Goals and Outcomes

In December the school nurse will meet with Rodger to review:◦ Signs and symptoms of a pain crisis◦ Actions that trigger a pain crisis◦ Modifications that can be taken to help prevent

pain crisis◦ How Rodger will signal the teacher that he needs

a break during physical education class◦ What Rodger should do if the teacher does not

respond

Interventions

During the semester that Rodger is participating in physical education class the school nurse will:◦ Check in with Rodger and the physical education

teacher weekly during the first month of class to ensure that everyone is aware of the modifications

◦ Check in with Rodger at least twice during the semester to review the modification plan

◦ Review physical education attendance to ensure that Rodger is attending class

Interventions

Using Outcomes to Guide Interventions

Assessment

Nursing Diagnosis

GoalsPlannin

g

Implementation

Outcomes

Case Management

Other Outcome Measures

One outcome that seems to be relevant to most children enrolled in case management is an improvement in quality of life

We have consistently found that children:◦ Feel that they understand and manage their

illness better◦ They worry less about the long-term

complications of their illness◦ They are more open about discussing their illness

with others

Improved Quality of Life

(Keehner Engelke, et al, 2009)

Levy, Heffner, Stewart, and Beeman (2006) completed a randomized control trial and found that students with asthma who received case management by school nurses had:◦ Fewer absences◦ Emergency department visits◦ Hospitalizations than students who received usual care

The case management included:◦ Weekly education and monitoring using a standardized curriculum ◦ Follow-up with school personnel, health care providers, and parents

including phone calls to parents in the evening

The nurses who provided the case management were full-time asthma case managers and each nurse covered four schools

Impact on Absences and ER

Gerald et al. (2006) developed a case management program for students with asthma that involved:◦ Case detection◦ Medical management by study physicians◦ Education of teachers, students, and parents

Role of the nurse included oversight of the asthma action plan

Only 7 school nurses in the district which had over 13,000 children

Absences, ER and GPA

The study found that there was no change in:◦ Attendance◦ Grade point average (GPA)◦ Emergency department visits◦ Hospitalizations for children enrolled in the project

The authors note that the study was difficult to conduct because school personnel were overburdened and could not provide the intervention consistently

In addition, documenting academic outcomes was impossible because schools did not count absences in the same manner and so measures of attendance were unreliable

Absences, ER and GPA

(Keehner Engelke, et al, 2009)

We intended to train teachers at each school to conduct the educational classes for the children◦ Teachers were overburdened with academic

duties and were not able to participate These time constraints also prevented the

teachers from assisting with the collection of pre- and posttest data

(Gerald, et al., 2006)

Overburdened

No electronic data collection Didn’t collect baseline data No standard way to track absences in the

school district Had to rely on teacher report for grades and

behavior Lack of a standard outcomes

documentation form

Limitations with the Research

This study had difficulty tracking healthcare utilization

Found that children used many different names and identities upon entering the health care system and were, therefore, difficult to track

The social security numbers that parents provided to study staff often did not match those given to health care providers

Tracking Healthcare Utilization

(Gerald, et al., 2006)

American Diabetes Association. (2014). Diabetes Medical Management Plan. Available at: http://main.diabetes.org/dorg/PDFs/schools/dmmp-form.doc

Bonaiuto, M. M., (2007). School Nurse Case Management: Achieving Health and Educational Outcomes. The Journal of School Nursing, 23(4), 202-209.

Forrest, C.B., Bevans, K.B., Riley, A.W., Crespo R., and Louis, T.A. (2010). School Outcomes of Children With Special Health Care Needs. Pediatrics, 128(2), 303-312.

Gerald, L. B., Redden, D., Wittich, A. R., Hains, C., Turner-Henson, A., Hemstreet, M. P., et al. (2006). Outcomes for a comprehensive school-based asthma management program. Journal of School Health, 76, 291-296.

GSK. (2015). Childhood Asthma Control Test. Available at: http://www.asthma.com/resources/child-asthma-control-result-25.html

Keehner Engelke, M., Guttu, M. and Warren, M.B. (2009). Defining, Delivering, and Documenting the Outcomes of Case Management by School Nurses. The Journal of School Nursing, 25, 417

Keehner Engelke, M., Guttu, M., Warren, M.B., and Swanson, M. (2008). School Nurse Case Management for Children With Chronic Illness: Health, Academic, and Quality of Life Outcomes. The Journal of School Nursing, 24: 205

Keehner Engelke, M., Swanson,M., & Guttu, M. (2014). Process and Outcomes of School Nurse Case Management for Students With Asthma. The Journal of School Nursing, 30(3) 196-205.

McDaniel, K.H., Overman, M., Guttu, M. and Keehner Engelke, M. (2013). School Nurse Evaluations: Making the Process Meaningful and Motivational. The Journal of School Nursing , 29: 19.

References

Levy, M., Heffner, B., Stewart, T., & Beeman, G. (2006). The efficacy of asthma case management in an urban school district in reducing school absences and hospitalizations for asthma. Journal of School Health, 76, 320-324.

National Association of School Nurses. (2014). Research Priorities for School Nursing. Available at: http://www.nasn.org/Research/ResearchPrioritiesforSchoolNursing

National Association of School Nurses. (2013). Individualized Healthcare Plans, The Role of the School Nurse. Available at: http://www.nasn.org/PolicyAdvocacy/PositionPapersandReports/NASNPositionStatementsFullView/tabid/462/smid/824/ArticleID/32/Default.aspx

Texas School Nurse Association. (2011). Diabetes IHP. Available at: http://txsno.org/files/DiabetesIHP.pdf

Texas School Nurse Association. (2011). Sickle Cell Disease Sample IHP. Available at: http://txsno.org/files/SickleCellIHP.pdf

Varni, J. W. (2015). PedsQL Measurement Model for the Pediatrics Quality of Life Inventory. Available at: http://www.pedsql.org/pedsql13.html

Weismuller, P.C., Grasska, M.A., Alexander, M., White, C.G., Kramer, P. (2007). Elementary School Nurse Interventions: Attendance and Health Outcomes. The Journal of School Nursing, 23(2), 111-118.

References