Enhanced Component Strategy 5

Domain 4, Strategy 5: Implement policies, processes, and protocols in schools to meet the management and care needs of students with chronic conditions.

States funded by CDC for this strategy are required to conduct all three interventions:

  1. Identifying and tracking students with chronic conditions that may require daily or emergency management, e.g. asthma and food allergies.
  2. Developing protocols that ensure students identified with a chronic condition that may require daily or emergency management are enrolled into private, state, or federally funded insurance programs if eligible.
  3. Providing assessment, counseling, and referrals to community-based medical care providers for students on activity, diet, and weight-related chronic conditions.

The intent is to target at least one of the following conditions:
asthma, food allergies, diabetes, seizure disorders, hypertension, obesity, and other chronic conditions related to activity, diet and weight.

In addition, this NACDD school health resource guide incorporates oral health conditions, e.g., dental caries (tooth decay). Oral health conditions are common chronic conditions among children, and oral health care is a common unmet need for children with special health care needs.

Performance Measures
Performance Measure 4.5.01

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Number of local education agencies (LEAs) that receive professional development and technical assistance on meeting the daily management and emergency care needs of students with chronic conditions.

The purpose of this performance measure is to determine reach of professional development and technical assistance on meeting the daily management and emergency care needs of students with chronic conditions by identifying and tracking students that may require daily or emergency management.

Results Statement: In the US, CDC funded grantees worked to educate and inform staff in LEAs about meeting the daily management and emergency care needs of students with chronic conditions, by identifying and tracking students that may require daily or emergency management.

Unit of Analysis/Measure: Targeted local education agencies (i.e., school districts)

Rate/Count/Percentage: Actual number of targeted local education agencies (i.e., school districts) (not to exceed 15) that received professional development or technical assistance on about identifying and tracking students with chronic conditions that may require daily or emergency management.

How to Count and Frequency: Training tracking system. Annually.

Disparities Focus: Academic, health, SES, free and reduced priced lunch data

Performance Measure 4.5.02

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Percent of schools that identify and track students with chronic conditions that may require daily or emergency management, e.g. asthma and food allergies.

The purpose of this performance measure is to determine the extent to which schools are identifying and tracking students that may require daily or emergency management.

Results Statement: In the US, CDC funded grantees worked to increase the number of schools that identify and track students that may require daily or emergency management.

Unit of Analysis/Measure: Schools within targeted local education agencies (i.e., school districts)

Rate/Count/Percentage: Percent of schools, among targeted LEAs, that identify and track students with chronic conditions that may require daily or emergency management, e.g. asthma and food allergies.

How to Count and Frequency: 2014, 2016, 2018 School Health Profiles (2016 Principal Questionnaire, Q42). Biannually

Disparities Focus: Academic, health, SES, free and reduced priced lunch data

Performance Measure 4.5.03

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Number of local education agencies that receive professional development and technical assistance on meeting the daily management and emergency care needs of students with chronic conditions.

The purpose of this performance measure is to determine reach of professional development and technical assistance on meeting the daily management and emergency care needs of students with chronic conditions by developing protocols that ensure these students are enrolled into insurance programs. School health personnel should establish systematic protocols and processes for determining the health insurance status of students with chronic conditions and if necessary, assist parents and families in enrolling eligible students into private, state, or federally funded insurance programs.

Results Statement: In the US, CDC funded grantees worked to educate and inform staff in LEAs about meeting the daily management and emergency care needs of students with chronic conditions, by developing protocols that ensure these students are enrolled into insurance programs.

Unit of Analysis/Measure: Targeted local education agencies (i.e., school districts)

Rate/Count/Percentage: Actual number of local education agencies (i.e., school districts) (not to exceed 15) that received professional development or technical assistance about developing protocols that ensure students identified with a chronic condition that may require daily or emergency management are enrolled into private, state, or federally funded insurance programs if eligible.

How to Count and Frequency: Training tracking system. Annually.

Disparities Focus: Academic, health, SES, free and reduced priced lunch data

Performance Measure 4.5.04

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Number of students identified with chronic conditions in local education agencies with staff that received professional development and technical assistance on meeting the daily management and emergency care needs of students with chronic conditions.

The purpose of this performance measure is to determine the extent to which students are identified with chronic conditions. School health personnel should establish systematic protocols and processes for determining the health insurance status of students with chronic conditions and if necessary, assist parents and families in enrolling eligible students into private, state, or federally funded insurance programs.

Results Statement: In the US, CDC funded grantees worked to increase the number of students identified with chronic conditions in local education agencies with staff that received professional development and technical assistance on meeting the daily management and emergency care needs of students with chronic conditions.

Unit of Analysis/Measure: Students within targeted local education agencies (i.e. school districts)

Rate/Count/Percentage: Actual number of students identified with chronic conditions in targeted LEAs with staff that received professional development and technical assistance on developing protocols that ensure students identified with a chronic condition that may require daily or emergency management are enrolled into private, state, or federally funded insurance programs, if eligible.

How to Count and Frequency: Student tracking system, school nurse or clinic records, and school registration records. Annually.

Disparities Focus: Academic, health, SES, free and reduced priced lunch data

Performance Measure 4.5.05

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Percent of schools that have protocols that ensure students identified with a chronic condition that may require daily or emergency management are enrolled into private, state, or federally funded insurance programs if eligible.

The purpose of this performance measure is to determine the extent to which schools have protocols that ensure that students identified with a chronic condition that may require daily or emergency management are enrolled into private, state, or federally funded insurance programs if eligible. School health personnel should establish systematic protocols and processes for determining the health insurance status of students with chronic conditions and if necessary, assist parents and families in enrolling eligible students into private, state, or federally funded insurance programs.

Results Statement: In the US, CDC funded grantees worked to increase the number of schools that ensure that students identified with a chronic condition that may require daily or emergency management are enrolled into private, state, or federally funded insurance programs if eligible.

Unit of Analysis/Measure: Schools

Rate/Count/Percentage: Percent of schools, among targeted LEAs, that have protocols that ensure students identified with a chronic condition that may require daily or emergency management are enrolled into private, state, or federally funded insurance programs if eligible.

How to Count and Frequency: 2014, 2016, 2018 School Health Profiles (2016 Principal Questionnaire, Q41). Biannually

Disparities Focus: Academic, health, SES, free and reduced priced lunch data

Performance Measure 4.5.06

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Number of local education agencies that receive professional development and technical assistance on assessment, counseling, and referrals to community-based medical care providers for students on activity, diet, and weight-related chronic conditions.

The purpose of this performance measure is to determine reach of professional development and technical assistance on assessment, counseling, and referrals to community-based medical care providers for students on activity, diet, and weight-related chronic conditions. Health, mental health, and social services staff members serve as liaisons between schools staff members, students, families, community programs, and health-care providers. Community resources can address health, mental health, and social service gaps that the school might not have the resources or expertise to address adequately. School health personnel should establish systematic processes and criteria for referring students to external primary health-care providers.

Results Statement: In the US, CDC funded grantees worked to educate and inform staff in LEAs about assessment, counseling, and referrals to community-based medical care providers for students on activity, diet, and weight-related chronic conditions.

Unit of Analysis/Measure: Targeted local education agencies (i.e., school districts).

Rate/Count/Percentage: Actual number of targeted local education agencies (i.e., school districts) (not exceed 15) that received professional development or technical assistance on assessment, counseling, and referrals to community-based medical care providers for students on activity, diet, and weight-related chronic conditions.

How to Count and Frequency: Training tracking system. Annually.

Disparities Focus: Academic, health, SES, free and reduced priced lunch data

Performance Measure 4.5.07

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Number of students identified with chronic conditions in local education agencies (LEAs) with staff that received professional development and technical assistance on assessment, counseling, and referrals to community-based medical care providers for students on activity, diet, and weight-related chronic conditions.

The purpose of this performance measure is to determine the extent to which students are identified with chronic conditions. Health, mental health, and social services staff members serve as liaisons between schools staff members, students, families, community programs, and health-care providers. Community resources can address health, mental health, and social service gaps that the school might not have the resources or expertise to address adequately. School health personnel should establish systematic processes and criteria for referring students to external primary health-care providers.

Results Statement: In the US, CDC funded grantees worked to the number of students identified with chronic conditions in LEAs with staff that received professional development and technical assistance about assessment, counseling, and referrals to community-based medical care providers for students on activity, diet, and weight-related chronic conditions.

Unit of Analysis/Measure: Students within targeted local education agencies (i.e., school districts).

Rate/Count/Percentage: Actual number of targeted local education agencies (i.e., school districts) (not exceed 15) that received professional development or technical assistance on assessment, counseling, and referrals to community-based medical care providers for students on activity, diet, and weight-related chronic conditions.

How to Count and Frequency: Student tracking system, school nurse or clinic records, and school registration records. Annually.

Disparities Focus: Academic, health, SES, free and reduced priced lunch data

Performance Measure 4.5.08

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Percent of schools that provide students with referral to community-based medical care providers for students identified with chronic conditions or at risk for activity, diet, and weight-related chronic conditions.

The purpose of this performance measure is to determine the extent to which schools provide assessment, counseling, and referral to community-based medical care providers for students on activity, diet, and weight-related chronic conditions. Health, mental health, and social services staff members serve as liaisons between schools staff members, students, families, community programs, and health-care providers. Community resources can address health, mental health, and social service gaps that the school might not have the resources or expertise to address adequately. School health personnel should establish systematic processes and criteria for referring students to external primary health-care providers.

Results Statement: In the US, CDC funded grantees worked to increase the number of schools that provide assessment, counseling, and referrals to community-based medical care providers for students on activity, diet, and weight-related chronic conditions.

Unit of Analysis/Measure: Schools

Rate/Count/Percentage: Percent of schools, among targeted LEAs, that provide students with referral to community-based medical care providers for students identified with chronic conditions or at risk for activity, diet, and weight-related chronic conditions.

How to Count and Frequency: 2014, 2016, 2018 School Health Profiles (2016 Principal Questionnaire, Q43). Biannually.

Disparities Focus: Academic, health, SES, free and reduced priced lunch data

Performance Measure 4.5.09

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Reduced absences for students identified with chronic conditions (in the local education agencies targeted by FOA funding).

The purpose of this performance measure is to determine the extent to which there has been a reduction in absenteeism among students identified with chronic conditions.

Results Statement: In the US, CDC funded grantees worked to increase attendance of students with chronic conditions, thus maximizing learning.

Unit of Analysis/Measure: Days absent

Rate/Count/Percentage: Percent absenteeism for students identified with a chronic condition in targeted LEAs.

How to Count and Frequency: Student chronic condition tracking system or database to identify students with chronic conditions. Student attendance records to determine the number of days missed. Annually.

To calculate percent absenteeism for the state, divide the total number of school days missed among students identified with a chronic condition in schools in the targeted LEAs by total attendance days multiplied by number of schools reporting. For some districts and schools, total attendance days may vary. In addition, actual total attendance days may vary significantly for each student. To standardize the number of attendance days, states are asked to select a total number of attendance days, for example 180 days, based on the accepted value for that state. States are asked to use this set number of attendance days when calculating this performance measure annually.

Performance Measure 4.5.10

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Percentage of students identified with chronic conditions who have a medical home (i.e., a medical home with skilled and knowledgeable health care professionals who, acting as a team, continuously monitor the child's health status over time and manage the medications (not merely episodic management of attacks) (in the local education agencies targeted by FOA funding).

The purpose of this performance measure is to determine the extent to which students identified with a chronic condition have a medical home (i.e., skilled and knowledgeable health care professionals who, acting as a team, continuously monitor the child's health status over time and manage medications.

Results Statement: In the US, CDC funded grantees worked to ensure that students identified with a chronic condition who require ongoing management for chronic health conditions will receive continuous care and monitoring at school.

Unit of Analysis/Measure: Students

Rate/Count/Percentage: Percent of students identified with chronic conditions that have a medical home in the targeted LEAs.

How to Count and Frequency: Annually. The following data sources can/should be used to determine whether a student has an identified primary care provider (e.g. physician, nurse practitioner, physician assistant) on file, and to serve as a data source for this measure. A school-based health center may count as a medical home if a primary care provider at the center has been identified for a student.:

  • Individualized education-related or condition specific plans, such as Diabetes Medical Management Plans, Asthma Action Plans, a Food Allergy Management Plans, 504 plans, Individualized Education Plans, or medication authorizations.
  • School nurse/clinical health-related, annual school registration and/or medical history forms.
  • The number of students who have a medical home should be aggregated across all targeted LEAs and divided by the total number of students with a chronic condition across all targeted LEAs.

Activities

Assess the professional development (PD) and technical assistance (TA) needs of local education agencies (LEAs). States should conduct a needs assessment of LEAs, and LEAs should provide a needs assessment to schools. An assessment could include a scan of existing state policies, LEA policies, and any data on implementation. It could also include a short survey to LEAs.

Based on the assessment of PD and TA needs specific to the above topics, identify relevant trainings and PD opportunities that are already available through organizations. If a training or PD opportunity is not already available, consider creating a new training, including when it will be offered and the method of those courses (e.g., in-person, online).

Identify a process for providing PD to LEAs in the state. This might include: development of courses, communication/marketing of the courses, registration for courses, number of courses and courses offered per topic, potential costs involved, identification of trainers, tracking of people taking the courses, continuing education credit, etc.

Identify a process for providing TA to LEAs in the state. This might include: who school districts and schools may call for assistance, the topic of the TA, how calls will be fielded, how questions will be tracked, and what types of tools, resources, and additional information are given, etc.

Provide TA on all topics offered for PD.

Identify an appropriate system for tracking PD and TA that is focused on meeting the management and care needs of students with chronic conditions (see Tips for Tracking Professional Development & Technical Assistance in State Public Health Actions’ (1305) School Health Strategies).

Suggested activities to meet performance measures 4.5.01 – 4.5.02:
Provide PD and TA to LEAs on meeting the daily management and emergency care needs of students with chronic conditions. States should work with LEAs to achieve the following:

  • Use 504 Plans, Individualized Education Plans (IEPs), or other health/education plans as appropriate, to officially document identified students’ chronic condition, required medications, possible activity modifications, and other key actions to address daily management of the student’s condition, in addition to key actions that must be taken during a situation requiring an immediate response.
  • Determine the level of knowledge and expertise of school staff, particularly school health and mental health services staff, in addressing the daily management and emergency response needs of students with specific chronic conditions.
  • Provide comprehensive PD to primary school health services staff, i.e. school nurses, consulting school physicians, and school nurse consultants, on specific chronic conditions to ensure they possess the broad knowledge and specific skills to address both the daily management and emergency response needs of individual students. This condition specific PD should include a broad overview of the condition, how to make subjective and objective assessments of the student’s current health status, how to recognize the signs and symptoms of a worsening condition, and what actions must be taken to assist students in situations that require immediate action.
  • Provide PD to additional school staff, such as classroom teachers, physical education teachers, janitors, bus drivers, as appropriate. This PD should ensure that these targeted staff have an awareness of the different chronic conditions being addressed at the school, can recognize the signs and symptoms of a worsening condition, and what actions must be taken to assist students in situations that require immediate action.

Work with targeted LEAs to establish protocols for identifying students with chronic conditions. These protocols should include:

  • Using or adapting existing school health records to identify all students with a diagnosed chronic condition. Adding one or two additional questions to emergency and school registration cards can provide an initial means for identifying students with chronic conditions.
  • Using health room and attendance records to identify students with chronic conditions.

Work with targeted LEAs to establish protocols for tracking students with chronic conditions. These protocols should include:

  • Using health room and attendance records to track students with chronic conditions. Focus particularly on students who may be having difficulties managing their condition on a daily basis as evidenced by frequent school absences, school health office visits, emergency room visits, or hospitalizations.
  • Use 504 Plans, IEPs, or other health/education plans as appropriate, to officially document the student’s condition, required medications, possible activity modifications, and other key actions to address daily management of the student’s condition, in addition to key actions that must be taken during a situation requiring an immediate response.

Suggested activities to meet performance measures 4.5.03 and 4.5.04:
Provide PD and TA to LEAs on meeting the daily management and emergency care needs of students with chronic conditions. States should work with LEAs to achieve the following:

  • Use 504 Plans, IEPs, or other health/education plans as appropriate, to officially document identified students’ chronic condition, required medications, possible activity modifications, and other key actions to address daily management of the student’s condition, in addition to key actions that must be taken during a situation requiring an immediate response.
  • Determine the level of knowledge and expertise of school staff, particularly school health and mental health services staff, in addressing the daily management and emergency response needs of students with specific chronic conditions.
  • Provide comprehensive PD to primary school health services staff, i.e. school nurses, consulting school physicians, and school nurse consultants, on specific chronic conditions to ensure they possess the broad knowledge and specific skills to address both the daily management and emergency response needs of individual students. This condition specific PD should include a broad overview of the condition, how to make subjective and objective assessments of the student’s current health status, how to recognize the signs and symptoms of a worsening condition, and what actions must be taken to assist students in situations that require immediate action.
  • Provide PD to additional school staff, such as classroom teachers, physical education teachers, janitors, bus drivers, as appropriate. This PD should ensure that these targeted staff have an awareness of the different chronic conditions being addressed at the school, can recognize the signs and symptoms of a worsening condition, and what actions must be taken to assist students in situations that require immediate action.

Suggested activities to meet performance measure 4.5.05:
Provide PD and TA to LEAs on developing and maintaining a repository of local resources and services that schools may access to assist families with determining eligibility and enrolling into private, state, or federally funded insurance programs if eligible. States should work with LEAs to achieve the following:

  • Develop a process for assessing the availability of local resources in targeted LEAs that offer families with insurance eligibility determination and enrollment assistance. LEAs may consider partnering with locally-based, federally trained designated individuals, faith-based entities, and community organizations that are now providing these services (in accordance and often with funding from the Affordable Care Act) to assist individuals with navigating the new Health Insurance Marketplaces within their states, and understanding their eligibility and options so they may make informed decisions about obtaining affordable health care coverage.
  • Maintain accurate and up to date repositories for use by local school staff to ensure families are being referred to currently available and qualified individuals and organizations. This professional development should ensure that local districts are aware of relevant local, state, and federal resources.
  • Ensure that an individual or team is designated to maintain an up to date listing/repository of resources for local use.

Suggested activities to meet performance measures 4.5.06 – 4.5.08:
Assess schools within targeted LEAs on the extent that they have established a referral system for students and for which conditions are being referred.

  • Work with the state-level affiliates of American Academy of Pediatrics (AAP), School-Based Health Alliance (SBHA), or National Association of School Nurses (NASN) to determine if any LEAs/schools within the targeted LEAs, or in the state, have had success with strategies and best practices for establishing an effective referral system. If yes, consider broadly disseminating.
  • Work with the state-level affiliates of AAP, SBHA, and NASN to identify, adapt, or develop appropriate guidance for LEAs/schools on referring students with chronic conditions.
  • Referral systems should be based on a systematic process and include criteria for referring students to external community-based medical care providers. Schools and LEAs should use strategies to increase student/family participation in following-up with a community-based medical care provider after being referred and evaluate the extent of follow-up.

Identify, adapt, or develop guidance for LEAs on referring students with chronic conditions.

  • Use the results of the assessment to inform the guidance.
  • Work with the state-level affiliates of AAP, SBHA, and NASN to identify, adapt, or develop appropriate guidance for LEAs/schools on referring students with chronic conditions.
  • Include guidance on informing community-medical care providers on referral system.
  • Consider involving representatives from families and community medical care providers on the development or roll-out of the new guidance on referrals.
  • Referral systems should be based on a systematic process and include criteria for referring students to external community-based medical care providers. Schools and LEAS should use strategies to increase student/family participation in following-up with a community-based medical care provider after being referred and evaluate the extent of follow-up.
  • Include guidance on assessing the effectiveness of the referral system. To assess the effectiveness of the referral system, LEAs might:
  • Ask students and families, who had been referred to an outside provider, whether they followed-up with the medical care provider. If the student or family did not follow-up with a medical care provider, inquire to the reason they had not. Identify potential barriers and help identify solutions to the barriers.
  • Ask students and families if the school health services staff can provide further assistance in daily management of chronic condition.
  • Identify if the student or family needs an IHP or 504 plan for the chronic condition.
  • If the student does not have health insurance, assist the family in enrolling the student into private, state, or federally funded insurance programs if eligible.

Provide PD and TA to LEAs on the guidance for referring students who are suspected of having a chronic condition or may have chronic conditions.

  • Identify the appropriate staff at the LEA-level (e.g., director of health services) or school-level (e.g., school nurse) that will be implementing the referral system and will need training on the guidance.
  • Encourage staff to communicate the new process with families.

Provide PD and TA to LEAs and schools on identifying appropriate community medical care providers for students to be referred.

  • Identify community medical care providers who are equipped to address the chronic conditions needs of a pediatric population.
  • Community medical care providers should be made aware that they are on the LEA/school referral list.
  • LEAs and schools need to also identify those community medical care providers who accept Medicaid patients or persons lacking health insurance. LEAs and schools may also consider engaging school social services staff and/or local community resources to address other barriers to seeking care (e.g., transportation).
  • Consider including behavioral services as part of the referral list including community-based nutrition and physical activity providers and services (e.g., dieticians, recreational programs, and cooking classes).
Model/Sample Policies

State School Health Policy Matrix 2.0

See Policy Guidance for policy and procedure information for the management and care of chronic conditions, including information organized by some types of chronic conditions (e.g. asthma, diabetes, food allergies and anaphylaxis, seizure disorders, and oral health conditions with a focus on dental caries (tooth decay))

Resources and Links
Asthma Diabetes Food Allergy and Anaphylaxis Seizure Disorders Oral Health Conditions Other Chronic Condition Resources

More Resources & Links