Source: Department of Health, Disease Outbreak and Control Division
An increasing number of students with congenital or chronic health problems, who may require individualized health care treatment/procedures during the school day, are coming to school. Students who were either born with or acquired difficulties with respiration, feeding, regulation, and other health difficulties attend school with the support of a team of professionals such as the nurse and other related services personnel, in addition to the classroom teacher. Some conditions cause mobility problems for children; others create enough fatigue to curtail the child’s participation and require special remedial efforts. Illnesses and their treatments frequently lead to greater-than-usual school absence and may, in that way, also hinder educational progress.
Although medical care is beyond the scope of an educator’s responsibilities, the educator should be sensitive to conditions affecting the student and family. The educator should be aware of a student’s health condition (including physical limitations), safety precautions to prevent injury, first aid care, and how to access emergency care. For any child with a chronic health problem, an interdisciplinary team approach to address the issues and concerns is best to meet the complex needs of this group of students. Such an approach allows for an exchange of information and sharing of strategies among professionals. At the school level, the team may be made up of, but not limited to:
For the community sector, the team leader is usually the physician. In the school sector, the team leader or care coordinator is the teacher.
Public education services are mandated for all students, including those with physical health needs. Not all students with physical health needs require special education. They do, however, require planning to determine how their special needs will be met — via accommodations or special education and related services. A student with physical health needs poses a challenge to the family, school staff, and community agencies. A safe and appropriate educational program requires a collaborative effort by all.
An interdisciplinary team approach is best to address the issues and to meet the needs of a student with physical health needs. This approach allows for a free exchange of information, sharing of strategies among professionals, and reinforcement of needed activities for learning throughout a student’s day.
Best practice suggests that partnering between public and private agencies as well as within the Hawaii Department of Education (DOE), school, complex, district, and state levels ensures a supportive infrastructure for students with physical health needs. This is essential to assure effectiveness and efficiency in planning and resource management. Coordination of services, involving collaboration between:
|The information contained in this handbook is a guideline to assist educators in providing the support services for a child with physical health needs. It does not substitute for the specific medical treatment/management plan prescribed by the student’s physician(s), nor does it invalidate the laws and rules established by the Board of Education and the State of Hawaii.|
When a child with physical health needs is eligible for special education services, the Individualized Education Program (IEP) becomes an important document that outlines the services the child needs in order to benefit from special education. For a student with physical health needs, eligible for services under Section 504, the Modification Plan (MP) becomes an important document that outlines the modifications and/or accommodations that are needed to ensure the child learns in a conducive environment.
Children with intensive medical needs may receive educational services in a wide variety of placements, from full-time placement in a general education setting to placement in a hospital or skilled nursing facility.
For the array of services provided to students with physical health needs, refer to the Comprehensive Student Support System Operations Manual, Department of Education, Office of Curriculum, Instruction and Student Support.
For children who reside in hospitals or skilled nursing facilities, the facility is responsible for the child’s medical care, including therapy services, as prescribed by the physician. The special education teacher, who may request consultation from the DOE therapists in order that the child’s educational goals can be met, is responsible for the overall implementation of the IEP.
It is imperative that the educational information concerning a student be kept confidential. Only the team members who work with a student or have written parental permission to evaluate a student may discuss or have access to educational or health related information. There are numerous federal laws that protect and ensure the privacy of a student’s information.
Family Educational Rights and Privacy Act (FERPA) sets out requirements designed to protect the privacy of parents and students. In brief, the law requires a school district to:
Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires the adoption of privacy and security standards in order to protect individually identifiable health information. Relevant to school staff in regards to medical records and Medicaid billing reimbursement.
Individuals with Disabilities Education Improvement Act (IDEIA) of 2004 ensures the confidentiality of personally identifiable information under §300.123, which stipulates that “the State must have on file, in detail, the policies and procedures that the State has undertaken to ensure protection of the confidentiality of any personally identifiable information, collected, used, or maintained under Part B of the Act.”
Chapter 56, Subchapter 9, Confidentiality of Information, §8-56-59 stipulates that the provisions relating to the Protection of Educational Rights and Privacy of Students and Parents, FERPA, and IDEIA apply to students with a disability or students suspected of having a disability and the students’ parents.
Board of Education Policy regarding student information and confidential records states, “Information relative to students or former students in the public schools shall not be divulged or permitted by any Department personnel except as authorized by the individual student, parent, or guardian, or permitted as required by the Department of Education or by law.”
Use Universal Precautions when working with children who require physical care.
To reduce the spread of infectious diseases (diseases that can be spread from one person to another), it is important to follow the Universal Precautions. Universal precautions are a set of guidelines that assumes that all blood and certain other body fluids are potentially infectious. It is important to follow universal precautions when providing care to any student, whether or not the student is known to be infectious. The following list describes the universal precautions:
The IEP is a written document developed by the IEP team, which sets out the specific instructional program and related services (which may include, but are not limited to: transportation, physical therapy, occupational therapy, speech language therapy, skilled nursing, etc.) to be provided to a student with a disability.
The term student with a “disability” under Chapter 56 means a student evaluated in accordance with IDEIA as having one or more of the recognized fourteen disability categories and who, by reason thereof, needs special education and related services.
IDEIA recognizes fourteen disability categories, which establish a child’s need for special education and related services. These disabilities include:
The special education teacher is usually the care coordinator. The teacher is the facilitator of the IEP team who develops the IEP with input from and collaboration with the other team members. In formulating the Present Level of Educational Performance (PLEP), it is highly recommended that the teacher consult with the medical professionals and other related services professionals to obtain comprehensive information on academic achievement and functional performance. The PLEP is a critical foundation on which the goals and objectives are built. In regards to specific related services, the team defers to the expertise of the respective services provider(s); however, it is the IEP team who determines if there is a need for a specific related service.
An interdisciplinary team approach is best to address the issues and to meet the needs of a student with physical health needs. This approach allows for a free exchange of information, sharing of strategies among professionals, and reinforcement of needed activities for learning throughout a student’s day. As the care coordinator, the classroom teacher is responsible for ensuring the effective implementation of the IEP. Although each related services personnel emphasizes and focuses on his or her area of expertise, it is primarily the teaching staff who addresses the IEP goals and objectives on a consistent, daily basis within the classroom curriculum. For many of these students with physical health needs, the daily educational program includes positioning with or without adaptive equipment, utilizing specific feeding techniques, and range of motion exercises (gentle passive movements to maintain flexibility). One of the primary roles of the related services personnel is to ensure that the teaching staff are doing these activities correctly and safely. Continuing concerns regarding the roles and responsibilities for implementation of these and other activities should be brought to the attention of the school principal.
Section 504 of the Rehabilitation Act of 1973 protects all students with a disability from discrimination on the basis of that disability. In public schools operated by the DOE of the State of Hawaii, students with a disability who are protected by Section 504 shall have access to a Free Appropriate Public Education (FAPE) under Chapter 53.
A student may be considered disabled under Section 504/Americans with Disabilities Act if they meet the following criteria:
When a student is assessed and determined eligible under Chapter 53, a FAPE is made available to the student in accordance with a Section 504 MP. The Eligibility and MP is a written document developed by the MP team. The MP ensures equal access to regular educational opportunities for a student with a disability who requires only modifications or accommodations. The plan shall include the following:
The MP for a Section 504-eligible student shall include:
Related services means transportation and such developmental, corrective, and other supportive services as they are required to meet the individual educational needs of a student with a disability as adequately as students without a disability. Related services may include, but are not limited to:
The care coordinator is determined by the student’s MP team. The care coordinator’s responsibilities are determined by the school administrator and often include facilitation of the MP team meetings, monitoring of timelines, and ensuring the implementation of procedural safeguards.
The DOE shall ensure that the Section 504 team for each student is a group of persons including:
The team, including any related services providers, has a collective responsibility to develop, review, and revise the student’s MP.
The Americans with Disabilities Act Accessibility Guidelines (ADAAG) includes specifications for accessible means of egress, emergency alarms, and signage. The United States Access Board develops and maintains accessibility requirements for the built environment, among other elements, under several laws including the Americans with Disabilities Act (ADA).
Administrative Directive No. 95-04, Emergency Evacuation Plans for All State Facilities, provides guidance and policy for planning the emergency evacuation of State buildings and facilities in an orderly and safe manner. Evacuation plans should include provisions for prompt new (and incumbent) employee orientations, annual drills, consideration of employees with special needs, and the public customer. Evacuation plans should be updated annually and maintained by the respective departments and agencies.
Each school should give special consideration in developing emergency evacuation plans for special education students and students who have physical health needs. In most classrooms the teacher to student ratio does not allow for a one-to-one assignment for emergency evacuations. Developing a practical plan will involve other adults on campus who should be assigned to assist the classroom staff. Therefore, the evacuation plan becomes not only a classroom endeavor but also a school-wide endeavor. (See page F-23 for sample school plan.)
Schools should include in their Evacuation Plan details such as who (by name) is assigned to evacuate the child with special needs; the equipment that must be taken with the child; and where to deliver the child and/or equipment. The plan must be readily available for substitute teachers or educational assistants. In addition, a contingency plan (to address absences of primary staff assigned in the Action Plan) needs to be developed and frequently reviewed.
Adults who are not assigned to a classroom should be considered and assigned to assist the students with physical health needs. These adults may include: custodial staff, office staff, cafeteria staff, volunteers, and resource teachers (music, art, physical education, librarian). The plan should include the who, what, where, and how. Who is assigned to go to the classroom to help? What will each adult be doing (i.e., two adults assigned to put the students in the wheelchairs while another adult begins to push a student out the classroom door, etc.)? Where is the final destination/location? (For general instructions on how to lift, refer to page 17.)
Individual plans for evacuation should be on file in the student’s confidential folder and practiced during drills for any student with physical, sensory, and/or cognitive disabilities who is unable to follow general evacuation procedures or for whom general supervision is not sufficient. During an actual emergency, students with physical or mental impairments may become disoriented or emotionally disabled and will require assistance to evacuate. Evacuation may necessitate that two adults lift and carry the student with a disability out of a building using proper methods of carrying/evacuating people.
Evacuation plans will need to include special school events, such as graduation, May Day programs, school assemblies in which the student participates, athletic contests, etc., the use of facilities such as school libraries, gymnasiums, auditoriums, stadiums, cafeterias, and multipurpose rooms, including their use during non-school hours.
Evacuation of students with physical health needs, especially wheelchair bound students, from the second floor is problematic. Consideration should be given to relocating these students to the first floor if at all possible.
The following are guidelines to follow for various emergency evacuation situations.
When the fire alarm is activated, act immediately to evacuate according to the fire evacuation plan. The four methods of fire evacuation from multi-story buildings are:
Never use mechanical stair climbers during evacuations since they may block the stairwell and present a hazard to others evacuating the building. Evacuation chairs may be used for those students needing assistance. If evacuation chairs are considered for use, discussion should be directed at identifying the number of evacuation chairs required, the selection of type of evacuation chairs, and training.
When the decision to evacuate a building is caused by a bomb threat, all persons shall evacuate the building to the identified evacuation sites (at least 300 feet away) or to a location with concrete barriers.
When a tsunami warning is issued, all persons shall evacuate the building to an evacuation site for schools located in tsunami evacuation zones and according to the school’s tsunami evacuation plans.
In the event of a hazardous materials release, follow the lead fire official’s orders to shelter in place or to evacuate. Evacuation is generally crosswind from the hazardous source.
General guidance during an earthquake is to remain indoors. Seek cover under sturdy tables, doorjambs, etc., and away from falling debris and live electrical wires until receiving instructions from emergency workers or school administration.
Note: Evacuation drills should be conducted periodically to ensure proper functioning of the evacuation plan and to determine areas in need of attention. Students with disabilities should participate in the drills although their level of participation may be accomplished by a “talk through.” Training should be provided, as necessary, for key personnel assigned to specific evacuation activities. For example, employees assigned to assist students with physical health needs through the use of evacuation chairs shall be trained in their proper use. Training for evacuation assistants should also include the proper use of assistive devices. If students are unable to evacuate independently, they are to go to or be taken to the cluster of students with disabilities. Evacuation maps should be clearly posted to inform everyone about identified exit routes.
The following evacuation checklist contains general items to consider and “check off” when designing and implementing an evacuation plan. It may need to be individualized for each particular student’s or school’s needs.
DO NOT RESUSITATE (DNR) means withholding of life-sustaining measure(s) in the event of respiratory or cardiac arrest. A life-sustaining measure, familiar to DOE staff, is cardiopulmonary resuscitation (CPR) or pushing down on the middle of the chest to begin a heart beat and manual breaths to provide oxygen to the lungs when a student’s heart stops or the student stops breathing.
A DNR order is a medical order or prescription written by a licensed physician in agreement with the client/parent/legal guardian to withhold life-sustaining measures. In the school setting, the decision about resuscitation is a medical, not an educational, decision.
The DOE maintains an expectation that school staff and school health care providers aid injured or ill students. Staff must act in a reasonable manner to obtain immediate care for the student in need of additional assistance to assure the safety of the student. Life threatening emergencies must be handled by calling 911. During the period between calling 911 and the arrival of emergency services personnel, school staff will provide first aid and/or CPR for all students in need. For students with physical health needs with a high probability of experiencing emergency situations during the school day, an Emergency Action Plan (EAP) should be developed so the DOE staff and all those involved with the student respond appropriately in getting emergency medical services for the student in need.
Therefore, the DNR order in the school setting is contradictory to the departmental policy of providing immediate care and to obtain emergency medical services by calling EMS or 911. If an order for DNR is presented, the school will not accept the DNR order under any circumstances. Please contact the Public Health Nurse (PHN) for assistance to collaborate with the parent/legal guardian and licensed physician to explain the policy of the DOE and to assure an EAP is in place for the student with physical health needs.
When planning a field trip, consideration concerning health and safety should be given to all students, regardless of the presence of physical health needs or being certified special education or Section 504. It is recommended that a plan for emergency preparation/evacuation be developed for both the field trip site and the bus. The IEP/MP team needs to carefully weigh all the elements involved and determine if the field trip(s) is appropriate based on the safety and educational needs of the student. The IEP/MP team needs to consider if there are alternate ways to meet the educational objectives instead of an excursion. If it is determined that only a field trip can meet an educational objective, there must be pre-planning to meet the student’s physical health needs. It should be documented in the “meeting notes” section of the IEP/MP ? what will be done to meet the physical health needs of the student and who will do it. It may not always be the licensed nurse who meets those needs on an excursion. Often times, a parent or legal guardian will accompany their child/student on a field trip as they are capable, willing, and legally authorized to care for the student’s physical needs without a medical or nursing license.
The A+ Program brings affordable after-school services to children in public elementary schools whose parents work, attend school, or are in job training programs, so that the high incidence of latchkey children is reduced. The program provides a safe, secure, and nurturing environment for the children after school.
The A+ Program shall be made available to all eligible children on a nondiscriminatory basis. For those disabled students who are identified by the parent or are known to the A+ program staff to have special needs, the district will provide reasonable accommodations to afford the student an opportunity to participate. Each student’s needs will be assessed on a case-by-case basis by the Site Coordinator (with consultation with the District Coordinator). For DOE sites, the Principal and the A+ District Coordinator in consultation with the District Specialists for special education or special services shall determine the disposition of each case. The Review of Special Needs form will be used to address the specials needs of children. The review procedure should be conducted on a yearly basis with parent involvement, input by school personnel, program modifications, and reasonable accommodations that are known to all program employees.
The A+ program is not an extension of the regular school day. The A+ program is not part of the student’s IEP. Hence, the IEP of the regular school program will not be in effect, and the information contained in the IEP and the confidential file will not be available for the A+ program.