I was invited, as a parent of a
T1 child in Maryland public schools, to attend a Stakeholder’s meeting to
discuss school management of diabetes. I was really excited to go, anxious to
hear what issues they were tackling, and eager to share my thoughts and
concerns as I had heard them through the DOC (Diabetes Online Community). The
meeting was jointly convened by the Maryland Department of Health and Mental
Hygiene (DHMH), the Maryland State Department of Education (MSDE), and the
Children’s National Health System.
**Let me clarify that I do not represent these organizations, I am not speaking on their behalf, and I did obtain permission to write this post
from the officials spearheading this initiative. I am simply a T1 parent volunteer with a stake in the goals set forth by the meeting, and my goal in sharing
this is to reach parents in other states who are struggling with diabetes management
in school. As I mentioned in a previous post, there is a breathtaking gap in
Type 1 management in schools across the US. The information contained here I
hope will serve as inspiration for parents in asking their own schools and
states to step up to provide the best possible care and safety for Type 1
students – parents can and should demand legislation and more state involvement
where it is lacking. **
The agenda was comprised of
perspectives from the diabetes care provider, the State Board of Nursing,
School Health Services, and the Parent/Family, to include management
challenges, needs, and opportunities in the school setting. After
introductions, we broke out into workgroups made up of members from the various
stakeholder groups represented that day, each to discuss a different focus
area. Obviously I don’t need to tell you that there were a number of Very
Important People in attendance that day.
The topics on task for the day
included communications between Providers, Schools, and Parents regarding
medication orders, the School Health Services Form for Diabetes Management, the
implementation of 504 plans and IHPs, issues related to the training of school
nurses and other staff, the training and oversight of unlicensed persons,
challenges regarding care on field trips and other school-sponsored activities,
promotion and support for self-management and essentially what that looks like
at each school level. Each workgroup was given a specific focus area to
discuss, with very focus-specific questions. The workgroups – again, each
comprised of diabetes care providers, school nurses, representatives from the
State Board of Nursing, Parents/Caregivers, and government representatives –
were tasked to come up with recommendations for these issues.
These
focus areas can serve as a foundation for parents nationwide to open dialogue if and where it is needed:
The School Health Services Form for Diabetes
Management – how orders are written and transmitted, whether it is standard
or individualized, best ways to transmit orders, whether a new order is necessary
for every change in insulin dose, and ways to improve the form.
Communications
between providers and schools – including provider accessibility to schools,
the parents’ role regarding medication orders, and strategies to improve
communication between all parties.
Training of school nurses and other school
staff – including unlicensed persons who may be needed to fulfill
diabetes needs of students (carb counting, calculating boluses, managing care
on field trips, and strengthening policies for self-management), with
recommendations on how state and local programs can enhance this training to
unlicensed persons. Here too, the focus is on the child’s safety in the school
setting, and what happens when a school nurse is unavailable.
Communication with and oversight of
unlicensed persons providing diabetes care, strategies to address
barriers for how and what school nurses delegate, and how communication is
achieved when nurses aren’t on location. In addition, how schools promote self-care at the age-appropriate level, what care
and management looks like in elementary, middle, and high school settings, how
this determines the location of diabetic supplies, and effective collaboration
with parents and providers on these issues.
Educational supports regarding
504 plans, Individualized Health Plans (IHP), how much and what type of
information is needed on those forms, accommodations regarding standardized
tests, challenges with regard to implementation that students and parents
encounter, how these challenges were addressed, and what communication
regarding education supports has been effective between the school nurse and
other personnel.
Diabetes Management Challenges as relates
to diabetes care on field trips and school-sponsored activities, what parents’
concerns are regarding safety in the school setting, how these concerns were
addressed, what expectations parents have of school personnel, as well as what additional
training/education might be needed to support students and parents.
The end
result of this Stakeholder’s Meeting, as well as ongoing committee meetings (on
which I continue to participate) is to have a new and updated Management of Students with Diabetes Mellitus
in Schools, a Maryland State School Health Services Guideline to be
completed and in effect for the 2016-2017 school year. I am not at liberty to
discuss the specific outcomes and recommendations stemming from these meetings
at this time, though I hope to share the final product once it is officially
implemented. But I have learned so much.
Being
the “parent” often means feeling like we’re being judged on everything from
helicoptering to being the demanding or hysterical parent to being judged on
our child’s management. That’s not to say that schools make us feel that way, though I’ve heard many a parent tell some
tales that would curl your hair… I have been gloriously blessed with a
fantastic school nurse who needs absolutely no supervision from me. Type 1
parents don’t sleep very much. We are frustrated and angered by the blurred
distinction between Type 1 and Type 2, the lack of understanding from our friends
and even from family of how scary this disease is, and how it is
life-threatening on a daily basis. That may sound overdramatic, but the fact is,
and remains, that our children are alive only through our tireless diligence and
a drug that can also kill them. It’s no small wonder that any of us can function while our children are away from our care.
That
being said, I have also now heard perspectives from schools and providers. I met people that genuinely care about the safety, well-being, and education of students with diabetes. Someone said she had actively pursued a pharmaceutical company to market a half-dose
of glucagon for children under 6 years of age to make it easier for licensed
personnel to administer the correct dose if necessary. Someone commented that in
an emergency situation where glucagon is warranted, there is no such thing as
overdosing. I’m not the only parent who would agree that it’s not worth arguing
details when it comes to glucagon, because not
giving it is not an option. I have heard that some parents haven’t even provided glucagon to the school, and the
reason is affordability – because some insurance companies are not covering it.
The cost of glucagon out of pocket is over $100 per kit, and I know we have at
least 4 – one at school, one in my purse, and at least one each at my house and her dad’s.
There
was mention of having education and training for all school personnel with
regard to glucagon – that in many schools they are already trained in the use
of EpiPens, so why not glucagon as well? Shouldn’t everyone know how and when
to use it, just like the EpiPen? Should schools require it, or request volunteers to learn how to
administer it? When we were still in Pennsylvania, our school nurse had a fit
over anyone but her using the glucagon kit. Her concern was liability, and she
may have been right, but it was always my feeling that I don’t give a rat’s ass
WHO gives my kid glucagon, so long as somebody DOES. I would never sue somebody
for attempting to save my child’s life. Alas, there probably is someone who
would and therein lies the problem the “officials” face.
Also
among the conversations I heard was of one kid whose parents didn’t want to
manage his diabetes at all, and his A1c was 17. Imagine that the person who
knew this information had to decide what to do with it. It’s certainly a
different perspective, something I urge all parents to consider when they’re
feeling sensitive about how they’re treated by school personnel. Unfortunately
there are children out there with diabetes
who do not get proper care, either due to lack of parent education about Type 1
diabetes or accessibility to health care, or both. Consider how school nurses
and other personnel who DO understand diabetes handle situations like these.
What is their responsibility to this?
What’s
really exciting and coinciding with the Stakeholder’s initiative is Maryland Senator
Ronald Young’s Senate Bill 71, Public and Nonpublic Schools - Student Diabetes Management Program, which will require
“the State Department of Education and the Department of Health and Mental
Hygiene, in consultation with certain other organizations” to provide for all
of the aforementioned focus areas (I’m really overgeneralizing here). Senator
Young is very passionate about diabetes management and safety in schools. He
expressed his concerns over the gaps in diabetes care in some counties (sidebar:
Maryland public schools are organized by county, ie: Cecil County Public
Schools, Baltimore County Public Schools, etc.) with regard to safety both in the
school setting and on school buses, as well as field trips, after-school
care such as extracurricular activities, and the absence of diabetes care providers in some schools.
There
are far too many points to mention for the purpose of this post; however, it
will provide for training guidelines for staff and employee volunteers to
become trained diabetes care providers, although not to be “construed as…
practical nursing or registered nursing” (the liability side of training
diabetes care providers). The bill will provide for a Diabetes Medical Management
Plan (DMMP) meeting for the student and all individuals charged with care. It will establish, among other points, where
and how the student will manage diabetes tasks, as well as allowing the student
to carry supplies and “possess a cellular phone to ask for assistance when
necessary.”
While
my workgroup focused on policy related to unlicensed personnel providing
diabetes care to students, one nurse asked me my feelings on my child’s safety
on field trips, either in a self-care situation or with an unlicensed person
managing her diabetes. I expressed serious reservations about someone making
decisions about her care without communication with me, and especially because
in some locations cell phone service is compromised. Senator Young was in my
workgroup, so he heard my concerns. Still, his efforts with the above bill have
merit in the general sense, where some parents have few options due to work
constraints.
There
is so much more and in the interest of time and space, I will wrap this up. I
don’t pretend to know what kinds of legislation have been enacted in any other
states, but I strongly urge you to have a look at this bill. Senator Young
expects to have it enacted by July 1, 2016, and I hope by that date to have
more to share.