Objective
The primary objective of this project is to evaluate the effectiveness of a pragmatic virtual school health nursing program on outcomes related to diabetes management of children with T1D. A secondary objective is to evaluate the impact of the program on children who receive care for acute health needs (i.e. illness, asthma, severe allergic reactions, and head injuries). By offsetting the initial start-up costs of the program, awarded funds would be used to expand programing to more schools and bring Avera eCARE School Health services to more states. As a respected national and international thought leader in the telehealth industry, Avera eCARE is uniquely qualified to address the lack of school nurses and healthcare resources in rural, frontier, and underserved schools.
Background Rationale
In 2015, Avera eCARE School Health began providing services to one school district in South Dakota and has since grown exponentially to provide services to 32 districts across Iowa, North and South Dakota. This equates to 46 schools with a school RN available at the push of a button and 10,320 children and youth who have access to evidence-based care throughout their school day. Avera eCARE School Health has had a remarkable impact on faculty, students, and their families. Not only does the availability of a school nurse via telehealth increase the likelihood for a student to stay in school, it also minimizes the need for parents to unexpectedly take time off from work, and decreases expenses for travel for health care consultation, especially for those in rural and underserved communities. As part of the proposed project, data will be gathered to capture these estimated cost savings/cost avoidance. To date, feedback from school leadership, staff, and parents has been overwhelmingly positive. Since the beginning of the 2019/2020 academic year, Avera eCARE School Health has conducted 4,253 telehealth encounters with an average return to class rate of 91.2%. Since May 1, 2018 Avera eCARE School Health has completed 5,390 total T1D encounters, providing skilled school nurse assessments, clinical judgement and overseeing the care of 45 students with T1D. If school health was not available for these students with T1D, either the parents would frequently go to the school or give directions to the school staff on specifics necessary for the students’ care depending on the scenario. Continued access to a highly skilled and experienced virtual school nurse for management of a chronic health condition during school hours remains invaluable. The purpose of this project is to evaluate the effectiveness of a pragmatic School Health nursing program on outcomes related to diabetes management of children with T1D, acute health (i.e. asthma, severe allergic reactions, and head injuries); and the increase in staff knowledge and care access as it relates to overall improvements in health outcomes, quality of life, and academic achievement.
Description of Project
School nurses bridge health care and education, help create healthy communities, and are critical to ensuring the safety of students living with chronic conditions like diabetes. The National Association of School Nurses’ (NASN) recommends students have daily access to a full-time RN; yet, only 39% of schools in the US employ a full-time school nurse, and just 35% employ a part-time school nurse – in some rural areas the coverage rate is even lower. Due to this shortage, delegation of healthcare responsibilities to unlicensed assistive personnel (UAP) has become a necessary and challenging practice to meet the needs of the population. The South Dakota Board of Nursing, in collaboration with Avera eCARE, piloted a virtual nursing model for children with diabetes in the school setting where a nurse is, either, not present or needs help to meet the health care needs of students. Findings from the pilot suggest the use of the virtual nurse model of care is a safe and effective method of supervising and delegating diabetes nursing care tasks to UAP, including insulin administration . In 2016, Avera received a $1.2MM 4-year grant from HRSA under the Telehealth Network Grant Program (TNGP) to expand the eCARE School Health model. Through this grant, eCARE established a robust school health model which has been implemented in 46 schools. The proposed project will examine the short- and long-term effects of a virtual school health program on outcomes related to 1.) diabetes management and the quality of life of children with type 1 diabetes; 2.) care for students who experience acute health needs (i.e. illness, asthma, severe allergic reactions, and head injuries); and 3.) staff knowledge around health-related topics and reduced staff burden associated with care management of students’ health-related needs.
This evidence of effectiveness will facilitate the long-term goal of scaling up eCARE school health to school districts nationwide. If proven effective, the expansion of this program will substantially contribute to improved quality of life and learning for students with diabetes and will provide all students with better access to acute health care.
Anticipated Outcome
Anticipated outcomes primarily focus on the improvement of treatment, diabetes care and quality of life of students with diabetes (type 1 diabetes and type 2 diabetes). Secondary outcomes will focus on improved care and treatment of the general student population and cost savings of eCARE School Health at both the student- and school-level. The following three aims further detail the anticipated outcomes of the proposed project: Specific aim 1. Evaluate the effect of Avera eCARE school telehealth program on physiological, social, emotional and cognitive outcomes in students with diabetes in school districts. Better diabetes care and management should result in improvements in the physical health of students with diabetes, as indicated by HbA1c, average daily glucose levels, and reduced episodes of hypoglycemia and diabetic ketoacidosis (DKA). With better control of their diabetes, students and parents should report improvements in their quality of life and self-efficacy for managing diabetes. In addition, previous studies suggest that students with diabetes experience lower grades in school as a result of missed instruction (due to chronic absenteeism) and difficulty concentrating, which is a symptom reflecting executive function difficulties that often arise from poor management of the disease. Better diabetes care and management should lead to improved executive functions. Sustained diabetes care and management should further lead to improved academic performance over extended periods of time (i.e., years 2-3 post-implementation of T1D program), particularly for those students who started with lower grade point averages. Specific aim 2. Evaluate the effect of Avera eCARE school telehealth program on school-related measures in students with T1D and acute care needs in school districts. Better access to healthcare at school should result in fewer absences due to illness or injury and an increase in the return to school rate during the school years in which the eCARE program is implemented, compared to the year prior to eCARE School Health implementation. The provision of trauma-informed mental health trainings with teachers and staff should result in long-term improvements in teacher-student relationships that reflect a more positive school and class culture and climate. Immunization rates for the general study body should also improve in the long-term. Also, staff who receive support and training through eCARE should report improved knowledge and skills for providing and managing care of students with T1D and acute needs. Specific aim 3. Explore the cost-effectiveness (family- and school-level) and program implementation and delivery of the Avera eCARE school telehealth program in school districts. For students receiving care for acute conditions (e.g., head injury or serious allergies), immediate access to a nurse should result in fewer 911 calls during the school years of eCARE implementation compared to prior school years. Provision of telehealth services should enhance care efficiency for families by obviating the need for travel to urgent care centers and emergency departments.
Relevance to T1D
Anticipated outcomes of the proposed project primarily focus on the improvement of treatment, diabetes care and quality of life of students with diabetes (type 1 diabetes and type 2 diabetes). Students with physician-diagnosed T1D or T2D attending a school that participates in the eCARE school health program will be invited to enroll into the study. Students will range from 3 to 18 years of age and will have varying duration of diabetes. This sub-population within the eCARE School Health Program will be used to evaluate the effect of Avera eCARE School Health on the physiological, social, emotional and cognitive measures; school-related measures; and cost-effectiveness (family- and school-level) and program implementation measures.