Pediatric Care Coordination and the Role We Play in Advocating for Our Patients Attending School

At a large tertiary care pediatric facility, hundreds of thousands of ambulatory care patients are seen annually. The majority of these patients spend countless hours a week attending school. As more care is transitioning to ambulatory care settings, it has become apparent that consistent and thorough care coordination between clinic and school settings is needed to meet the complex needs of pediatric patients. An educational program was developed specifically for ambulatory care nurses to increase awareness around the importance of communicating, educating and coordinating care with schools. This educational program development has required the work of a multidisciplinary task force, including care coordinators, school nurses, primary care nurses, and specialty care nurses to address the specific needs of school-aged pediatric patients. The goal of this task force is to streamline communication between ambulatory care facilities and the school nurses who support our patients day to day.

The program was developed after research indicated an abundance of issues families face returning to school after being diagnosed with a chronic illness. Additionally, research was done to address the gaps in knowledge among nurses. School nurses were interviewed to address their concerns when children return to school. This information was combined into a presentation with the goals of educating nurses regarding knowledge of the barriers families and school nurses face when children with a chronic illness attend school, awareness of educational and healthcare plans and the role providers should take when their patients attend school. The presentation has been given to a home care/hospice group, multiple groups of ambulatory care nurses and school nurses. An evaluation was given after the presentation.

Lack of consistency educating schools regarding patients who are returning with a chronic illness creates gaps in care that can lead to poor school attendance, decreased school performance, and undue stress to our patients and families. These gaps are only increasing as we encounter more chronically ill children returning to school. Nurses have the ability to bring change even in a large tertiary facility. Through this process, it has become clear we need to include school nurses as part of our care teams. An important step in this process is continuing to educate ambulatory care nurses on the importance of school health and school attendance. We need to develop guidelines that include consistent and clear lines of communication with school nurses. We can, as nurses, bridge these gaps by advocating for the most comprehensive quality care for our patients.