HEALTH SERVICES: SPECIAL FACTOR CONSIDERATIONS

Health as a Special Factor & Individual Health Plans

School Personnel Supporting Health Services

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Health as a Special Factor

An elementary aged boy with dark hair smiling while sitting in a wheelchair The IEP team needs to consider health when developing a learner’s IEP. When the learner’s ongoing health concerns impact their access to educational programming, health would be a special factor and included as part of the learner’s IEP. This may include accommodations, supports, or health services.

The following questions may be helpful to IEP teams when making the determination as to whether or not health is a special factor:

Does the learner’s medical condition impact strength, vitality, alertness, endurance, or restrict activity at school?
Does the learner have health needs which require school health services, school nurse services, and/or outcomes/goals to promote learner health, prevent disease, and/or support academic achievement?
Due to the health condition, does the learner require:
- Safety precautions (bus, playground, gym, lunchroom)
- Assistance with activities of daily living (dressing, toileting, feeding)
- Medication
- Medical supplies
- Specific equipment or appliances
- Prosthetics including limbs and devices
- Mobility devices
- Emergency Evacuation Plan
- Modified dietary needs

If the team determines that health is a special factor for a learner, this is indicated in the IEP. The team will determine what health services or activities are necessary to meet the learner’s unique needs and to ensure educational benefit from the IEP. Additionally, the IEP will indicate whether an Individual Health Plan (IHP) is needed.

Accommodations and Supports

There may be accommodations and supports that are provided as a result of the learner’s health needs. These supports are not direct health services by a nurse or other provider, but rather a way to provide access to the educational environments or instruction.

(Examples: A learner may utilize a prosthetic device for mobility; A learner may take medication at home, but there is no ongoing health service provided during the school day. However, there may be educational supports that are needed and would be included as part of the learner’s IEP.)

Special Health Services

“School health services and school nurse services” means health services that are designed to enable a learner with a disability to receive FAPE as described in the learner’s IEP. School nurse services are services provided by a qualified school nurse. School health services are services that may be provided by either a qualified school nurse or other qualified person.

The team determines if there is an educational impact to programming for the eligible learner if the ongoing health services were not provided. Special health services include but are not limited to, services to eligible learners whose health status requires:

interpretation or intervention,
administration of health procedures and health care, or
use of a health device to compensate for the reduction or loss of a body function.

Health services included in the IEP are determined by the IEP team, and represent those services that are educationally relevant and necessary for a learner to have a FAPE. A learner’s community healthcare provider can be a member of a learner’s IEP team and provide recommendations, however, orders from the community healthcare provider are not required to be implemented by the IEP team.

Individual Health Plan (IHP)

An Individual Health Plan (IHP) is written documentation of the confidential, preplanned and ongoing special health service for a learner using the nursing process developed by a licensed school nurse with collaboration from the parent or guardian, learner, an individual’s health care provider, or the IEP team.

An IHP is created if there is ongoing health service delivery required for a learner while at school or during school activities.

School nurses may use a district developed IHP or the Iowa Individual Health Plan template developed by the Iowa Department of Education.

An Individual Health Plan must include the steps of the nursing process and is updated at least annually. The IHP includes:

Assessment, Nursing diagnosis , Outcomes, Planning, Interventions, Evaluation, Learner goals (expected outcomes if applicable), plan for emergencies to provide direction in managing an individual’s health needs.
Personnel responsible for the equipment shall be designated in the individual health plan. The individual health plan shall designate the role of the school, parents and others in the provision, supply, storage and maintenance of necessary equipment.

If a learner has a health-related, regular and ongoing service in their IEP, an IHP is required and will be uploaded to the state system as a supplement to the IEP. The uploaded plan should, at minimum, have an annual evaluation of goals, so that the plan is current and compliant with rules.

If a learner does not have a health-related service in their IEP but has an IHP, the IHP may be maintained securely by the nurse in district records, and the location of the plan will be stated in the IEP.

Emergency Action or Evacuation Plans

Learners with a life-threatening condition or impairment may require special health management outlined in an Emergency Action Plan. Additionally, learners with ongoing health needs may require an Emergency Evacuation Plan to safely evacuate in case of crisis or disaster.

The emergency action plan or emergency evacuation plan is written in the intervention portion of the IHP or in separate documents referenced in the IHP. The plan should include: learner demographics, condition or impairment, triggers (if applicable, e.g. flashing lights or loud sounds), signs or symptoms of an emergency, actions to be taken, and special written instructions staff need to know in plain language that can be easily understood by all school personnel.

The Iowa Department of Education has developed templates for the Emergency Action Plan and Emergency Evacuation Plan, which may be used as needed.

Reviewing and Revising an Individual Health Plan (IHP)

An Individual Health Plan is required to be updated at least annually and as needed for health changes and to ensure measurable outcome goals are being attained from the interventions outlined. The review of the IHP may align with the annual review of the IEP and whenever there is a significant health change impacting the relationship to academic or functional skills.

A licensed health professional may revise components of an IHP without reconvening the IEP team when the modification to the IHP is not within the discretion of the IEP team (e.g., a change in prescription or physician’s order). The IEP team carefully considers the need to convene an IEP meeting any time a revision affects another professional’s practice. If an IHP connected to an ongoing IEP service is modified in a way that results in an IEP amendment, the expectation would be that the revised IHP be uploaded in the system as a new, amended document. When minor changes are made, not within the discretion of the IEP team, the school nurse would maintain the amended IHP in their records, at the location specified in the IEP.

The licensed health professional, as an integral member of the IEP team, should communicate any changes in required activities (e.g., a change in schedule, medication, responsibilities, etc.) to the IEP team and all relevant school personnel.

School Personnel Supporting Eligible Learner’s Health Services

Special Education Teams

Teams determine if special health services will be identified in the IEP for the learner to benefit from special education. Some learners may require additional nursing or health support that go beyond the general health service delivery offered in school to all learners. Teams may request that the school nurse, a qualified professional on the team, provide a completed Special Health Care Needs Assessment form as a piece of data to assist the team in determining what level of additional special health supports are needed for an eligible learner.

School Nurse

School Nurses are the qualified professionals on the team who:

Provide a health assessment. This may include interviews with the learner, family, or staff; review of the learner’s health records, health history, consultation with other healthcare providers; and nursing observations conducted in practice
Develop the IHP
Supervise the delegated special health services
Define the level of supervision
Document the supervision provided for delegated health service delivery

Qualified Designated Personnel (QDP)

Qualified designated personnel are unlicensed persons instructed, supervised, and competent in implementing health services or the individual’s health plan as determined and delegated by the school nurse.

1:1 Registered or Licensed Practical Nurses

Some learners have health needs that require immediate assessment and nursing judgment as the next course of action in health care delivery. The team relies on the school nurse’s judgment in their professional practice to assist in delegation of licensed nursing tasks for the learner to receive safe healthcare. The team can have the school nurse complete the Special Health Care Needs Assessment form to assist in this team decision.

A Licensed Practical Nurse (LPN) is “permitted to provide supportive and restorative care to a specific student in the school setting in accordance with the student’s health plan when under the supervision of and as delegated by the registered nurse employed by the school district.”

Contracted 1:1 Nursing Services

There are families that receive home nursing services for their learners paid through Medicaid or private insurance. While a parent, as an integral team member, may elect to use prior authorized home nursing hours to care for their learner at school, the team determines whether to accept these hours even if a 1:1 nurse is required during the school day. This determination is made as part of a health domain evaluation, conducted by the school nurse, in collaboration with the IEP team and based on the Iowa Board of Nursing laws regarding nursing practice.

Ultimately, the school district determines whom to utilize or employ to staff the learner’s needs. The school nurse, as a qualified licensed professional on the team, provides rationale to the team that services do not go above the ascribed level of licensed practice for the individual who is being employed or utilized for a learner.

The Iowa Department of Education provides a resource, “Guidelines for Contracted Health Care Providers Working in Our School District” to assist teams regarding private duty healthcare agency nurses.

Documenting Nursing & Health Services on the IEP

The Special Education Services and Activities document defines the variety of services and activities that may be provided and described to meet the unique needs of eligible individuals. Guidance is included in this document regarding documentation of nursing and health services in the Services + portion of the IEP.

Prohibition on Mandatory Medication

It is the policy of the Department of Education to prohibit AEA and LEA personnel from requiring any learner with a disability to obtain a prescription for a substance covered by the Federal Controlled Substances Act, for example, Ritalin, as a condition of:

Attending school
Receiving an evaluation, or
Receiving services under IDEA

AEA and LEA staff are permitted to consult and share with parents and guardians their classroom-based observations regarding learner:

Academic and functional performance, or
Behavior in the classroom or school, or
Need for evaluation for special education or related services.

Records & Documentation of Health Service Delivery

When the AEA or LEA receives and maintains medical records from a parent or community healthcare provider(s), the records become part of the learner’s education record and are protected under the Family Educational Rights and Privacy Act (FERPA). Records created by the school nurse are also considered educational records and are protected under FERPA.

For additional information on learner health records, refer to the USDOE and USHHS Guidance on Student Health Records, 2019.

Teams that determine contracted nursing services are necessary for a learner to access their educational environment will ensure that the school nurse has a developed IHP for the learner and that the health service delivery records are maintained by the district to show services were delivered.

Parental consent is required for the release and/or exchange of health information.