So good evening, everyone. The American Diabetes Association Safe at School Program and Johns Hopkins Division of Pediatric Endocrinology like to welcome you to this evening, welcome you this evening to the sixth part of our seven part series of webinars designed for school nurses. My name is Jackie McManaman and I will be presenting tonight's program. I'm a member of the ADA Safe at School Working Group and I also volunteer as chair of the Virginia Diabetes Council Schools Committee. My day job is as a nurse manager with the Fairfax County Health Department School Health Division. Prior to accepting that job, I was a school nurse with Fairfax County Health Department in the Fairfax County Public Schools. I have been a certified diabetes care and education specialist since 2013. And before I came to the health department, I worked in a busy endocrinology clinic, primarily working with pediatric patients with diabetes and their families. So the ADA Safe at School Program is devoted to protecting the legal rights of students with diabetes so that they may learn and thrive in a safe and healthy school environment and be treated fairly. School nurses play a critical role in making sure the needs of children with diabetes are met in the school setting. Tonight's session, ADA's Diabetes Medical Management Plan, will cover an overview of what the DMMP is, including changes to the form and a section by section look into the document. Our hope is tonight's program will provide school nurses with increased knowledge, skill and confidence to best support students with diabetes, to optimize their education and have the ability to safely participate in all school sponsored activities. The school nurse is the student's advocate and the key provider and coordinator of diabetes care in the school setting. School nurses, parents, providers and students working together can make sure our children with diabetes are indeed safe at school. So please type your questions in the chat box, and I will do my best to answer your questions at the end of the presentation. Soon after the program concludes, attendees will receive an email containing a link to the evaluation and post-test. Free continuing education credits will be awarded upon the completion of the evaluation and the post-test. This program is also being recorded and will soon be available on ADA's professional member website. In addition, attendees will be emailed a notification enabling you to register for the remaining program in the series. And the next webinar will be on March 26 at 4pm Eastern time and will cover continuous glucose monitoring in the school setting. So be on the lookout for this email coming soon. And finally, the information provided by this program does not constitute legal or medical advice. For medical or legal advice, please seek out a medical provider or attorney. And thank you so much for joining us this evening. Again, please be sure to type any questions you have in the chat box. All right. So again, this session is being recorded by ADA and will be made available for public access and viewing. And while the American Diabetes Association attempts to ensure that all information is accurate and current, this general information about potential legal protections and medical practices is not a substitute for individualized legal or expert advice and assistance. The American Diabetes Association and staff and volunteers do not provide legal or medical advice or represent you. For detailed legal advice or representation, contact and consult an independent attorney. And for healthcare consultation and advice, consult with your professional healthcare provider. All right. So let's get started and talk about the Diabetes Medical Management Plan. So the Safe at School Committee is very pleased to offer the Diabetes Medical Management Plan for use by families and schools and pediatric diabetes healthcare providers. The DMMP offers us a unique opportunity to optimize diabetes care at school for school for students everywhere while also allowing for that important personalization necessary for optimal results for each student. This form recognizes and permits the important role of families and that families and school nurses play as important collaborators in the care. It also allows and provides guidance for the many new and budding technologies that make staying in range safer and more possible than ever. Some of the changes to this document when it was first put out includes a comprehensive content that covers a full spectrum of diabetes therapy. And approaches from fixed insulin dosing to the automated insulin delivery systems. Also includes specific content to help facilitate the safe and effective use of the advanced features of newer diabetes technologies. The document also includes earlier preventative measures and more precise use of carbohydrates to prevent hypoglycemia. As well as the inclusion of temporary basal rates and temp targets and bolus adjustments that promote safe participation in physical activity and athletics at school. The DMMP is available for download. It's on ADA's website at diabetes.org slash DMMP. The document is a fillable PDF and that makes it easy to complete and easy to send via email and upload to your schools as well as to your health care provider. We know here at the ADA and you know school nurses as well that the best plans begin at home. And so this document is very important for providing the background for the diabetes health care team specific instructions to school staff. So that the school may model what is done at home as close to the best extent possible. And the DMMP offers that comprehensive and detailed plan to start the school year with. There's a dosing page that can be updated throughout the year as well that we're going to touch on when I go section by section through the form. I know in some of the other presentations that we've done for this summit, particularly the the day-to-day management one that I did, one of the things we talked about is the importance of collaboration with the school nurse. And this document is that pathway to success. It's that opportunity to collaborate not only with our school nurses, with you all, but also with the health care provider. And of course the parents. It allows us to be able to work with our school nurses the parents. It allows us to be able to look at all those key facets when we're taking care of our students with diabetes. At the beginning of the school year, we as school nurses ask for updated documents, updated forms, updated medication orders prior to the start of the school year. And the DMMP is no different. And so what I strongly encourage our school nurses to do is to schedule those meetings with the parents prior to the school year starting so that you can take this line-by-line review with the families or with the parent and the student as you prepare for for them to start the school year. All right, so now let's take a look at each of these, each of the pages of the DMMP, each of the sections of the DMMP. So to start the DMMP, right at the top of the page in the upper right-hand corner of the screen, you'll see the new table, the table of contents. That table of contents serves as a quick guide for helping you find that critical information that you're looking for. And it also designates the sections of the of the form that the parent guardian can complete and which sections of the form the health care provider or diabetes care provider needs to complete. There's also a spot right up here for your student's picture. And I think that that's extremely helpful when we're, you know, when we're taking care of students with diabetes in school, because we have multiple students often in a school building. And so this will allow us to make sure that we have that extra check there for that student. All right, and then let's take a look at the next part of page one, which is the demographic information. And again, this sections one through five, as the previous slide illustrated, are the sections that the parent guardian can complete. And then section six through nine are the sections that the health care provider completes. So in this section, section one is the demographic information. So certainly looking at, you know, obviously the student's information, but it's really helpful too, to see the date the student was diagnosed so that you have that point of reference as when you're taking care of those students as well. There's also the student's schedule. And this is where you can find out from your student or from the parent as you're having that meeting, you know, how do they get to and from school each day? Do they, you know, do they walk? Do they take a car? Do they kiss and ride? Do they take the bus? Or do they attend before or after school program? This is where we can find out what times they generally eat their meals at school. And this is sometimes hard before, if you're meeting with the parent prior to the start of the school year, because I know those school schedules can kind of change at the last minute. But this is certainly a section we can revisit later too. But it's helpful to understand the student's schedule and their meal time so that we can make sure that their meal times are at appropriate times during the school day. Physical activity is there. And so this is where I really like to kind of dive into with my older students, if there's any athletics that the student is going to be doing so that I can make sure to connect with any of the athletic coaches. And then of course, the last box there is, you know, how they get home from school. So all really critical information to be working or to be talking to your parents about as you're planning for the students to start the school year. And then below that, you have the parent guardian section of where they're, of their contact information, which I know is in other places too, but it's certainly helpful to have that. And then the preferred contact method, I like to talk with my parents about, you know, what's the best method of contact during school day? Do you prefer email? Do you prefer text messaging if you have that capability? Or do you prefer a phone call? So just kind of making sure we nail down their preferred communication. And then the last part of page one is the necessary supplies list, as well as a little bit more information about field trips and disaster planning. The necessary supplies list I used quite a bit. I think that it's extremely helpful, and I always direct my parents to take a look at this list before our meeting so that they can come prepared with all of the supplies. And then I actually use this to check them off as I receive them. So then I can make sure I have everything I need for my student with diabetes. There's also some information about the disaster and emergency planning, which does refer back to the Safe at School Guide, which is on the American Diabetes Association's website. But I also like to take this time to just have a conversation with a parent about that, that we want to make sure that we have enough supplies to be able to take care of the student in the event of an emergency, at a minimum a three-day supply, and then that we have their different snacks and load treatments sprinkled around the school building in their various different classrooms if they do change classes, so that we have access to those in different locations. And then I also talk about extended day field trip planning, and that there is sections of the DMMP that the parent can, or that the health care provider can complete in the event that the student will be at school for longer than the normal typical school day. So lots of information on page one that's very helpful as you're meeting with your students to kind of discuss and make sure that you collect all that information. We don't want to just breeze past that page, it really has a lot of value there. All right, and then moving into section three, which is the self-management skills section. This section is certainly very important to have that one-on-one conversation with the parent and the student to understand where they are with their diabetes management, so that you have that good understanding of the level of support that they're going to need in the school setting. And I'll point you to the bottom of the slide first. It does define the different self-management skills, the definition, so full support, supervision, and self-care. So for the full support, that means that all care is going to be provided by either the nurse or the trained school staff. Supervision means that the staff will assist and supervise the student, but that the student is likely able to do to perform those procedures themselves. And then self-care, which means the student can manage their diabetes independently, and that of course support will be provided if upon request. And so then they have, so that kind of defines the different areas, and when you're meeting with your families, you know, you want to talk with them about those different areas of support. And this section really should be completed by the parent and the health care provider before meeting with you, the school nurse. These next three sections should be completed in advance. And so that way, you know, the parent has had that conversation with their health care provider to discuss where the student currently is with their own self-management. You know, diabetes, a lot of the care or a lot of the training that the student and the families get by the doctor's office is how to self-manage their diabetes. And so we certainly want to encourage that independence as much as possible. And we want to make sure that we're giving our students those opportunities to be independent or as independent as they are able in the school setting. So those are those definitions again. So again, that should be discussed between the parent and the health care provider. And then you as the school nurse want to review that. You're going to see the students coming into the clinic and either performing their own skills themselves or needing that support. And so you can always communicate back to the parent if you're noticing that, you know, maybe carbohydrate counting, they can't quite do that independently yet. They need a little bit of support with that. So this helps with that dialogue. So there's a couple of areas to mark here. So glucose monitoring, you know, can they use the meter independently? Can they use the CGM independently? Carbohydrate counting, insulin administration. And certainly for our pump users, we want to also acknowledge whether they're independent with the pen or syringe for their backup insulin administration. Can they calculate insulin doses themselves or do they need assistance? How about glucose management lows and highs? Will they need assistance? And then what about the self-caring of their diabetes supplies? Will they have some supplies with them? And if so, which ones? So we can indicate that here and kind of have a free text box to be able to list what's there. Will they be utilizing a smart phone? This is very important to know because we as a school nurse want to make sure we communicate that with their teachers and that it is a considerate of medical device, but certainly you don't have to text with your CGM. So we would want them to understand what that looks like. We also want to indicate what their device independence is, not only their self-management skills, but how about their independence with using different devices? And so this is just a checkbox if they're independent in that particular device management. So you can see there is CGM, we have sensor insertion, calibration pumps, tempasal adjustment, site insertion, et cetera. So those checkboxes can be utilized to indicate when they're independent in those areas. So lots of information in just this small section that we want to take the time to review and discuss with our parents and our students. And then section four is the student's recognition of high or low glucose symptoms. And so this is a good conversation starter with the parents of what does it look like when your student is high, and what does it look like when your student is low. And then you can, you know, together kind of check off or indicate those symptoms. And then certainly has the student ever experienced a glucagon or ever been hospitalized related to DKA after diagnosis. So these, this is helpful information for us as school nurses, as we care for these students. And you can dig a little deeper and find out, you know, for the glucagon, what was going on related to the use of glucagon, why did that happen? Same with DKA. And this can also help you, for example, perhaps they have had several admissions for DKA, and this is a teenage student, that perhaps having them come to the clinic so that you can be that, that person to supervise them might be a good idea to make sure that they're able to take care of their diabetes according to their medical management plan. And then the next section, section five, has a lot of information in there about glucose, is the section about glucose monitoring at school. So when are we going to check glucose? And this is a great time to really talk to the parents about what this is going to look like in the context of a school day. So certainly we want to check anytime this, before the student is going to eat anything or have a snack so that we can give insulin. We're going to do it anytime they complain of physical complaints or illness or high or low symptoms. But what are some of the other important times that we might want to consider checking? And that might be surrounding physical activity, surrounding testing, or before leaving school at dismissal, or other times that the parent might feel would be beneficial for this, for this individual student. And now with CGMs, you know, the frequent checking is, you know, our goal is to keep the student in school, in the classroom learning as much as possible, not missing class time due to their diabetes. And so with CGMs, we can often build in these extra checks, certainly before physical activity, before and after by just taking a peek at that CGM. The teacher can do that right there in the classroom, depending on, you know, the the availability of staffing in your school district. So I think that that's extremely helpful for these students as they're navigating their school day and avoiding that missed class time. So that, we want to start off by understanding when are we checking? And then we want to understand how are we checking? And so does the student use a CGM? What type of CGM do they use? What viewing equipment do they have? Are they using a, you know, a device reader or a smartphone or a smartwatch to view their CGM data? Is it being remotely monitored at home by the parent? Can we use the CGM for treatment and insulin dosing decisions? Unless, of course, the symptoms don't match. So we want to make sure we indicate those check boxes there. And then under CGM alarms, you see the low and high alarms. And what are those parameters? What are they set for? And I always encourage you to listen and hear the alarms and play the alarms for the school staff members as well, so they know what to listen for as they're working with the student. And then on the right-hand side or the right-hand side column, it talks about making sure we're allowing the student to view those devices at all times, permitting access to the school Wi-Fi for sensor data collection. This is so important, asking to be on the school's Wi-Fi, as sometimes you're asking for the hardest thing in the world. So just make sure to advocate for your students and get them on that Wi-Fi. And then certainly not discarding any pieces of the CGM if it falls off. And then when should we perform a finger stick for our students with CGMs? And I think this is another section you can spend a lot of time talking with a parent about, or with the student about, with their comfort level with CGMs and using CGMs for treatment decisions. So certainly, you know, do we want to perform a finger stick if it's low or if it's above a certain threshold? And that's again a conversation to have. I know in my experience and personally working with families, they often want you to use the CGM for that first initial treatment and then for any subsequent treatments to then check by finger stick. So for example, if the CGM is still reading low to then go ahead and do the prick at the 15 minute mark versus doing it at the onset. Okay, so we certainly don't want to over treat lows either. We don't want to give more and more since the CGM can sometimes lag behind the blood sugar. So that's something to really talk to your parents about. I know sometimes our students with CGMs can be a little hesitant or resistant to wanting to do the finger sticks, but this might be a situation to really advocate for doing it is that follow-up low. And again, that's a follow-up low is checking 15 minutes after you've treated it. So making sure that that 15 gram of carb treatment or whatever you use is working. It will need to perform a finger stick if the CGM isn't working. So for some reason it's not, if it's showing that sensor readings are unavailable, if you're not seeing both a number and an arrow present, like what would happen on a Dexcom or there is inconsistent readings or the Libre might display the checked blood glucose symbol. These are all examples of when we would need to potentially perform a finger stick. And then for the Medtronic system with the Guardian sensor, that section or that the Medtronic is now approved to use for treatment decisions, but it depends on the model number. So you would want to be aware of that as well. And we also want to make sure that we notify ParentGuardian if glucose is at a certain threshold. And you may have these already built in, in your school districts with your emergency action plans of when you have to call home to report a low or report a high. And so this is just kind of further articulating that in this section. I know in our district, it's if they're less than the low threshold of 70, if they're less than the low threshold of 70, or above 300, or 250, depending on what the diabetes provider writes as their high limit. And then you see the little checkbox where sections one through five completed by ParentGuardian. This indicates that the ParentGuardian completed those sections. And again, ideally, those sections are completed in collaboration with the provider's office as well as you. So that is all of the sections for the ParentGuardian to complete. Then the subsequent sections that we're going to be going over today are going to be the sections that the health care provider, the diabetes care provider completes. So starting with section six, and you can see on the red banner at the top where it says health care provider to complete, so that we've made that designation clear. This is how does the student get their insulin. So what insulin administration device or insulin delivery device is the student using? And so you see syringes, the insulin pen, smart pens, iPort, insulin pump. So those would be checked off indicating which ones the student uses. If the student is using an insulin pump, there should be another insulin delivery device also checked off. So whether that's the insulin pen or the syringe, so that we know what the student is using for backup insulin. And then under insulin pumps, you see that either the student is using an FDA approved AID device or students using one of the DIY devices. And so that that checkbox would get checked by the doctor. And then dosing is to be determined by the bolus calculator in an insulin pump. And so we want to understand that section 6A, which we're going to get to next is for backup insulin. So that is, excuse me, if insulin is provided via injection. So whether they're using the syringe or the pen, then we would move to the dosing table. Otherwise, for insulin pumps, we are going to utilize the bolus calculators that are built into the pumps. We're not going to be doing a separate calculation. Okay, and then the next section talks about insulin administration guidelines. So when are we giving the insulin? Are we giving the insulin before meals? Are we giving it some before and then some after? Or are we giving it after the meal? It's really important, ideally in a perfect world, to be giving insulin before the student eats food. Because of the way insulin works, you know, we want the insulin to start working prior to that first bite of food. But we understand, or as diabetes educators, understand that that isn't always possible. Some of our students can be very picky eaters or very unpredictable eaters. And so in that case, it may be that they need to get it following the food. And so that would be again indicated here on the diabetes medical management plan, whether you're doing it prior or after. And you can see next to after, it's after meal as soon as possible and within 30 minutes. So we do have kind of a tight window of when we want to get that in. And then we have partial dosing instructions there. That's again maybe for our unpredictable eaters and perhaps they use an insulin pump. We certainly for multi MDI students or multiple daily injection students, we don't want to be giving them multiple doses of insulin in one encounter. So we would want to avoid that. But if they're on an insulin pump, then some can be dosed prior to the meal. And then they can get the rest of the dosage when they after the meal. And then the last part of this section is some rounding information. So whether we're rounding to the nearest half unit or to the nearest whole unit, and what are those typical rounding rules. And certainly, if you have an insulin delivery device that is only administering whole unit dosing, you can't round to the nearest half unit. If you have an insulin pen, that is only whole an insulin pen, that is only whole units. So those are important conversations too to have. If the health care provider has indicated half unit dosing, but you don't have a device that can do it, it warrants a conversation with the health care provider that perhaps it's a pharmacy issue, perhaps they're not dispensing the right medication, or it's that they just didn't realize they've been right for the right, the right prescription for that student. And then at the bottom of this page, right underneath this section is supplemental insulin orders. And so this is where you'll find your insulin orders for checking ketones, depending on what the blood sugar is, or if a student is complaining of physical symptoms, and then it refers you to section nine, which is where we go into high glucose management. So we'll be covering that here in a couple of slides. But a really important part of this section is the next part, where it talks about parent guardians are authorized to adjust insulin dose. And this is where the doctor can indicate whether or not the parent can adjust the dose plus or minus a certain number of units, or a percentage, whether we're going up or down on the carb ratio, that's the most common one I see where the doctor will write, you know, plus or minus 30 grams per unit, or the correction factor plus or minus a certain amount of milligrams per deciliter per unit. And so this this section is certainly, you know, as school nurses, we don't always like to take this, these changes, or these adjustments from a parent, we're very, you know, programmed as nurses to take our orders from a physician or from a healthcare provider. And if you're, if your state laws allow it, you can certainly follow those, those guidelines as as a doctor puts it in there for you. And, you know, I just want to emphasize with with diabetes, self management, that's what's encouraged we as diabetes educators, you know, what is happening at the doctor's office level is training the parents and eventually the student to be able to make those real time adjustments for themselves. And so we certainly wouldn't want to wouldn't want to not advocate for that as well. diabetes is different. It's not, you know, just a milligram dose of a medication, like some other, you know, chronic conditions are treated with diabetes, your diabetes, the diabetes needs of the students is constantly changing, because they're growing and constantly changing. And so we want to be able to make those real time adjustments for the parents to avoid, you know, a delay in care, or certainly a student remaining hyperglycemic or high or low, because we couldn't make an adjustment fast enough, or a doctor's office couldn't get a form faxed back fast enough. So a lot of benefits there. So I just wanted to point to that section. And I know in our school district, you know, we just we allow the parents to make those adjustments, and they just provide it to us in writing, whether it's a quick email after we have that conversation, just so we have that supporting documentation of the change. All right, and then this section, section six, a is the dosing table. And so this is what I like to say is the kind of the most important page or when I'm taking care of students with diabetes, this is the page I look at every single day, because it has my dosing instructions on there. And so at the top, it talks about, you know, the type of insulin the student uses. So most of our students are using the rapid acting insulins. So that's there for you. And then you go into the meal times. So which meals is the student going to be participating in a school? And then what is their carbohydrate food dose. So we can see there's different carb doses, potentially for the different meals of the day. So breakfast, lunch, and dinner, potentially dinner, if it's a field trip type situation, as well as their snack times. Now, I know in our schools, it's either a morning snack or an afternoon snack, depending on the timing of lunch. And so that might be indicated as well. And then you can also see the fixed meal dose for our students who received a fixed dose of fixed number of units with their meals, that will be indicated next to that carbohydrate ratio dose. And then the next little, the next section on this table is the glucose correction dose. And it'll be checked whether we're using the formula method or we're using the sliding scale. And I'll show you guys the sliding scale at the next slide. And then we can see here that we can give the correction dose every blank hours as needed. And for our MDI students, you'll see our multiple daily injections every three hours is often indicated in that box. And then again, the meal time target glucose correction factor is listed there for you and can be changed depending on the meal. And in some situations, depending on the timing of snack and of snack and the previous meal, there may not be a correction dose that's indicated, it may be just carb coverage. So we want to look at that too. And then the last section of the table is the PE or activity day dose. And so this is a reduction potentially in the number of carbohydrates related to or total insulin related to activity. So that's a really nice section as well on those planned activity days where we know the students might be might be more active than normal. And then Section 6B is the sliding scale. So again, the doctor would indicate here whether we're using the formula method or the sliding scale. It's one or the other. We can't use both. The answers can sometimes be different. So we would want to commit to one or the other. And then Section 6C is long acting insulin. So this may be indicated for us particularly for those overnight or extended day field trips where we might be giving the long acting insulin. And maybe that we're doing it every day in school. There might there might be a particular reason for for your student. Or for to have for emergency planning to if a parent wants to have that, you know, dose of Lantus available in the refrigerator that we store for the for the school year in the event of a disaster or emergency. And then any other medications is going to be 60. And then you'll see a signature spot there for any other medications that or excuse me for the diabetes provider to sign. If and and that's only if this is a one page dosing update. So when this this page was developed, the idea was that for their subsequent doctor's appointments through the course of the school year that they could use this one page to update the dosing table rather than the whole, you know, six page document. Section 7 is looking at low glucose prevention, hypoglycemia. So this is how how can we prevent the low from happening? The the CGMs often give us that, you know, it's dropping or you might have a down arrow and it's dropping rapidly. So what should we do? So this section kind of gives the school nurse a little extra information of how to handle that and maybe a amount of carbohydrates to use to to boost up that number. So it's always that question of, it's not quite low, but it's gonna be. So how do we prevent it from the, it's gonna be? And this section helps with that. And then the next part of this section is about insulin management for the pumps. And it goes into the temp basal rates. And so either the temp rate or the temp target, exercise rate or exercise setting, if it's a tandem pump or the activity feature for the Omnipod 5 and the instructions about when to start it and when to stop it and who can do it. So generally speaking, and this is again, a generality, but most of our students who are using temp basals in the school setting are often doing sports, afterschool sports or are student athletes. Don't generally need to use these type of features for PE or recess, but that may depend. And so certainly that's a conversation to have with your family or with your student and with their parent to make sure that you have a safe plan for them. And then exercise follows that. So a nice segue to talking about exercise. We wanna make sure that we're monitoring the glucose appropriately related to exercise, and then certainly adding in some snacks if needed to prevent a low or to just kind of provide that boost. So having that conversation with the parent about snacks is very important. And again, this is one of the sections that the healthcare provider completes. All right, and then section eight is low glucose management. So this is when we're talking about what is their low. So most all of the DMMPs put 70 milligrams per deciliter here, and then how many grams of carbs are we going to use to treat the low? And the default is typically 15, but we see a range. It may be that the parent wants eight grams used for that. So, and again, this is a healthcare provider section. So you may see the healthcare provider puts a range there or does not use the default, may use eight grams or a difference, a number of grams there. And you just wanna make sure that you're using fast acting carb. This is very important that it's something with refined sugar, because that's what's gonna boost the blood sugar quickly. If it's something that, you know, has more complex carbohydrates in it, our body has to break it down. So it's not gonna work quickly like we want it to. So there are some examples of fast acting carb listed there for you as well. And then when to check it every 15 minutes and retreat until glucose is above. And most of the plans I've seen 80 is utilized there. And then of course, underneath that are your severe low, your emergency medication orders. So this is where you'll find which emergency device is being utilized and, you know, what the dosage is for that. And there's lots of different devices on the market available now. And I know our doctors often check all the boxes so that in case, you know, a formulary changes and they switch from one product to another, their DMMP is still valid. And then section nine is high glucose management or hyperglycemia management. So again, what are we doing to support the student with high glucose? Typically, I see the default on this one as well, whether it's 250 or 300, depending on their insulin delivery device. And then of course, when to check for ketones and then referring back to that dosing table or in section 6A to determine if we can give an additional correction dose at this point. So again, lots of information in this document. It is six pages of information, but all of it is to make sure we're providing optimal care for our students with diabetes. I think I have one more. Yes, so the signatures is the bottom block of that last page of page six, where you'll see the diabetes, who has approved the plan. So again, the healthcare provider would sign here, the parent guardian would sign here, and the school nurse or designee would sign here. And this also gives permission to the nurse or other qualified healthcare professional to collaborate with your student's healthcare provider too. So this allows you to have that conversation with the healthcare provider when you're working with a student with diabetes. So I just wanna share a couple of resources that are available too, before we kind of jump into the Q&A portion of the presentation. But we do for the DMMP, we do have a DMMP available that's been translated into Spanish. There's also a section by section slide deck kind of similar to what I just did here today that is on the website as well. When the form first launched, we put together that slide deck last school year so that folks could benefit from it. We also have the diabetes medical management plan process guidance to kind of walk you through the steps and a sample cover letter to be able to provide from the school to parents about the DMMP and why we need it and why we like it and how to get it completed by their healthcare provider. All of those resources are available at the diabetes.org slash DMMP so that you can utilize those in your school setting too. And I will also share the diabetes medical management plan is undergoing updates right now. And so they're based on the, we did a survey at the beginning of this year, collected a lot of valuable feedback from school nurses around the country as well as providers, offices and parents so that we can make the form even better. So changes are coming, although I don't have more information than that at this point, but did wanna give you guys a heads up about that. And then I think my next slide is just the next one. So I talked about it a bit at the beginning. The next one is gonna be on Tuesday, March 26th at four and you can register now. And I think Crystal is gonna drop that into the chat if she hasn't already so that you guys can see it or so that you guys can register for it if you haven't already. And then that leads us into our Q&A portion. So Crystal, I can turn it over to you if there's any questions. Yes, yes. Thank you, Jackie for fabulous presentation, very informative, but we do have some questions. So the first one is on the supplemental insulin orders, it has to be checked by the provider for the parents to make adjustments to insulin, et cetera, question mark. So if that box is not checked, then parents are not allowed to tell the school nurse to give extra insulin, for example? Correct. That's a great question, Crystal. So correct. So the idea behind that box being checked is then it is that the physician has authorized the parent to be able to make those dosing adjustments. So if that box is not checked, they have not given that permission. So if you're utilizing this form, and the parent would like to make adjustments, I would encourage you to talk to the parent about it that they can get this completed by their diabetes care provider. And certainly you can help facilitate that as well by either emailing it or faxing it to the healthcare provider, if that's within your, you know, within your abilities. Okay. Our next question, do you typically see DMMPs or even this ADA sample DMMP that have been electronically done from EMRs, example, Epic, for better ease of updating? That's a great question as well. And I think the EMR question has been, it's been a challenge integrating this particular document into EMRs such as Epic. I know in our area, some of the providers have been able to integrate it into some of the other EMR systems, but that's certainly a possibility. It's not outside of the realm of possibility. And as a Safe at School group, we're doing more investigation into how can we get this better integrated into those EMRs to make it easier for the end user? Because we often see, you know, we would love this to be a more collaborative document where the parent starts it off, sends it to the doctor's office, they complete it, and then it comes to the school nurse. It just doesn't always work out that way. But the EMR integration is certainly very important with how many of our providers are now using it. And unfortunately, it can sometimes be a challenge to get it integrated. Okay, next question. I am always questioning if we need to add guidelines to DM and P that are technically state law. For example, do we need to check a box stating a student can self-carry if it is state law that they can? Yeah, thanks, Crystal. So I think, you know, this is a national form. So it's not, it doesn't have those particular nuances built into it. There is a section on here that does talk about self-carry, which is over here under section three. And again, this entire document is signed off by the healthcare provider at the end. So the idea is that if the parent has indicated the student is self-carrying, the doctor is aware of that as well and has signed off on it. But as far as those, you know, individual nuances for each state's laws, that's something that your school district will need to investigate or your state, yeah, your school district will need to investigate with the state to determine, you know, best practice. Very much appreciate you highlighting the parent allowed dose adjustment section separately. Where do you recommend providers, nurses, and parents include qualifying or free text information for certain sections? So that is actually a piece of feedback that we got quite a bit in the survey is having some opportunities to free text. I can share on that particular section. Whoops, I went too fast there. There is a box here about additional guidance on parent adjustments. What I've also seen from providers' offices, if they wanna change a particular order, for example, the ketone order, some of the providers, instead of checking at the onset of hyperglycemia, at least in our area, have said to wait three hours and they've just inserted a text box into the PDF themselves. So like an overprint that has those instructions in there. So it is a PDF. So you can insert text boxes at the doctor's office level as well, which we would certainly be comfortable with the doctor's office inserting those text boxes, but a parent guardian inserting those text boxes, I think you would need to have kind of further conversations and make sure that the healthcare provider is in agreement with those. You mentioned changes are pending. How often does ADA plan to update this form and what's the best way to offer feedback to future provisions? So we did collect a survey from this current version that's up there. You can always email the Safe at School group. And Chris, so I don't know if there is a way, like a form or a way to contact on our website that we could point people to to provide feedback. The hope is that a new, that these forms are gonna be revised every two years. We wanna stay on top of the changes that are happening. The technological changes are advancing so quickly. So we want this form to be as up to date as possible. And so we anticipate making these updates frequently to meet those needs. I would say too, Jackie, just to add the survey, the National Association of School Nurses helped to disseminate the survey last summer. And I'm sure when we update it the next time, which won't be for a couple of years, I'm sure the School Nurse Association will help again. So there are different, there were different platforms for dissemination. So I would just be on the lookout for those. I will type my email in the chat box. So if you do have any feedback or any other questions or comments, you could feel free to email me and we'll try to get you to the right person. If a student is on a pump, do we confirm settings with the dosing table? That's a very good question. So the pump settings are, that's certainly a good idea. In the beginning of the school year, when you're looking at the pump or when you're meeting with your parent, you're receiving your dosing table. These are the most up-to-date settings that are put into the dosing table for the new school year. However, I know with insulin pumps, adjustments might be made and the DMMP may not have the most up-to-date dosage listed. And so I would encourage you when you do have pumpers who have DMMPs is to check in with them and make sure when they go to their endocrinology visits every three to four months that they're providing you this one pager so that it can stay as up-to-date and current as possible so that you can, in the event of pump failure, you're using the most updated orders. And then there was a comment, and we were aware of this, that Children's National has the DMMP integrated into Cerner. Yeah, we do know about that. We actually had a good meeting with the folks at Children's maybe a month or so ago. So that's definitely a model for us to take a look at. Okay, let's see. What is considered an electronic signature on the DMMP? Can it be accepted with just a type name or typed electronically signed with the physician's name since it is available electronically and anyone could fill it out? Yeah, that's a great question. And electronic signatures, I think it kind of depends on your school district policy, but most of them have a stamp to indicate who signed it and at what time. And so it's not, you can verify that that was actually done by that person. I think when you're looking at an electronic signature that's just a font change, that would give me pause of whether or not that this is truly signed by a healthcare provider versus just insert it into the form. So I think you have to be astute with electronic signatures and then also talk to your school district about whether or not they're accepted in that way. But I know when we get orders from Children's National by us who actually has everything integrated, they are electronic, but they are stamped. So you can see who signed it at what time and then it has the information for CNMC or for Children's National on there as well. Yeah. Is there a situation where the DMMP has been utilized for students with type two diabetes? Absolutely. The DMMP is here for type one or type two. I think if the student has type two diabetes, you may not see a DMMP for that particular student if they're, depending on what their treatment plan is. You know, if we're not checking glucose, if we're not administering insulin, there may not be any orders that are being followed in school. So I think it would just depend on what level of support we're providing for that student and what their treatment plan is. But the DMMP is good for type one and type two. And there is a question on the first page to indicate diabetes type. So it's meant for both. Okay. That is the end of our questions. So Jackie, I'm gonna pass it back off to you for closing us out. All right, again, well, thank you all so much for attending tonight's webinar on the Diabetes Medical Management Plan. I think this is a great resource and tool provided by the American Diabetes Association. And you should be receiving an email soon from ADA directing you to the evaluation as well as the post-test. So make sure you claim those continuing education hours. And thank you all. It was a pleasure presenting to you tonight.

ADA Safe at School Program

Diabetes Medical Management Plan

school settings

students with diabetes

comprehensive form

school nurses

glucose monitoring

insulin administration guidelines

hypoglycemia prevention

emergency medication orders