Good evening. The American Diabetes Association's Safe at School Program and Johns Hopkins Division of Pediatric Endocrinology welcome you this evening to our number four of our seven-part series of webinars we've designed for school nurses. My name is Crystal Woodward, and I am the Managing Director of the American Diabetes Association's Legal Advocacy Division, and I have led the Safe at School effort for 25 years. In addition, I am the parent of a daughter with type 1 diabetes who was diagnosed 33 years ago at the tender age of 17 months. I am presenting this evening's program entitled Legal Protections for Students with Diabetes. The ADA Safe at School Program is devoted to protecting the rights of students with diabetes so that these students 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. Our hope is that tonight's program will provide school nurses with increased knowledge, skill, and confidence to best support students with diabetes in order 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 so we can make sure our children with diabetes are indeed safe at school. A couple of housekeeping items. Please type your questions as we go along in the chat box, and at the end of my presentation, I will do my best to answer your questions. Also, soon after this program concludes, attendees will receive an email containing a link to an evaluation and a post-text. Three continuing education credits will be awarded upon the completion and submission of the evaluation and 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 programs in the series. Our next webinar will be held on February 22nd at 6 p.m. Eastern time, and it will cover insulin pumps, so be on the lookout for that information. Also, the registration link for the February 22nd program will be provided in the chat box near the end of my presentation this evening. Thanks so very much for joining us this evening, and again, please be sure to type your questions in the chat box. Please know that this session is being recorded by the American Diabetes Association and will soon be made available online for public access and viewing. While the American Diabetes Association attempts to ensure that all of our information is accurate and current, this general information about legal protections and medical best practices is not a substitute for individualized legal, medical, or other expert advice and assistance. The American Diabetes Association, its staff, and volunteers do not provide legal or medical services for representation. Legal advice and or representation for medical advice, an independent attorney and or professional health care provider should be consulted. Safe at School was established over two decades ago, and for those two decades, it has been based on three basic principles. These three principles are the foundation for all of our Safe at School efforts. All school staff members need to have basic knowledge of diabetes and know who to contact for help in the event of a diabetes emergency. At a minimum, everyone who has custodial responsibility for a student with diabetes should have a basic understanding of diabetes and know how to recognize a low and know how to get help. The school nurse is the primary provider of diabetes care, but other school personnel must be trained to perform diabetes care tasks when the school nurse is not present. These tasks may include insulin and glucagon administration, blood glucose monitoring, carbohydrate counting, and the recognition and treatment of hypoglycemia and hyperglycemia. Last, students should be permitted to provide self-care whenever they are at school or at any school-sponsored activities. This applies to students who possess the maturity level and the skill set to do so. It's not always based upon age or grade level. Also, school nurses need to support the gradual transition to independence, which means many students may become independent in one diabetes care task at a time, but may not be independent in other diabetes care tasks. So, the school and the school nurse are instrumental in supporting that gradual transition. These Safe at School principles are supported by a number of stakeholders, and I've listed those here. The principles will help, do help, to foster a safe environment for children with diabetes in the school setting. Schools adhering to Safe at School principles are best positioned to achieve these goals and to ensure the safety of students while the students are at school. It is important for students to have their diabetes management needs met to keep them safe and healthy in the classroom and at all school-sponsored events. So, here are three goals for school diabetes care. Schools must provide a medically safe environment for students. This means having a school nurse and or trained personnel on site who are trained and prepared to provide the routine and emergency care to students with diabetes. Students must have the same access to education as other students who don't have diabetes. So, in other words, it's important to plan for field trips and extracurricular activities and other school-sponsored events outside of the school day in terms of making sure that there is a school nurse or a trained staff member available who can provide this care so that students with diabetes are able to safely access this environment. And students in schools, schools must work with the parent, the guardian, and the provider to support the student's gradual transition to independence. Very, very important. So, what do students need to manage their diabetes in the school setting? First and foremost, students need timely access to a school nurse and or trained school staff. So, there should be a school nurse or a trained school staff person available on site at all times when the student with diabetes is at school, when the student with diabetes is at a school dance, on a field trip, at an after-school chess club, drama club, sports. There needs to be a school nurse or another school staff member who has been trained. And the key to this is planning at the beginning of the school year and throughout the school year and having the knowledge of what activities a student might be involved with. So, determining what staff members it makes the most sense to train. Is it the football coach? Is it, you know, the chess club coach? Is it, you know, the teachers on the field trips? Is it the school bus driver? The school nurse and trained staff should be able to recognize and treat highs and lows. School-based emotional support and psychological services as needed should be provided. As we've talked about already, self-management should be permitted for those capable school students and there should be support offered to the students who are transitioning to self-management. And I'll just say this again, the gradual transition to independent should be supported. Students with diabetes may know how to react when a CGM alarm responds and goes off, but they may not know how to draw up, for example, insulin in a syringe. So, their care task and the level of their skill needs to be supported by that school nurse. Full and safe participation in all school-sponsored activities for these students, meaning there needs to be a school nurse or trained school staff member available at all times. And for those students who are independent in their diabetes management, they will still need or may need help in the event of a hypoglycemia emergency. So, there should always be somebody available who can help to treat the low or even to administer glucagon if needed. Students should have access to accurate carbohydrate and nutrition information. Many school districts now provide all of this information on their websites ahead of time. We know sometimes the lunch and the breakfast menus might change and we need to plan and account for these changes and still provide these students and their families with accurate nutrition information so that they can accordingly adjust their insulin dosage. And students must have access to supplies, equipment, medication, their smartphone, Wi-Fi, and food. So we talk about discrimination in the context of federal laws, and I'm going to cover federal laws in a few moments, but discrimination occurs for students with diabetes when they do not get the care they need at school in order to participate in a safe and healthy environment. So these are some of the most common issues or problems that we hear from parents here at the ADA. We hear about parents who are required to come to school to give insulin or to provide other diabetes care. And again, it's critical that school nurse or trained school staff are available to provide this care. The parent should not and cannot be required to come to school to provide diabetes care. There are schools, unfortunately, without a school nurse and without trained school staff members making it impossible for students to receive appropriate care. So there needs to be someone at school who has received training to provide safe care to students. Students being told they can't go on a field trip unless the parent comes along. It's fine if the parent wants to come along, but as the kids get older, become teenagers, for one thing, many of them don't want their parent coming along. Parents work. Many parents can't take time away from their jobs. Parents have other child caretaking responsibilities, family responsibilities, for whatever reason. Parents cannot be required to attend field trips or to provide support during extracurricular activities. Another example of discrimination is when student-athletes aren't able to safely participate in school sports or other after-school activities because the school refuses to provide trained coaches or other staff. So if the football team has an away game, for example, there should be a trained coach, athletic trainer, or other staff member who is on the bus with the student who could help the student in the event of a low or could help the student on the sidelines, help the student on field. We also hear about students who use diabetes technology, insulin pumps, and CGMs, who are denied smartphone access and or Wi-Fi access to manage their diabetes. Students who are denied the opportunity to take an exam at an alternate time if their blood sugars are high enough. We know that patients with diabetes, their cognition, among other things, is impacted by low blood sugar and high blood sugar. So if students are out of their target range, if they are low, if they are high, they should be given the opportunity to take a test at a different time. So the last slide, I talked about examples of discrimination. There are federal and state laws, I'm sure most of you are aware of these, that are relevant to the provision of care to students with diabetes in the school setting. These laws provide protections to children with diabetes, these laws provide protections to children with diabetes at the federal level. Also, 34 states, plus the District of Columbia, have statutes in place that support the provision of care to students with diabetes, not only by the school nurse, but by trained school staff. So the major laws that impact students with diabetes and where students with diabetes and disabilities, any disability really, where they have protections, the Americans with Disabilities Act, sometimes referred to as ADA, which is different from the ADA of the American Diabetes Association, so sometimes that gets confusing. Section 504 of the Rehabilitation Act of 1973, or just plainly Section 504, and the Individuals with Disabilities and Education Act, or IDEA or IDEA. These laws help to level the playing field for students with diabetes and ensure a safe and fair school environment for all students. And ADA has a wealth of information on its website describing these laws. You can find information by going to diabetes.org slash fed laws. This will give you a better understanding of how these laws work and how these laws can be used to ensure that students with diabetes do get their needs met during the school day and at all sponsored activities. So the first law is the Americans with Disabilities Act, and there are various titles or sections of this law. So to whom does the ADA apply? Well, under Title II of the Americans with Disabilities Act, this part of the Act applies to schools and child care programs operated by a state or local government or conducted on public school grounds. So this would be, for example, public schools, charter schools, after-school programs. And then we have Title III of the ADA, which applies to what we call places of public accommodation. And these are public schools. They're private schools except religious schools, child care camp, summer recreational program. But under the ADA, there are businesses that are defined under this law who have legal obligations under this law to meet the needs and to provide access to people with disabilities. And some examples of businesses that are open to the public are examples of public accommodation. They fall into 12 categories. Hotels, restaurants, movie theaters, grocery stores, banks, and other service establishments, bus depots, museums, parks, schools, daycare facilities, recreation facilities, and doctor's offices are just some of the examples of places of public accommodation. Also, just so that, you know, to give you an idea and have you consider the scope of this law, it also includes a nursery, elementary, secondary, undergraduate, and postgraduate private schools and other places of education, daycare centers, senior citizen centers, homeless shelters, food banks, adoption agencies, or other social service center establishments. So, covers a broad spectrum. So, most of you are probably more familiar with Section 504 of the Rehabilitation Act of 1973. So, Section 504, under Section 504, schools and child care centers receiving federal funds have legal obligations to provide diabetes care under this law. Under this law, diabetes is a disability that substantially limits major life activities, such as walking, talking, eating, and different function. The major life activities substantially limited in order for students to be eligible for protections and services under this law need not be learning. So, the students' grades and academic progress need not be adversely impacted in order for the student to be eligible for services under this law. Also, I just want to emphasize that the school nurse is an important member of the student's 504 team. And there is a team that's gathered to determine, not only to determine 504 eligibility, but this team also works with the parents to develop the Section 504 plan or an individualized education program known as an IEP or other written accommodations plan. So, the school nurse is a critical member of the 504 team. So, generally, what are the ADA and Section 4 requirements? Well, both prohibit discrimination on the basis of disability. Schools cannot exclude children from participating in its activities just because the student has a disability, such as diabetes. And also, under these laws, schools are required to make what's called reasonable accommodations or modifications in its policies, practices, and procedures to ensure that a person with a disability can access the program. And then the last federal law I'm going to talk about is the Affordable Care Act. And then the last federal law I'm going to talk about is what we refer to as a special education law. So, under IDEA, it must be demonstrated that the diabetes or another disability adversely impacts the student's ability to learn and to make academic progress. Also, if the diabetes in and of itself adversely and significantly impacts the student's ability to learn, this student may qualify for services under this law. And for students who are eligible for services under this law, that 504 IEP team would then develop an IEP or individualized education program for that student, which would address not only learning and academic needs, but would also be inclusive of accommodations or modifications on how the diabetes needs. So we had, I spoke about federal laws. In addition, there are state laws and regulations. While all schools must comply with the federal laws, we do, we should, must take state laws into consideration. As school nurses, you know that all of the states have their own nurse practice act and other laws and regulations that speak to who may or may not provide care to students with diabetes. And then to add to the confusion, often there's no statewide policy and rather a policy is determined district by district. And sometimes even different schools within the same district will have different policies. Some states have developed school diabetes management guidelines. On ADA's website, if you go to diabetes.org slash fed laws, there's a link to state laws. For each state, we've created a separate webpage, which lists and explains the laws in any given state that are relevant to the provision of care to students with diabetes in the school setting. And within those webpages, there are numerous state resources, which can include diabetes guidelines, DNMPs, training curriculums. So in addition to ADA having developed a lot of very comprehensive and useful resources, many of the states have already developed these resources as well. So take a look at those webpages when you get a chance. Regardless of state law, the requirements of federal law must always be met. Many states have passed diabetes care legislation and dispatched or changed regulations that have the effect of permitting trained school staff to provide diabetes care tasks, such as insulin and glucagon administration, like glucose monitoring, carbohydrate counting. And as I mentioned earlier in the program, as of today, there are 34 states plus the District of Columbia that now permit teachers, administrators, clerical staff, and other school staff to be trained to give insulin and glucagon to students with diabetes. And then there are a handful of states beyond that that permit trained school staff to give glucagon. And then there's just a small handful of states where only a school nurse can provide that care. But again, if you go to the state webpages on ADA's website, you will be able to learn more about your state laws. So what does it mean if a state, if there is no state law or if there's a state law that prohibits anyone from providing diabetes care but for the school nurse? Well, what that essentially means is that a school nurse needs to be available at all times. And we know that that is not a practical solution. So really, having these trained school staff who've been trained by the school nurse, and many times with the help of a diabetes educator, having trained school staff helps the school nurse to provide more timely care and comprehensive care to students with diabetes. Sometimes school nurses, they do go on field trips, as I said before, but certainly in these states where there are permissive statutes and regulations, trained school staff can go on field trips as well, and they should do so. Again, there's the website, diabetes.org. So if you want to learn more about the federal laws and your own state's laws. So I highly encourage you to do that because I cannot cover all of the state's laws in this webinar. That's a different webinar. So next, we're going to talk just briefly about Section 504 plans. I'm sure that most if not all of you have been involved with the 504 process and are familiar with 504 plans. Certainly the school nurse needs to be a member of the 504 IEP team. And what I always tell parents and recommend to school administrators and school nurses and other stakeholders is, and I'm always asked the question, if everything is going well at school, is the 504 plan needed? And my response is always yes. Even if things are going well, that's the time to develop a 504 plan because things can change quickly. At school, staff can change. Situations can change. So the American Diabetes Association recommends that a 504 plan, an IEP, and other or other written accommodations plan be individualized and developed for every student with diabetes. But it's this written document where the services, modifications, and accommodations are going to be documented. Every, each and every child with diabetes has individual needs. It's not a one-size-fits-all. Every child, every patient is different. The 504 plan is based on the student's diabetes medical management plan, which we're going to talk about in a minute, or DMMP, or provider's orders. But most schools do use the diabetes medical management plan. And again, the Section 504 plan must be individually developed. It's not a one-size-fits-all. Also, the accommodations should be reasonable. They should be in writing, and everyone needs to understand their role. And the 504 can really help to clarify all of this. That a DMMP or an IHP is not a substitute for a 504 plan. Get that question a lot of times too. We have the DMMP and the IHP. Why is the 504 needed? Well, a 504 plan is, is the document that lays out all of the services and modifications. And it is the legally binding document. And then with the 504 plan, if challenges do arise, the 504 team can be reconvened to discuss and hopefully resolve any kind of challenges that may arise during the school year. So, why is it important for a student with diabetes to have a 504 plan, an IEP, or other written accommodations plan? What are the benefits? Well, as I mentioned before, it helps to clarify the roles, responsibilities for school staff, school nurse, for students, for parents. It provides validation of the health condition, and what the student needs to function optimally during the school day and during school-related activities. It enables the student to better understand the accommodations that are available to help them to focus on their education, to help them have unrestricted access to the help room, to the restroom, to their supplies, medications. These plans also utilize a formal legal process for determining how needs will be met, and also for addressing needs that are not being met, if that's the case. It also provides students and parents, guardians, with a comfort in knowing the student will be safe and treated fairly, and then the school nurse, the parent, guardian, student, can become better advocates by understanding the rights of students with diabetes, and what types of supports can be provided to hopefully help promote optimal learning, safety, and equal access. So, you know, it's just really important that the family and the school work together to develop an individualized plan, and just remember that what works for one student with diabetes may not And just remember that what works for one student with diabetes may not work for another student, and the plan should be individualized. So now I just want to provide some examples of what the law requires in the context of schools, and these are some examples of reasonable modifications or accommodations needed by students with diabetes. You know, this is especially important for younger students who are not yet independent in their diabetes management, and even for older students who will need help from time to time if they experience a diabetes emergency, such as hypoglycemia. And so, for example, monitoring blood glucose levels. It's something done by and for a student with diabetes multiple times a day. As you know, it could be done with the traditional finger stick with the blood glucose meter, or it could be done using a continuous glucose monitor, which those more kids are using CGMs these days. And as you know, the CGM is attached to the student's body, and it provides a continual measure of glucose. So that is something that while it's addressed in the DMMP, it's also important to have that in the 504 plan, which staff has been trained to help where the diabetes care is going to occur. You know, if a student's blood glucose is too high, they're going to need insulin. And for students who are not independent, there's going to need to be a plan for who is going to administer that insulin. For those students who cannot independently manage counting carbohydrates should be addressed. Knowing how many carbs a student is ingesting is a key part of appropriate insulin administration. So rolling in the DMMP into the 504 and incorporating many of those provisions, it's more of, you know, more of the implementation piece where the DMMP is. Just wanted to mention some newer developments and some newer resources from ADA. In November of 2018, the American Diabetes Association and three families of New York City public school students filed a federal class action lawsuit with the U.S. Court for the Eastern District of New York against the New York City Department of Education and others. And basically what the lawsuit alleged was that the schools were failing to provide diabetes care during extracurricular activities and at other times, and that there were a lot of barriers and undue delays to procedures for students with diabetes in order that they get, you know, so that they, their 504 plans were being delayed and there wasn't a timeline. And also there were a lot of gaps in training school nurses and school personnel. So last spring, that would be April 2023, a settlement agreement was approved by the court along with a court order on a couple different issues. So now, you know, New York City public schools, they're very, so very committed to making sure that these kids get the accommodations they need. They've established new timelines related to the 504 process and to the submission of the DMMP or what they call the DMAF. There are robust new trainings for school nurses, for teachers, administrators, 504 coordinators, paraprofessionals, bus drivers, bus attendants, and other staff on how to care for students with diabetes. And there also were changes to ensure that there's proper coverage on field trips and at other school sponsored activities. The settlement also provided for a very robust monitoring and reporting period for three years. And the settlement agreement really is a model for other school districts across the country to take notice of and, you know, to look at their policies and see how the school district policies and practices are aligning with the good work that New York City public schools are now doing. So we really, you know, I commend New York City Department of Education, Office of School Health, and all the folks there for the training they've been doing and they've been working so hard to make sure those New York City school students with diabetes do get the care they need at school. So you can check that out on our website as well. It's diabetes.org slash NYC students if you'd like to learn more. And then we have our diabetes medical management plan that was updated by ADA Safe at School Working Group in 2022. And let me just explain our Safe at School Working Group at ADA. We have an advisory group of pediatric diabetes health care providers who do, you know, they are the advisors for Safe at School and they are the experts who are developing these forms and who are creating the guidance that you see. So these forms and any of the guidance, these resources are created by pediatric diabetes experts. Also, you'd be interested in knowing that this DNMP is currently under revision. Some of you may have received and responded to a survey last summer. We did a survey of diabetes health care providers, school nurses, and parents to gauge their feedback, to acquire their feedback on using the form or if they didn't use the form, why they didn't use the form. And we have analyzed the feedback and we have a set of recommendations. We had about, oh, probably just over 550 responses. Most of those responses, survey responses, were from school nurses. So I thank you for that. But just know this form is currently under revision and the plan is to have this form ready by late spring. So I would say by May, the new form should be out. But the DNMP, as you know, includes orders for all aspects of diabetes care, including pumps and CGMs. It's a fillable form with a parent section that we recommend be completed first by the parent. There's a single-page insulin dosing order. And the reason for that is so the provider, if the insulin dose changed, the provider wouldn't have to go back and review and sign the entire form again. Also, what's important about this form is that it does provide the foundation for the development of the 504 plan or IEP. And ADA has developed and we provide supplemental support resources to help providers and school nurses and parents to understand how to use the form. And this form is also available on our website. We've also got it available in Spanish if you need that. And it's available at diabetes.org slash DNMP. Here's a list of some of the updates, the provisions that were included in the 2022 form. I won't go through and read them. You can see some of the conclusions. Again, it's just important to know that the DNMP or healthcare provider orders serve as the foundation for the individualized healthcare plan that's created by school nurses, the 504 plan, or an IEP. And again, this is the document that is signed by the student's provider that sets out how the student's diabetes needs will be met at school, including during field trips and school-sponsored activities. So now I just want to talk about the importance of training school staff to provide diabetes care. We know that diabetes management for patients with diabetes is a necessity, it's not optional. Patients with diabetes need 24-7 care. Also millions of people who are not licensed healthcare professionals have been trained to safely perform and assist with diabetes management tasks. So something to consider when you're developing your training program to train unlicensed staff. So with appropriate support and staff training in place, proper diabetes care can be achieved. Children with diabetes can thrive academically and children with diabetes can access all school activities safely. So there are a number of resources that ADA has developed. We offer a wealth of free, I want to mention these resources are free, you don't have to pay for them. You can get them from our website, you can download them, you can print them out, you can distribute them. But we do have a wealth of free resources to help school nurses, to train school staff, and to help staff to become more knowledgeable about diabetes. All of these resources I'm getting ready to tell you about are available at diabetes.org slash SAS training. Here I'm showing our school guide, Helping the Student with Diabetes Succeed, a guide for school personnel. This guide was originally published, I believe, in 2002 by the National Diabetes Education Program, and then ADA had an opportunity to take it over in 2020, so we did so. Our last update was in November 2022. And again, this is a publication that is written by our Safe at School Working Group. The key audiences for this particular resource, school nurses, school administrators, staff, child care, even child care providers, families, diabetes providers, and policymakers. There's information on diabetes technology and treatment therapies, type 2 diabetes, mental health, roles and responsibilities of various school staff members. There's the sample DNMP that's available in there as well. And this guide can be used alone, or it can be used in conjunction with ADA school training modules. And again, you can feel free to download the guide, and we will soon be looking at doing some updating to the technology references in the school guide, so you can look for that later this year. A lot of you are probably familiar with our slide decks. This is our training curriculum for the school nurse and diabetes educator to use to train school staff. It contains 19 separate slide decks that may be presented as a group all at one time, or they may be presented separately. Maybe you want to do a refresher training on glucagon, so you might use the glucagon module and the hypoglycemia module. So there's a post quiz available at the end of each module that can be used. So you could use this to train school staff. You could also use the modules just to increase diabetes awareness at school. You could use them for staff meetings or PTA meetings. The first module, which is shown here, Diabetes Basics, would be a really good module to share with parents and PTA, and perhaps present at a staff meeting. We have our continuous glucose monitoring guidance, which also was developed by our Safe at School Working Group. It was most recently updated in 2023. We know that the use of CGMs by students with type 1 diabetes has increased dramatically over several years. According to data from a large type 1 diabetes registry, over 50 percent of children with type 1 diabetes under the age of 18 have adopted this technology, and it's growing. This number is growing all the time, and the numbers are growing because the technology is becoming more accessible, easier to use, and it further reduces the burden of diabetes. So there are many benefits to CGM, including immediate access to glucose levels and immediate response to those levels. Data sharing is possible when a student uses a smart device to view their CGM. In addition to convenience, it gives the student the ability to share glucose data with multiple followers, who might include a school nurse, a parent, guardian, or provider, or someone else. The utility and need for the school nurse to remotely monitor should be individualized for each student with diabetes, based on their individualized diabetes medical management plan, prescriber's orders, also based upon their unique needs. The school nurse and the 504 team should discuss the student's needs and determine if remote monitoring is necessary, based on, again, the individualized student's DMNP or provider's orders. Also, you know, clear expectations should be established with parents by the school district on the ability of the schools to monitor the CGM in real time. If the CGM falls off during the school day, the school nurse should help the student to place all the pieces in a sealable plastic bag to be sent home with the student. No portion of the CGM should be discarded while at school, and until the sensor is replaced, the child should be monitored by finger stick with a blood glucose meter. Most recently, we have updated our child care position statement. I know this talk is about school, but I thought this might be of interest to you. Our child care statement was published in this year's standards of care, and includes updated diabetes technology information. There's an added psychosocial section. There are some new legal developments that are discussed in the statement, including some settlement agreements with camps and daycare providers, and there are updated lists of resources, data, and statistics. So, other state school resources that may be of interest to you as school nurses, there's a variety. There are case studies for school nurses covering various scenarios, such as CGM remote monitoring, and minimizing interventions, case study on correction doses, transitioning to independence, and the importance of training non-clinical staff. We also have a review of insulin concentrations for school nurses, and the importance of looking at a syringe or insulin pen for the concentration before dosing. We have emergency lockdown preparation and guidance for how to care for students during an emergency lockdown or evacuation situation. We have tips for school nurses, provides ideas to help the school nurse coordinate diabetes care in the school setting, planning for newly diagnosed or just returning students, where to seek training resources, preparation for field trips, what information to provide to transportation, and other information. So, again, be sure to check out these comprehensive resources on ADA's website. So, you know, there are some key takeaways and actions that school nurses can take to make sure your student is safe at school. We want to make sure that the orders, your DMMP, is current and complete. You want to be prepared to train school staff. And, again, I just told you about some of the resources that are available for training on ADA's website. School nurses should provide input to the 504 plan, IEP, or other written accommodations plan for each student. You should be part of that team. Provide a prompt response to parent inquiries about the student. Communication is key. Communicate with the family and school to make needed adjustments and to address concerns. Also, you know, provide input to school district policies relevant to medication administration and diabetes management at school. And make sure your families are informed about those relevant school policies. And then just briefly, what is the ADA Safe at School initiative working on now? Well, we're working on updating our diabetes medical management plan, updates to the school guide, the training slide decks on pumps and CGM. Those are being updated all the time because we know diabetes technology is improving and changing quickly. We are now updating our school position statement. The last update was 2015. So I'm really looking forward to completing that update. And that will become part of ADA's 2025 standards of care. We're working on updating our 504 plan template. We are working on hypo and hyperglycemia one-pagers, just kind of, you know, cheat sheets. There are some states that state legislatures that are considering the passage of undesignated glucagon bills. What these bills are, if you haven't heard of them, it would enable the school to obtain a prescription for glucagon so that glucagon would be on hand and available for that student with diabetes who experiences a severe hypoglycemic episode and perhaps the student's glucagon kit is expired or for whatever reason isn't available. So we do have several states where that legislation is feeding up. And we are planning a school nurse CGM discussion panel for this spring. So be on the lookout for that. That might be of interest to many of you. And as always, we have a variety of back-to-school programs during the summer. This summer we are planning a workshop for school nurses and we are planning a workshop for parents this summer. In addition, as I mentioned earlier, this is webinar number four of a seven-webinar series. We have three more webinars that will be offered. The next one will be on insulin pumps. The speaker is Dr. Henry Rodriguez, who is co-chair of our Safe at School Working Group. It's going to be held on Thursday, February 22nd, 6 p.m. Eastern time and the registration link should be in the chat box. So please register for that right now. And that concludes my presentation. And I have time for a few questions. So just bear with me while I look in the chat box to see what's on everybody's minds. And oh, I'm sorry if you were having trouble hearing me. So, one question, who is, where is the other staff members to be trained to treat a high and administer insulin? So, those staff members could be teachers, they could be school administrators or others who are willing to be trained to administer both glucagon and insulin. And also, there are probably staff at your school who have children with diabetes or relatives with diabetes who are already familiar with the provision of diabetes care. So, those might be good folks to tap into for training. Okay. Okay, who will define the maturity of the student for self-care? What needs to be in place for a student to have self-care and not go to the nurse's office at all? Parent and student want to care for self in classroom. I would be concerned about hypo or hyper and cognitive ability being impaired. Yes, the decision on the student's independence should be made by the student's provider with input from the parent. And obviously, if the school nurse has any concern, because we know diabetes care at school looks different from diabetes care provided at home. So, certainly, if there's any concerns, the school nurse should have input. But usually, that determination is made by the child's diabetes provider. Someone commented, we have the 504 in place for most of our students with diabetes. It's offered to all students with diabetes. Students with type 1 diabetes who are on an IEP have a specific learning disability or other health condition as the qualifying condition for the IEP. And that's exactly right. I have a newly diagnosed student with diabetes who attends an enrichment program at one of the schools I cover. She's homeschooled and comes to class once a week. Does she need a 504 plan? The school does not do any state testing. Yes, I would advise students who are homeschooled should have, and they come to school and they participate in school from time to time, they certainly should have a 504 plan. Staff is often hesitant to accept responsibility for diabetes care. Can a staff member be forced to assume responsibility? Yeah, that's a legal question that I really, you know, I can't answer, but I will tell you that in the states that have statutes allowing staff to provide diabetes care, these staff have to volunteer to be trained. The provision of diabetes care cannot be a requirement of their job. So hopefully that answers your question somewhat. So please clarify accommodations for afterschool activities. So any accommodations that are, or care that's provided during the school day should also be provided at afterschool activities. So, you know, if there's an afterschool activity that involves food, then there should be somebody there who can help with insulin. Any of the orders that are in the DMMP should carry through to afterschool activities and field trips and other extracurricular events. Who is responsible for training staff for afterschool activities? Well, if it's a school-sponsored activity, then the school would be responsible. If it's an outside organization who's maybe running space, then that organization would be responsible. But also, you know, that organization would, because the activity is taking place at school, the organization would have to provide care. There's a question about CGM, remote CGM monitoring. Again, CGM monitoring, remote monitoring should, whether it's provider or not, should be based upon the DMMP and the provider's orders. There should be an individualized assessment done, but definitely based on the provider's orders. All care should be stemmed from the provider's orders. Okay, somebody said the 504 plan link doesn't work. I will have to check that out. Thanks for letting me know. Okay, what happened to the training videos that were with the PowerPoints? I get that question, I'm getting that question. We took those down from the website because they're really old. I can tell you they are still available on YouTube if you really want to access them, but we're hoping to update them in the near future and make them available again. I know that school nurses and others really, really liked those videos. At the Barbara Davis Center, the orders say level of independence is determined by the parent and the school nurse, not the provider. I can tell you that in our DMMP, there is a section for completion by the provider and the parent as to the independence level of the child. So this might differ. I mean, different school districts have different practices, but generally speaking, it's the provider who determines the level of independence. Well, I think we're running out of time. I want to thank you all for attending tonight's presentation. I'm sorry that there was a problem with the volume in the beginning. I'll go back and take a look and see if we can get that fixed, if that is a problem. School nurses, we need you. We know you have lots of competing priorities. We thank you for everything that you do for children with diabetes. Keep on learning, keep on supporting, keep on advocating. You know, we know things change quickly and it's challenging, but you all are doing an amazing job. So just keep on doing what you're doing. If you have any questions, give us a call at 1-800-DIABETES. There's also an email, askada at diabetes.org. Check out our training resources, be on the look for new training resources. Again, after this program concludes, you should receive an email with a link to the evaluation and the post-test. Please complete, submit, and then you will receive your CEU credit and please consider attending future webinars. So again, I thank you very much for attending and for all you do to help support children with diabetes.

American Diabetes Association

Safe at School program

Johns Hopkins Division of Pediatric Endocrinology

webinars

school nurses

legal protections

students with diabetes

diabetes care

federal laws

individualized plans