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Although the school nurse is a familiar figure, school-based healthcare is unfamiliar territory to many medical professionals, operating in a from other community-based medical services.

Now, as both schools and healthcare systems seek to ensure that children coping with chronic conditions such as diabetes and asthma get the comprehensive, coordinated care the students need, the schools and health systems are forming partnerships to better integrate their services. In these projects, , school health professionals gain access to students' electronic health records and/or specialists and other health system resources. Such initiatives currently exist or are on the drawing board in Delaware, Miami, and Beaverton, Ore., among other locations.

School nurses today do a lot more than bandage skinned knees. They administer vaccines and medications, help diabetic students monitor their blood sugar, and prepare teachers to handle a student's seizure or asthma attack, among many other things.

A 2007 study found that on site, while 30 percent have one who works part time. In addition to school nurses, 12.5 percent of school districts have at least one school-based health center that offers both health services and mental health or social services, according to the federal Centers for Disease Control and Prevention's . School nurses often work closely with school-based health centers, referring students there as needed.

"Chronic disease management is what school nurses spend most of their time doing," says Carolyn Duff, president of the National Association of School Nurses. "We do care for students in emergencies, but we spend more time planning to avoid emergencies."

School-based healthcare providers may bill Medicaid for some services, but rarely bill private insurers.

"The juice isn't worth the squeeze," says John Schlitt, interim president for the , an advocacy organization for school-based health centers. "It takes so much energy to track these bills from the commercial insurers, many just stop trying."

Although school nurses see many students regularly, they don't always have the most up-to-date information about the students' health. School nurses must get permission from parents to communicate with a child's doctor. Once the doctor gives them a care plan for the child, they generally rely on the doctor and/or parents for updates and changes.

"When things change, we don't always get told in a timely manner," says Nina Fekaris, a school nurse in the Beaverton, Ore., school district. "It works, but it takes a lot of coordination."

School nurses in Delaware voiced similar concerns a few years ago to administrators at Nemours Children's Health System that serves residents around the state.

"Lots of nurses expressed that they had difficulty communicating with providers" at Nemours, says Claudia Kane, program manager of the Student Health Collaboration at Nemours. In 2011, the health system got together with the Delaware School Nurses Association and the state Department of Education to develop a program that, with parental approval, now gives school nurses read-only access to the electronic health records of more than 1,500 students who have complex medical conditions or special needs such as diabetes, asthma, attention deficit hyperactivity disorder, seizure disorders, or gastrointestinal problems.

Now that she has access to the Nemours system, Beth Mattey can check the recent lab test results of a student who has diabetes.

"It's helpful for me to monitor his [blood sugar levels] and work with him to make sure he's in better control," says the Wilmington school nurse who is president-elect of the National Association of School Nurses.

When a student put a staple through his finger, she was able to check to make sure he went to the doctor and got treatment.

"Checking with him directly involves calling him out of class," she says.

Eventually school nurses will be able to put information into the Nemours electronic records system as well, says Kane. In the meantime, Nemours doctors, some of whom were initially skeptical about allowing school nurses access to health system medical records, are warming up to the arrangement. It encourages communication between Nemours physicians and school nurses, and eases the burden of routine tasks because Nemours doctors no longer have to fax over care plans or instructions to the school nurse every couple of months for students who are part of the program, says Kane.

The Nemours Student Health Collaboration project is operating in all as well as half of charter schools and about a third of private schools. Nemours plans to extend the program to school-based health centers next, says Kane.

"Our primary care practices are going through the process to become certified as medical homes," says Kane. "School nurses have a big role in care coordination, and this program is integrated as a piece of that."

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