1. The hospital-to-school transition
Erin Stroud, MD
Pediatric resident, St. Louis Children’s Hospital

2. Learn goals of transition from hospital to home and school
Understand the people involved during a student's transition from hospital to school.
Discuss how school nurses and healthcare providers can better collaborate and communicate to improve care of recently hospitalized students.
Learning objectives

3. Outline Case discussion
Discuss the providers involved in the transition from hospital to school
Parent and provider goals for hospital-to-home transition
AAP/NASN recommendations
School Reintegration Programs
Discussion
Outline

4. A 5 yo boy recently discharged from the hospital after being admitted with a new diagnosis of asthma
Case 1

5. A 15 yo girl with a complex medical history who was recently discharged from the hospital for gastrostomy placement
Case 2

6. Goals of Transition Planning
For the student
For peers and staff
Goals of Transition Planning
Maximize health
Maximize academic experience
Reduce isolation/improve social reintegration
Increase knowledge about disorder
Decrease negative emotions surrounding return of child to school

7. Family priorities during hospital to home transition
Pain and symptom control
Respect for families’ discharge readiness
Effective engagement with healthcare providers
Care coordination
Timely and efficient discharge processes
Normalization and routine
Self-efficacy to support recovery and ongoing child development
Family priorities during hospital to home transition

8. Medically complex children: care map
Kuo DZ, Houtrow AJ, AAP COUNCIL ON CHILDRENWITH DISABILITIES. Recognition and Management of Medical Complexity. Pediatrics. 2016;138(6):e

9. Communicate with health care teams and families regarding care plans
Maintain the clinical skills to provide necessary services in school
Implement care plans and supervise care
Maintain awareness of local, state, and federal laws
Maintain awareness of local resources
NASN Recommendations

10. Pediatricians should discuss school-related health problems at visits and provider relevant information directly to the school
Pediatricians and school nurses should work together to establish an agreed-upon method of communication
Standardized forms
Pediatricians and school nurses should collaborate on the development of Individualized Health Care Plans
Written or electronic
Integrate subspecialty care, dental care, emergency care, home- nursing services, physical therapy, community mental health, and school-based services
AAP recommendations

11. Plan of Care Two components:
The Medical Summary
Care providers and roles
Diagnoses/problem list
Goals with “Negotiated Actions”
Patient, family, and provider goals
Contingency plans
Available in real-time and across care settings
Fluid document

12. School re-entry interventions
Workshops with school staff
Education with students
At age 5, children are capable of understanding new facts about illnesses
Address concerns, brainstorm future interactions
Contact with peers during recovery
Pre-return meetings with schools and family
School re-entry interventions

13. School Reintegration Programs
Royal Manchester Children’s Hospital Burn service
School reintegration team: psychologists, OT, PT, nurses, play specialists
Results: mean length of time from discharge to return to school dropped from 53 days to 20 days
Increased student/staff awareness
Decreased anxiety
Teachers, students, parents felt supported
School Reintegration Programs
Arshad et al. “Measuring the impact of a burns school reintegration programme on the time taken to return to school: A multi-disciplinary team intervention for children returning to school after a significant burn injury. Burns 2015; 41,

14. Communication between hospital and community providers should be initiated early in the hospitalization
Care plans should be created, implemented, and adapted by all members of the care team
Teachers and fellow students should receive education on the child’s illness
Efforts should be made to maintain contact between the child and his/her peers during the hospitalization
Summary

15. What changes has your program made to improve children’s transition from hospital to school?
How should a child receive extra attention following return to school?
Discussion

16.
Questions?

17. References
Kuo DZ, Houtrow AJ, AAP COUNCIL ON CHILDREN WITH DISABILITIES. Recognition and Management of Medical Complexity. Pediatrics ;138(6):e
Leyenaar JK, O’Brien ER, Leslie LK, et al. Families’ Priorities Regarding Hospital-to- Home Transitions for Children with Medical Complexity. Pediatrics. 2017; 139(1):e
AAP COUNCIL ON SCHOOL HEALTH. Role of the School Nurse in Providing School Health Services. Pediatrics. 2016; 137(6)e:
National Association of School Nurses. Transition Planning for Students with Chronic Health Conditions. January atementsFullView/tabid/462/ArticleId/644/Transition-Planning-for-Students-with- Chronic-Health-Conditions-Adopted-January-2014
Arshad et al. “Measuring the impact of a burns school reintegration programme on the time taken to return to school: A multi-disciplinary team intervention for children returning to school after a significant burn injury. Burns 2015; 41,
Canter KS and Roberts MC. “A Systematic and Quantitative Review of Interventions to Facilitate School Reentry for Children with Chronic Health Conditions.” J Pediatr Psychol
McAllister, JW. “Achieving a Shared Plan of Care with Children and Youth with Special Health Care Needs: An Implementation Guide.” Lucille Packard Foundation for Children’s Health. _of_care_implementation.pdf