Due to an expressed interest by a local school district and a desire to spread the chronic disease model to a population that could start early on managing life long chronic disease states, a couple of us met with a Special Needs Coordinator and three school nurses to discuss their potential use of the Shared Care Plan. This session was an eye opener which confirmed the value and need for truly coordinated Virtual Care Teams.
Communication is sketchy between local healthcare providers, parents, out of area specialty providers and school officials trying to manage the daily education and healthcare needs of students with diabetes and other conditions. The school district has an impressive set of tools and guidelines for handling variations in blood sugar levels, but much better coordination is needed among all who are involved in the care. In addition to monitoring status and creating care plans for the students, the school nurses really end up supporting these kids as they learn to manage their own conditions.
The Shared Care Plan, and the Virtual Care Team concept being tested here in Whatcom County have promise for bridging the communication gap for these students, their healthcare providers, and families. We need to further explore how to make the other tools, such as the state's individual health plan more readily available to other care team members.
Our encounter reminded me of the system in Jonkoping Sweden that Marc Pierson described after the recent visit by Pursuing Perfection Project Leaders and executives. In that county, children receive the majority of their primary care in the schools. It makes so much sense. How can we get there, or at least build a system to support the care and communication needs? I believe we are on the right track.
