Nursing Case Management Referral Process

Vision: Nash-Rocky Mount Public School Nurses willprovide additional support and services for students with identified health needto enhance success in academics and personal health management.

Mission: To establish a case management program and an organized student referral process with input from teachers and involvement with parents complying with all regulations related to informed consent and confidentiality as well as school district policies.

Goal 1:To identify students with chronic illnesses who would benefit from case management services from the school nurse.

Process/Procedure:

  1. Complete a student referral form.
  1. Reason for nursing support/service
  2. Interventions previously used.
  1. Submit completed referral form to the school nurse via email attachment
  2. School nurse will send email reply to confirm receipt of referral form.
  3. School nurse will review the referral form, assess student’s situation, and
    determine if student/family would benefit from nursing case management.
  4. Priority acceptance will be students at greatest risk of academic failure and/or poor management of health condition.
  5. Students/families not meeting nursing case management criteria may be referred for other school services such as counseling, EC services, alternative placement, etc., and/or to outside providers/agencies for supportive resources and assistance.

Goal 2: To assess student status, gather/document relevant data, create and implement a case management plan.

Process/Procedure:

  1. The school nurse will meet with student for baseline assessment.
  2. The school nurse will contact student’s family for information.
  3. The school nurse will determine other individuals and/or providers that need to be contacted.
  4. The school nurse will obtain release of information forms from parent/legal guardian and make the consultations.
  5. The school nurse will obtain, document, and analyze the baseline data.
  6. The school nurse will develop the individualized case management plan in conjunction with student and parent/legal guardian.
  7. The case management plan will be shared with other stakeholders, as agreed upon by parent/legal guardian.
  8. Collaborative partners and timelines will be identified.
  9. The case management plan will be implemented.

Goal 3: To track student success, provide follow-up, and evaluate results.Process/Procedure:

  1. Nursing follow-up will play a key role.
  2. The school nurse will meet withstudent and/or family at least monthly and more often as needed.
  3. The school nurse will periodically contact the referral source, other identified stakeholders, and collaborative partners. Student progress will be tracked.
  4. Degree of student improvement will be used to evaluate results and the guideline to reformulate the case management plan.

Examples of nursing case management referrals:

  1. Absenteeism related to health condition or emotional health issue.
  2. Student/family having difficulty with or improperly managing a newly diagnosed or existing health condition, e.g., medications, provider appointments, prescribed treatment recommendations, etc.
  3. Student/family lacking adequate resources or needs assistance in identifying, contacting, and utilizing health-related resources.
  4. Student/family lacking adequate understanding of student health condition and its’ impact on success in academic and personal life of student.