Innovative Care Coordinator

Through an AEF Development & Expansion grant in 2015, the Innovative Care Coordinator program is expanding to the elementary schools.


Excerpt from November 2014 Superintendent’s Newsletter. 

Care Coordination Grant Drives Collaboration to Support Safety, Health and Learning

Creating and maintaining safe schools is a focus area in our district. Many of you have visited our website where we talk about the comprehensive program that includes safety and security audits, development of emergency plans and staff training. These are the areas that most often come to mind when we think about safety. In our schools today, however, safety goes beyond emergency management and preparedness. District Nurse Leader Susan Franchi thinks about safety and security in an additional way. She knows that safety includes having students feel that school is a place they want to be, and a place where they can learn and be included. Over the last few years, she has discovered that the problem of school adjustment is growing. Our nurses are seeing more and more students with anxiety and depression. Some have a desire to hurt themselves. More students are also presenting with concussions, as this condition is diagnosed more frequently today.

Students with these problems end up in a vicious cycle. As they try to manage school along with their health issues, their absence rate increases. This leads to more stress. Parents are often unsure what to do, and the medical professionals involved may not even know how many days their patients have missed.

It became clear to Ms. Franchi that our district needed a point person, or case manager, if we were going to be able to help these students succeed. When the Massachusetts Department of Public Health (DPH) announced that they were thinking of awarding grants to support an innovative school care coordination pilot project, she jumped at the chance to apply.

The $35,000 award that we received is enabling AHS nurse Sarah Lee to spend four days each week acting as a Care Coordinator. She services students with short and long-term acute disorders and injuries, and acts on mental health evaluation recommendations leading to necessary referrals and treatment. Having a Care Coordinator allows Nursing, Special Education, Guidance, Social Work and Primary Care providers to work collaboratively with parents and students to optimize positive health and academic outcomes. Communication is a large part of Ms. Lee’s job. She is involved in multiple meetings and conversations with all the parties, does check-ins with at-risk students, visits them at home and manages all the data. She also works closely with Cindy Sheridan Curran, who serves our district in the roles of Diversion Coordinator, Court-Home Liaison Officer and Attendance Officer.

There is solid evidence across the state that nursing care and management makes a positive difference in school attendance. We also know that anxiety and school adjustment issues can begin as early as the elementary years. In an effort to start interventions and care sooner, we have expanded the current effort to a small cohort of students in one of our elementary schools and at the middle school.

Nurses in each of our schools spend increasing amounts of time collecting, documenting and reporting information. Data management is in addition to the immediate services they provide to the increasing number of students who walk through their doors. We are fortunate to also have a DPH Essential School Health grant that enables the district to hire per-diem nurses to cover offices when there is overload.

Today we have a greater understanding of the variety of needs that we must address in order for young people to have a successful school experience. When students are having trouble, it is often our nurses who see them first. I want to thank Ms. Franchi, Ms. Lee and our other school nurses for the vital role they play in recognizing and serving at-risk students. Ms. Franchi is inspired by a quote from historian Carter G. Woodson that I would like to share with you here: “Real education means to inspire people to live more abundantly, to learn to begin with life as they find it and make it better.”


Comments are closed.