Providing Health-Related Services to Medically Involved Children

Providing Health-Related Services To Medically Involved Children

I.  STATUTORY AUTHORITY

The IDEA is the controlling statute.  The relevant sections of IDEA and its implementing regulations state in pertinent part:

Statute

1. Any state receiving federal funds under the IDEA must provide its students with a free appropriate public education.  20 U.S.C. 1412(1).

2. The term “free appropriate public education” means special education and related services that have been provided at public expense.  20 U.S.C. 1401(18).

3. “Special Education” means specifically designed instruction at no cost to parents or guardians, to meet the unique needs of a child with a disability including instruction conducted in the classroom, home, hospitals and other settings.

4. “Related Services” means transportation, and such developmental, corrective, and other supportive services … (including medical services, except that such medical services shall be for diagnostic and evaluation purposes only) as may be required to assist a child with a disability to benefit from special education.  20 U.S.C. 1401 (17) (emphasis added).

REGULATIONS

5. “Related services” for handicapped children include “school health services.”  34 C.F.R. 300.13(a).

6. “School health services” are services provided by a qualified nurse or other qualified person.  34 C.F.R. 300.13(b)(10).

7. “Medical services” are services provided by a licensed physician.  34 C.F.R. 300.13(b)(4).

II. CAPSULE SUMMARY

The school district will be obligated to provide a particular health-related service if service at issue constitutes a “related service” as provided by IDEA, as opposed to a “medical service” as provided by IDEA.  Therefore, in every case summarized below, the primary question before the court is whether the disputed health-related service constitutes a “related service” or a “medical service.”

III.  CASE LAW

A.  Irving Independent School District v. Tatro, 104 S.Ct. 3371 (1984)

Facts:  Amber Tatro was an eight-year-old severally orthopedically impaired girl with spina bifida.  Her health problems included a neurogenic bladder which prohibited her from emptying her bladder, resulting in the need for her to be catheterized every three-four hours to prevent injury to her kidneys.  The catheterization procedure could be performed in a few minutes by a lay person who received less than one hour of training.

Held:  Catheterization constitutes a related service because it is a supportive service required to assist a handicapped child to benefit from special education, as provided in 20 U.S.C. § 1401(17).

Reasoning:

*  In creating the Act,[1] Congress sought primarily to make public education available to a handicapped child and to make such access meaningful [Rowley].

*  The Act makes specific provision for services, such as transportation for example, that do more than enable a child to be physically present in class.

*  School nurses have long been part of the education system and one can reasonably conclude that school nursing services are not the sort of burden Congress intended to exclude as a “medical service.”

*  The definition of “medical services” in the regulations suggests that Congress intended to spare schools from an obligation to provide a service that might well prove unduly expensive and beyond the range of their competence.

*  By limiting the “medical services” exclusion to the services of a physician or hospital, both of which are far more expensive than the catheterization procedure, it is permissible to conclude the catheterization services do not constitute a “medical service” excludable under the Act.

*  The obligation to provide services that relate to both the health and educational needs of handicapped students does not create an undue burden on the school districts.  Several limitations within the statute and regulations minimize the burden.  The limitations are:

1. To be entitled to “related services” the student must be handicapped so as to require special education.  (20 U.S.C. 1401 (1), 34 C.F.R. 300.5).

2.Only those services necessary to aid a handicapped child to benefit from special education must be provided, regardless of how easily a school nurse or lay person could furnish those services.

For example, if a child required an insulin shot one time a day and the shot could be administered at night, the school would not be required to provide those services.

3. School nursing services must be provided only if they can be performed by a nurse or other qualified person, not if the service must be performed by a physician.  (34 CFR 300.13(a), (b)(4), (b)(10)).

B.  Tokarcik v. Forest Hills School District, 655 F.2d 443 (3rd Cir. 1981)

Facts: A fourth grade girl, also named Amber, was also born with spina bifida, and required intermittent catheterization every four hours.

Held:  For the child under reasoning similar to Tatro.

Reasoning:

*  Because special education specifically contemplates instruction in a regular classroom (see 20 U.S.C. § 1401), “related services” necessarily include what is required within reason to make such a setting possible for a child who can benefit from it.

*  An appropriate education for a physically handicapped child with normal intellectual ability aims at promoting achievement roughly equivalent to that of her non-handicapped peers.  Special educational for Amber should entail classroom instruction, for the nature of her handicap is not so severe as to preclude the possibility of education in a regular environment.  Such a placement would demand in terms of related services, only that the school make the classroom physically accessible to Amber and reasonably provide for health needs that might otherwise interfere with classroom performance which is exactly what catheterization would accomplish.

*  The definition of related services (20 U.S.C. §1401(17)) foreclosed the argument that related services pertains only to services directly linked to the effort to educate, and excludes therapeutic services contributing to other than educational needs.

*  Related services need not be education-specific and may be critical outside the formal educational setting.  The regulations clarify that related services includes school health services (34 C.F.R. 300.12(a)).  In light of the findings that catheterization can require no more than a few minutes a day, and no expenditure of funds if performed by the school nurse already required to be on staff at every school district, or very little expenditure of funds if performed by a part-time nurse, such services constitute a related service.

*  Even if school did not have a nurse or nurse’s aid to catheterize, the school would still be obligated to provide Amber with an appropriate education (presumably, it would then have to hire someone to provide these services).

*  The regulations place realistic limits on the nature of school health services to be provided under the Act.  (See limits in Tatro).  Drastic medical services that only a doctor can perform are excluded by the Act.

*  In this case, the court is not confronted with difficult value choices between placing the burden of fiscal limitations on handicapped children as opposed to school districts, or between advantaging a handicapped child by mainstreaming rather than enhancing the education of her nonhandicapped students by excluding her.

* The alternatives of a special classroom or at home instruction are less cost beneficial.

Note:  Notice how the court states that the responsibility to provide related services is limited to “what is in reason,” and how the court emphasizes that the disputed services are inexpensive, relatively easy to provide, and do not harm the education of other students.  This reasoning represents the court’s own value judgment and interpretation of the law.  No where do the statutes or regulations provide for this interpretation.

C.  McKenzie v. Jefferson, 566 F.Supp. 404 (1st Cir. 1983)

Facts: A very intelligent, but severally emotionally disturbed girl spent a year in a psychiatric facility where she received residential care.  The girl attended school at the facility.  The school agreed to pay for the educational placement, but disputed the residential hospitalization services, claiming they were not related services under the Act.

Held:  For the district.

Reasoning:

*  The services at issue are clearly medical in nature and do not fall within the related services category as set forth under the Act.

*  The hospitalization services are not something a layman with training can provide — here, there must be doctors.

* The only type of medical service a school is obligated to provide a handicapped student are those that are for diagnostic and evaluative purposes.  (20 U.S.C. 1401(12)0.

D.  Detsel v. Board of Education of the Urban Enlarged City District, 637 F.Supp. 1022 (N.D. N.Y. 1986)

Facts:  Melissa, a seven-year-old with severe physical disabilities, required constant respirator assistance, a continuous supply of 40 percent oxygen, and constant observation by an individual trained to monitor her health.  The individual would have to know how to check Melissa’s vital signs, administer medications through a tube, perform a “P, D and C” procedure, which calls for the ingestion of saline solution into the child’s lungs and suctioning of the child’s lungs, and perform CPR.

Held:  For the District.  The required services are not related services.  The school is not required to provide a severely disabled child with constant in-school nursing care.

Reasoning:

*  The care Melissa requires is complicated and requires the skill of trained professionals.

*  In Tatro, the Supreme Court clearly considered the extent and nature of the [related] service to be performed.

*  Here, the provision of the disputed services undoubtedly enables Melissa to attend school during the day.  However, it does not necessarily follow that because Melissa can attend school only with the assistance of the services, that they must be provided by the school.

*  The disputed services do not fall squarely within the terms of the “medical services” exclusion because they need not be performed by a physician.  Nor do they qualify as simple school nursing services.

*  Because of the ongoing and extensive nature of the disputed services, they closely resemble “medical services” and are thus precluded under the Act.

Note:  Notice again how the court is further carving out an exception to the obligation to provide related services when the student requires continual care from a highly skilled individual (but not a physician).

(This case abrogated on 3/3/99 by the U.S. Supreme Court in Cedar Rapids case)

E.  Max M. v. New Trier High School, 859 F.2d 1297 (7th Cir. 1988)

Facts:  Max M. sought attorney’s fees based on the passing of the Handicapped Children’s Protection Act (“HCPA”).  His case was pending on July 4, 1984 and was not resolved until March of 1986.  The Act was passed in August 1986 as an amendment to the education for All Handicapped Children Act.  The district court awarded Max attorney’s fees and the school district appealed on the grounds that the HCPA amendment was unconstitutional and inapplicable.  The school district argued that Max had not filed his request within 90 days of the judgment in compliance with Local Rule 46.  Max argued that it was impossible to have met the 90 day rule as the HCPA amendment had not yet been passed.

Held:  The district court held that although the time frame should be shortened to facilitate intelligent decisions about appeals, the 90 day rule governed.  The district court reduced the amount of fees Max had been awarded to reflect the lack of success on other issues.  The decision was affirmed by the Seventh Circuit.

Reasoning:  The district court opinion dealt with the substantive issue of whether “psychotherapy” was a related service.  The holding was in the affirmative, along the lines of the Garret F. case.  The court simply asked whether the service was capable of being delivered by a non-physician; answer was yes.  The district had to reimburse the parents at the cost level of a non-physician. [Author’s case on the administrative level.]

F.  Macomb County Intermediate School District v. Joshuas, 715 F.Supp. 824 (U.S. Dist. 1989)

Facts: A severely multiple impaired student with a tracheostomy required constant monitoring from a trained individual.  The school refused to pay for those services during the child’s transport to and from school.  The issue on appeal was whether the school must monitor the student’s medical needs during transport (not during the school day).

Held:  For the student.

Reasoning:

*  Both Detsel and Bevin refused to acknowledge the Supreme Court’s directive in Tatro.  Instead, Detsel and Bevin incorrectly held that “extensive therapeutic health services” not requiring administration by a physician were medical in nature.  This is an incorrect expansion of the medical services definition under the IDEA.

*  No evidence was presented to suggest the disputed services had to be performed by a licensed physician.  Therefore, the services do not fall within the medical services exception.

*  While disagreement exists as to whether a trained lay person could adequately service the student’s needs, Tatro supports the conclusion that use of a medical professional, other than a physician, if necessary to safely transport the student, is a “related service.”

G.  Three Villages Central School District Board of Education, 18 IDELR 938 (New York, 1991, Level II)

Facts:  A minor with cervical spine injury, quadriplegic, recurrent urinary tract infection, neurogenic bowel and bladder, and scoliosis, required assistance with catheterization and tracheostomy care.  The minor required continual care by a person trained and certified in the use of ventilator equipment.

Held:  For the school under reasoning similar to Detsel.

H.  Granite School District v. Shannon M., 787 F. Supp. 1020 (U.S. Dist. 1992)

Facts:  Shannon was a six-year-old with congenital neuromuscularatrophy and severe scoliosis.  She was confined to a wheelchair, breathed through a tracheotomy tube which required suctioning five times during a three hour school day, and ate through a nasogastric tube.  Sometimes she required a portable ventilator.

Held:  For the school.

Reasoning:

*  The Tatro decision cannot be read as an endorsement of the proposition that all school health services performed by persons other than licensed physicians are related services under the Act, regardless of the amount of care, expense, or burden on the school system, and ultimately on the other school children.

*  Following subsequent interpretations of Tatro by a majority of courts, the issue of whether a school health service is a related service or excludable medical service must depend on the amount of care required, the cost of the care, and the other children.

*  In dicta, the court indicated that the facts might be different if the state regulation did not allow home bound instruction.

I.  Barnegat Township Board of Education, 19 IDELR 724 (N.J. 1992, Level I)

Facts:  A six-year-old with cerebral palsy was placed in full leg casts for three to four weeks, during which time she required repositioning throughout the day to prevent medical complications.

Held:  For the child.

Reasoning:

*  Repositioning services can be performed by a school nurse, physical therapist, or other school employee with little, if any, additional training.

*  The student would not be able to attend school while she remained in the leg casts but for the repositioning performed on a daily basis during school hours.  Thus without the services, the child would not receive the special education to which she is entitled.

J.  Neely v. Rutherford County School, 68 F.3d 965 (6th Cir. 1995)

Facts:  Samantha, a seven-year-old girl, had a medical condition requiring a tracheosto­my, resulting in the need for regular suction of her throat, nose and mouth to avoid serious and life threatening consequences.  She required continuous care by a well-trained individual to provide respiratory care.

Held:  For the school.

Reasoning:

*  This case is distinguishable from Tatro.  In Tatro, the service required was not unduly expensive or beyond the school’s range of competence.

*  A school district is not required to provide every service which is medical in nature.

*  The services required here are too burdensome.

*This case abrogated on 3/3/99 by the U.S. Supreme Court in Cedar Rapids case*

K.  River Forest School District. No. 90 v. Illinois State Board of Education, 1996 U.S. Dist. LEXIS 4988 (N.D. Ill. 1996)

Facts:  Christopher D. was diagnosed as having Landau-Kleffner Syndrome, a severe form of communication disability, which is a developmental neurological disorder marked by autistic behaviors and epilepsy.  To treat his seizure activity, Christopher had two major brain surgeries.  His doctor said the second surgery was his only chance of recovery.

In February 1994, after the first surgery, the district determined Christopher to be eligible for special education services and developed an IEP which identified nine annual goals, including improvement of his language skills.  The district recommended private placement of Elim Christian Day School (“Elim”).  At the beginning of the 1994-95 school year, the district did not have all the supplemental related services outlined in the IEP in place at Elim.  Christopher’s mother requested a Level I due process hearing and in November 1994, she notified the district that Christopher would be undergoing a second brain surgery due to a “pre-operational loss of some critical cognitive functions.”

Following surgery, the district planned to return Christopher to Elim and reportedly failed to increase Christopher’s related services to the extent necessary as a result of the second surgery.  Christopher’s mother placed him on the inpatient unit of the Rehabilitation Institute, a hospital specializing in the rehabilitation of brain injured patients, from January through March 1995.  At the Rehabilitation Institute, Christopher receive intensive daily speech and language services, occupational and physical therapy, and a one-to-one aide.

Upon his discharge from the Rehabilitation Institute, Christopher received services from Cognitive Rehabilitation Services (“CRS”) for speech, language and occupational services.  The district offered CRS an unacceptable, significantly reduced payment rate and in March 1995, the district informed Christopher’s mother that CRS was not an “approved” state board special education facility.  It further stated the placement was “medical, not educational,” and that it would not pay for the placement.  The district did agreed to provide a one-to-one aide as a related service for the time Christopher was at CRS.  Christopher’s program at CRS consisted of speech and language therapy, occupational therapy, and monitoring by the medical staff.

In July 1995, Christopher was transferred to Rehabilitation Institute and received services similar to those provided at CRS.

A Level I due process hearing was held in April and May 1995, and the hearing officer found that Elim was not an appropriate placement.  The district was ordered to immediately convene a MDC to consider the CRS as a private placement, to reimburse the parent for occupational and speech therapy at the Rehabilitation Institute, as well as for daily transportation to CRS, and to maintain the employment of the one-to-one aide.  The holding was later affirmed at a Level II due process hearing.

Appeal:  Medical v. Educational Placement

On appeal, the district argued that the placement at the Rehabilitation Institute was medical, rather than educational in nature.  The court gave due deference to the hearing officers’ decisions and stated the services were “educational” because Christopher received therapy in order to facilitate his ability to communicate.  Christopher’s “most pressing service need is for a highly structured integrated educational program which will be directed at restoring former functional levels in communication, sensory motor skills, and daily living skills.”  Furthermore, as noted in the Babb case,

The concept of education under the Act clearly embodies both academic instruction and a broad range of associated services traditionally grouped under the general rubric of ‘treatment.’  Any attempt to distinguish academics from treatment when defining ‘educational placement’ runs counter to the clear language of the Act.

Looking specifically at Christopher’s unique situation, the court said:

Christopher’s severe communication disability precludes academic learning.  Simply because a child is so severally disabled that he is unable to participate in reading, writing and arithmetic lessons does not mean that his treatment is ipso facto medical.

Reimbursement:  After determining that Elim was an inappropriate placement and that the Rehabilitation Institute was appropriate, the court ordered the district to reimburse the parent for the rehabilitation services.  However, the court followed the holding of Max M. v. Thompson,[2] 592 F.Supp. 1437 (N.D. Ill. 1984) and stated the district was limited to reimbursing the occupational and speech therapy at the customary rate the district pays to such personnel.

State Board Response: The school district argued that the State Board of Education was financially responsible for the placements at the rehabilitation facilities, because pursuant to regulation, the district is precluded from placing students at non-state-board-approved placements.  The state board pointed to relevant state regulations and argued that because the district failed to submit any undisputed facts establishing it took the necessary steps with the parent or the state board to provide Christopher with a comprehensive program following his second brain operation, the parent was compelled to unilaterally place Christopher at non-approved private facilities.  The court found the State Board’s argument persuasive.

L.  Cedar Rapids Community School District v. Garret F., 1999 WL 104410 (U.S. Supreme Court, March 3, 1999)

Facts:  Garret F. was a wheelchair-bound and ventilator dependent student.  He requires, in part, a responsible individual nearby to attend to certain physical needs during the school day.

Held:  The Individuals with Disabilities Education Act (IDEA) required a public school district in a participating state to provide a ventilator-dependent quadriplegic student with one-on-one nursing services during school hours.  Garret F.’s continuous care is not medical treatment, and therefore must be publicly funded under the IDEA.  The school district was required to provide nursing service to Garret F.

Reasoning:

* The Court affirms and employs the reasoning in its previous decision of Irving Independent School District v. Tatro, 104 S.Ct. 3371 (1984).  The services at issue had to be provided if the student was to remain in school.  Under the statute, relevant Supreme Court precedent, and the purposes of the IDEA, the school district was required to fund such “related services” in order to help guarantee that disabled students were integrated into the public schools.

*  Most of the requested services were already provided by the school district to other students.  Further, the in-school care necessitated by the student’s ventilator dependency did not demand the training, knowledge, and judgment of a licensed physician, and did not fall within the “medical services” exclusion.

*  The continuous character of certain services associated with the student’s ventilator dependency had no apparent relationship to whether they were “medical” services.  Continuous services might be more costly and require additional school personnel, but they were not thereby more “medical.”

* A rule limiting the medical services exemption to physician services is a reasonable and generally workable interpretation of the statute.

*  Finally, although the school district raised legitimate concerns about the financial burden that it would be required bear to provide the services that the student needed to stay in school, IDEA did not employ cost in its definition of “related services” or excluded “medical services.”  Accepting the school district’s cost-based standard as the sole test for determining the scope of the provision would require the Supreme Court to engage in judicial lawmaking without any guidance from Congress, and would create tension with the purposes of IDEA.

IV.  CONCLUSIONS

The U.S. Supreme Court has now adopted the Tatro “bright line” test: if a related service is required to enable a qualified disabled pupil to remain in school, it must be provided as long as it is not a purely “medical” service.  And the determination of “medical” is provider controlled, that is, if the service can only be provided by a licensed physician, it is an exempt “medical” service unless it is needed for diagnostic or evaluative purposes.  If, however, the service is capable of being delivered by a non-physician, it must be provided by school districts regardless of any financial or staffing burdens the services might impose.  The Supreme Court has again – and quite predictably in light of the Honig case on expulsion – read the Act for its plain, simple meaning and has again declined to “read in” exceptions are not present in the statute.

[1]  “The Act” refers to the IDEA or its predecessors.

[2]  Handled at Levels I and II by Brooke Whitted.