School Nursing Services for Special Children

By Phil Stinson, Esq.

Parents of children with special needs are often confronted with problems relating to the delivery of nursing services while their child is at school. On rare occasions, without the provision of such services, it is impossible for a student to attend school on a regular basis. This situation can be highly disruptive to family operations, as parents struggle to juggle the impossible burden of work obligations, while, at the same time, taking the time to personally provide the services for the child.

On March 3, 1999, the U.S. Supreme Court addressed this issue in Cedar Rapids Community School District v. Garrett F., ___ U.S. ___ (1999). The Court held that the federal special education law (known as the "Individuals with Disabilities Education Act" or "IDEA") requires that the school district provide children with any nursing services required by the child during the school day. In so doing, the Court rejected the school district’s request that any nursing services only need be provided based on a "cost-based multi-factor" test. The Court further chastised the school district for attempting to frustrate a purpose of the IDEA, that is, that Congress intended to open the doors of public education and required States to educate disabled children with non-disabled children whenever possible.

The Garrett F. Court did not address how the 1997 Amendments to the IDEA impact on the issue of providing school nursing services for children with special needs (because the issue before the Court dealt with facts and law prior to the enactment of the revisions to the special education laws in 1997). In 1997, Congress amended the IDEA to clarify that public educational agencies (local school districts) are the payors of last resort whenever another public agency has a funding responsibility to an exceptional child. 

If a child is the recipient of State Medicaid services, then Medicaid funding must be exhausted prior to the school district incurring any funding liability. If, on the other hand, a non-school public agency - such as Medicaid - refuses to pay for nursing services at school, then the school district must pay for the services and seek reimbursement from the other public agency. The parents of children with special needs should never be put in the position of having to fight with Medicaid authorities to obtain funding for school nursing services. Congress recognized that there might be occasions when public educational agencies and other public agencies might get into a dispute over which agency is responsible for payment of special nursing services for an exceptional child. Under the IDEA, each State is required to establish an interagency coordination system to handle interagency disputes regarding funding of services. Typically, these disputes involve school districts, state educational agencies, state health agencies, mental health agencies, and insurance agencies. The most effective State interagency coordination systems are ones where a representative of the Governor’s office chairs the interagency coordination meetings, such as in Delaware, because the agencies are put under intense pressure to resolve the funding disputes or suffer the consequences of letting the Governor resolve the issue.

In one recent case, a federal Court of Appeals held that a school district does not need to provide a person to administer medications to a child on homebound instruction, and that the school district’s policy of requiring a parent to remain at home during in-home instruction does not violate the IDEA. See Daniel O. v. Missouri Board of Education, 32 IDELR 113 (8th Cir. 2000).

Parents seeking at-school nursing services for a child with special needs should take the following steps:

1. Do provide medical documentation. The need for at-school nursing services should be documented by a medical doctor. Ask your child’s doctor to write a letter to the school district explaining what nursing services your child needs at school. The letter should state whether the services are necessary in order for the child to be able to go to school, and should state what level of professional qualifications or training is necessary to deliver the services. The doctor should clearly state if the services can be provided by a non-nurse who is trained to deliver the services (such as non-sterile catheterization). If the services can be provided by a non-nurse with special training, the doctor should outline specifically what training is necessary. Likewise, if the services require skilled nursing services, the letter should state exactly what specialized or advanced training is necessary for the nurse.

2. Do provide access to health insurance and Medicaid coverage information. School districts are far more willing to provide expensive nursing services for a child if the school district knows that the parent is exhausting all outside funding sources to pay for the services. Provide documentation to the school district showing that you have applied for Social Security, Medicaid, and CHIP benefits for your child, even if you think that your child is not eligible for SSI or Medicaid benefits. Give the school district copies of denial letters from your private health insurance carrier.

3. Demand that the child’s IEP specifically include the nursing services that you are requesting. Often, school district’s try to side-step this issue by claiming that it is not proper to include services to be paid for by another public agency. Stately conversely, the school districts think that they are financially liable for the services if the services are identified in the IEP. However, you will not be able to invoke the IDEA’s interagency coordination process unless the IEP specifically identifies the nursing services required for the child to access his or her educational program and placement.

4. Proceed to a Due Process Hearing if the school district does not provide the nursing services. It is time to file a request for a special education due process hearing if all of the above steps are followed by you, and the school district still refuses to provide the necessary nursing services. Ask the school district to provide you with a copy of the "Procedural Safeguards Notice." The Notice outlines the steps to request a due process hearing. When drafting a request for a due process hearing, be sure to affirmatively state in writing that "the child is being denied a free appropriate public education pursuant to the IDEA and Section 504 because necessary nursing services are being denied."

Phil Stinson, Esq. is a senior partner at Stinson Law Associates, P.C., a Philadelphia-based law firm dedicated to representing parents of children with special needs in federal courts throughout the country, is Director of the Special Education Law Clinic in Chester, Pennsylvania, is President and General Counsel of the Center for Education Rights ( and is the editor of, a multidisciplinary Internet resource portal ( Parents of children with special needs may contact Phil Stinson by e-mail at