DoD Directives
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Department of Defense |
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INSTRUCTION |
NUMBER 1010.13
August 28, 1986
Incorporating Change 1, February 2, 1990
ASD(HA)/ASD(FM&P)
SUBJECT: Provision of Medically Related Services to Children Receiving or Eligible to Receive Special Education in DoD Dependents Schools Outside the United States
References: (a) Public Law 95-561, "Defense Dependents' Education Act of 1978," as amended (Sections 921-932 of title 20, United States Code)
(b) Public Law 94-142, "Education for All Handicapped Children Act of 1975," as amended (Sections 1401 et seq. of title 20, United States Code)
(c) DoD Instruction 1342.12, "Education of Handicapped Children in the DoD Dependents Schools," December 17, 1981
(d) DoD Directive 1342.13, "Eligibility Requirements for Education of Minor Dependents in Overseas Areas," July 8, 1982
(e) through (m), see enclosure 1
1. PURPOSE
This Instruction:
1.1. Establishes policies and procedures to provide medically related services to children receiving or eligible to receive special education under references (a), (b), (c), (d), and (e).
1.2. Establishes policies and procedures to promote the development of a coordinated network for healthcare provider training and delivery of medically related services to children receiving or eligible to receive special education from the Department of Defense Dependents Schools (DoDDS) in order to ensure that these services are provided in the most appropriate, efficient, and effective manner.
1.3. Cancels reference (f).
1.4. Authorizes the publication of DoD Regulations and Manuals, consistent with DoD 5025.1-M (reference (g)), and DoD Forms consistent with DoD Instruction 5000.21 and DoD Directive 7750.5 (references (h)) and (i)), to implement this Instruction.
2. APPLICABILITY AND SCOPE
2.1. This Instruction applies to the Office of the Secretary of Defense, the Military Departments and all DoD Components that make use of the DoDDS.
2.2. The provisions encompass children who are or may be identified as handicapped under reference (c) and who are receiving or entitled to receive education from the DoDDS under reference (d), and their parents.
2.3. The provisions do not apply to children attending schools operated by the Department of Defense (DoD) within the United States, and children outside the United States who attend non-DoDDS schools when they have not been placed in those schools by the DoDDS.
2.4. This Instruction does not create any rights or remedies and may not be relied upon by any person, organization, or other entity to allege a denial of any such rights or remedies. To the extent that this Instruction conflicts with reference (c), reference (c) shall govern.
3. DEFINITIONS
Terms used in this Instruction and related service providers are defined in enclosure 2.
4. POLICY
It is DoD policy that:
4.1. The Military Medical Departments be responsible for the provision and professional supervision of medically related services in designated areas.
4.2. The following services be provided at identified sites with the same priority as medical care is provided to active duty Service members:
4.2.1. Medical evaluations and other services of a medical nature that are necessary to determine if a student is eligible for special education and related services.
4.2.2. The medically related services that the student requires as specified by the student's Individualized Education Program (IEP).
4.3. The existing quality assurance program in each medical treatment facility that provides medically related services monitor and evaluate the medical care for children receiving such services as described by this Instruction. Standards used by the Joint Commission on Accreditation of Hospitals (reference (j)), or equivalent standards shall be used, where applicable, to assure accessibility, acceptability, and adequacy of medically related services.
5. RESPONSIBILITIES
5.1. The Assistant Secretary of Defense (Health Affairs) (ASD(HA)) shall:
5.1.1. Ensure the review of medically related service implementation plans and programs of the Military Departments for compliance and suitability with this Instruction.
5.1.2. Ensure the provision of advice and consultation about the provision of medically related services to the Assistant Secretary of Defense (Force Management and Personnel) (ASD(FM&P)) and the General Counsel of the Department of Defense (GC, DoD).
5.1.3. Ensure the development of healthcare provider workload standards and performance levels that will determine staffing requirements of designated centers. These standards shall take into account the provider training needs and the additional time required to provide medically related services for assessment and treatment and for coordination with other resources, such as the DoDDS.
5.1.4. Assign the Military Medical Departments geographical areas of responsibility for providing medically related services under subparagraph 6.6.1., below.
5.2. The Secretaries of the Military Departments shall:
5.2.1. Ensure the coordination and cooperation between the Military Departments when considering assignment(s) to an area where medically related services are the responsibility of another Military Department.
5.2.2. Ensure that the Surgeons General share appropriate medical information when providing medically related services becomes the responsibility of another Military Department.
5.2.3. Ensure the establishment of procedures that provide for the assignment of Service members with handicapped children (who are entitled or close to the age of entitlement to receive educational services from the DoDDS) to areas where necessary special education and medically related services are available or can be readily obtained.
5.2.4. Ensure that medically related service programs are developed and implementation plans are submitted to the ASD(HA).
5.3. The Surgeons General of the Military Departments shall:
5.3.1. Ensure the development of policies and procedures for providing, documenting, and evaluating medically related services.
5.3.2. Ensure that medically related services are provided in accordance with this Instruction.
5.3.3. Ensure that resources are allocated in accordance with the healthcare provider workload standards and performance levels developed under the direction of the ASD(HA).
5.3.4. Ensure the cooperation and coordination between their respective offices, the offices of other Surgeons General, and the DoDDS with respect to the implementation of this Instruction.
5.3.5. Ensure that training is available for each healthcare provider serving as a member of a Case Study Committee (CSC). This training shall include information about the roles and responsibilities of the CSC and the development of an IEP.
5.3.6. Ensure the provision of in-service training on medically related services to educational, legal, line, and other suitable personnel, if requested and feasible.
6. PROCEDURES
6.1. Each Military Service shall establish a mechanism for obtaining or determining specific information regarding the possible medically related service need(s) of potential DoDDS handicapped students before they leave the United States. This information shall:
6.1.1. Include the child's medical and/or educational needs.
6.1.2. Be used when necessary to facilitate assignment to areas designated as centers for medically related services in accordance with this Instruction.
6.2. Medical and other information shall be shared with other Service medical personnel when medically related services are to become the responsibility of another Military Department. This information, while in no way binding on the CSC, shall include:
6.2.1. The medical and educational information needed to determine the specific type and extent of medically related services the child is likely to require.
6.2.2. The type and frequency of medically related services likely to be specified in the IEP in compliance with DoD Instruction 1342.12 (reference (c)).
6.2.3. Diagnosis based on, and consistent with, current acceptable professional usage and the four- and five-digit International Classification of Diseases (ICD)-9-CM categories in DoD Instruction 6040.33 (reference (k)).
6.3. Sponsors shall be advised to ensure that information about the child's medically related needs remains current.
6.4. If medically related services are likely to be required or should be considered, assignments shall be pinpointed to areas with the resources available.
6.5. The assignment personnel of all Military Services in coordination with Service medical personnel, who provide advice on medical services available, shall coordinate with DoDDS personnel so that handicapped children who are entitled to receive or are receiving education from the DoDDS and who require or are likely to require medically related services are sent to locations where those medically related services can be provided. Medical personnel and personnel officials shall cooperate in efforts to assign sponsor(s) with children needing medically related services to overseas locations where those services are currently available or can readily be obtained.
6.6. Each Military Department shall establish centers in consultation with the DoDDS, within designated areas of geographical responsibility outside the United States capable of providing necessary medically related services to support the needs of eligible beneficiaries.
6.6.1. The ASD(HA) shall assign the Military Departments geographical areas of medical responsibility using the Military Health Services System Sizing Model methodology. The Military Service sending members or civilian employees to unassigned areas or without first verifying the availability of medically related services shall be responsible for providing medically related services for the children sent to those areas.
6.6.2. If any parts of this Instruction create a potential disruption of established medically related services to children, the DoDDS and the Military Departments in the areas involved shall devise an interim agreement for a phased shift of responsibility to the medical facility having geographical responsibility. The agreement shall: provide for a shift of responsibility as soon as possible, but not to exceed 3 years; be formulated so that no eligible child goes unserved; and clearly describe referral procedures to be used during the transition. Copies of such agreements shall be forwarded to the ASD(HA) for review within 90 days of publication. The ASD(HA) shall provide copies to the ASD(FM&P) and the GC, DoD.
6.6.3. Centers shall be staffed with appropriate professional staff, which should include occupational therapist(s) with pediatric experience; physical therapist(s) with pediatric experience; audiologist(s) with pediatric experience; child psychiatrist(s); clinical psychologist(s) with pediatric experience; social worker(s) with pediatric experience; community health nurse(s) or equivalent; and pediatrician(s) with experience and/or training in developmental pediatrics.
6.6.4. Before assigning civilian employees with children outside the United States, the employing DoD Component shall provide such employees with information on the location of existing centers that are fully equipped to provide medically related services to children receiving or eligible to receive special education, and the medically related services currently available where the civilian is to be assigned. The employing DoD Component shall not suggest that if such employees accept overseas assignments, their handicapped children who are entitled to receive an education from the DoDDS will fail to receive a free appropriate public education.
6.7. Each Military Department shall ensure that medical treatment facilities responsible for providing medically related services in a geographic area initiate memoranda of understanding with the DoDDS schools served specifying the referral and evaluation process.
6.8. Upon request by a CSC, the responsible Military Department shall ensure that a qualified medical authority conducts or verifies a medical evaluation for use by the CSC in determining eligibility for special education, including the specific medically related services necessary for the student to benefit from the individually designed special education curriculum delineated in the IEP. This medical evaluation, including necessary consultation with other medical personnel, shall be supervised by a physician or other qualified healthcare provider.
6.8.1. This medical evaluation shall include a review of general health history, current health assessment, systems evaluation to include growth and developmental assessment, and, if pertinent, detailed evaluation of gross motor and fine motor adaptive skills, psychological status, and visual and audiological capabilities, including details of present level of performance in each of these areas affecting the student's performance in school.
6.8.2. Evaluation reports from physicians or other healthcare professionals shall address the present level of performance, the impact of the child's medical condition(s) on his or her educational performance, and, when pertinent, offer specific recommendations on the nature, frequency, and amount of medically related services. Replies to CSC referrals shall include evaluation results, relationships of findings to educational functioning, and response(s) to question(s) posed in the original referral.
6.9. The Commander of the Medical Treatment Facility (MTF) shall ensure the provision of a summary evaluation report to the CSC and appoint a healthcare coordinator to serve on the CSC when eligibility, placement or requirements for medically related services are to be determined.
6.10. Each MTF designated as a center or providing medically related services under this Instruction shall designate a healthcare provider known as the "Medically Related Services Liaison Officer" to:
6.10.1. Provide liaison between the MTF and DoDDS schools.
6.10.2. Offer, on a consultative basis, training for DoDDS personnel on medical aspects of specific handicapping conditions.
6.10.3. Offer consultation and advice as needed regarding the health services provided at school (for example, tracheostomy care, tube feeding, speech and language therapy).
6.10.4. Participate with the DoDDS and legal personnel in developing and delivering in-service training programs that include familiarization with various conditions that handicap a child's educational endeavors, the relationship of medical findings to educational functioning, medically related services, DoD Instruction 1342.12 (reference (c)), and this Instruction.
7. EFFECTIVE DATE
This Instruction is effective immediately. Forward two copies of implementing documents to the Assistant Secretary of Defense (Health Affairs) within 180 days.
Enclosures - 2
E2. Definitions
E1. ENCLOSURE 1
REFERENCES, continued
(e) Secretary of Defense Memorandum, "Provision of Medically Related Services to Handicapped Dependents in Overseas Areas," September 16, 1983
(f) Office of the Assistant Secretary of Defense (Manpower Reserve Affairs and Logistics) Memorandum, December 1, 1982, "Assignment of Responsibility for Related Services of a Medical Nature under DoD Instruction 1342.12, "Education of Handicapped Children in the DoD Dependents Schools," December 17, 1981 (hereby canceled by agreement with Assistant Secretary of Defense (Force Management and Personnel))
(g) DoD 5025.1-M, "Department of Defense Directives System Procedures," April 1981
(h) DoD Instruction 5000.21, "Forms Management Program," December 5, 1973
(i) DoD Directive 7750.5, "Management and Control of Information Requirements," August 7, 1986
(j) Joint Commission on Accreditation of Hospitals, "Accreditation Manual for Hospitals," 1985
(k) DoD Instruction 6040.33, "Medical Diagnoses and Surgical Operations Nomenclature and Statistical Classification," May 12, 1986
(l) DoD Directive 6025.11, "DoD Health Care Provider Credentials Review and Clinical Privileging," May 20, 1988
(m) DoD Directive 6025.6, "Licensure of DoD Health Care Providers," June 6, 1988
E2. ENCLOSURE 2
DEFINITIONS
E2.1.1. Audiology. Audiologic, diagnostic, and prescriptive services provided by audiologists who have a Certificate of Clinical Competence - Audiology and pediatric experience. Audiology shall not include speech therapy.
E2.1.2. Case Study Committee . A multi-disciplinary team comprising, among others, educators and medically related service providers who determine the eligibility of the student for special education and formulate an individualized educational curriculum reflected in an (IEP) that is based upon the diagnosis of handicapping conditions of school-aged children in the DoDDS. Full committee membership is detailed in DoD Instruction 1342.12 (reference (c)).
E2.1.3. Handicapping conditions. As defined in the definitions listed in DoD Instruction 1342.12 (reference (c)).
E2.1.4. Handicapped student. One identified as being eligible for special education by a multi-disciplinary CSC in accordance with DoD Instruction 1342.12 (reference (c)).
E2.1.5. Medically Related Services
E2.1.5.1. Medical services (as defined in E2.1.6., below) and those services provided under professional medical supervision that are required by a CSC either to determine a student's eligibility for special education or, if the student is eligible, the special education and related services required by the student under DoD Instruction 1342.12 (reference (c)).
E2.1.5.2. Provision of either direct or indirect services listed in an IEP as necessary for the student to benefit from the educational curriculum. These services may include medical; social work; community health nursing; dietary; psychiatric diagnosis, evaluation, and follow-up; occupational therapy; physical therapy; audiology; ophthalmology; and psychological testing and therapy.
E2.1.6. Medical Services. Those evaluative, diagnostic, therapeutic, and supervisory services provided by a licensed/credentialed physician to assist CSC(s) and to implement IEP(s). Medical services include diagnosis, evaluation, and medical supervision of related services that, by statute, regulation, or professional tradition, are the responsibility of a licensed and credentialed physician.
E2.1.7. Occupational Therapy. Therapy that provides developmental evaluations and treatment programs using selected tasks to restore, reinforce, or enhance functional performance. It addresses the quality and level of function in areas such as behavior, motor coordination, spatial orientation; visual, motor, and sensory integration; and general activities of daily living. This therapy, which is conducted by a qualified occupational therapist, provides training and guidance in using special equipment to improve the patient's function in skills of daily living, work, and study.
E2.1.8. Physical Therapy. Therapy that provides evaluations and treatment programs using exercise, modalities, and adaptive equipment to restore, reinforce or enhance motoric performance. It focuses on the quality of movement, reflex development, range of motion, muscle strength, gait, and gross motor development, seeking to decrease abnormal movement and posture while facilitating normal movement and equilibrium reactions. The therapy, which is conducted by a qualified physical therapist, provides for measurement and training in the use of adaptive equipment and prosthetic and orthotic appliances.
E2.1.9. Psychological Services. Services listed below that are provided by a qualified psychologist:
E2.1.9.1. Administering psychological and educational tests and other assessment procedures.
E2.1.9.2. Interpreting test and assessment results.
E2.1.9.3. Obtaining, integrating, and interpreting information about a child's behavior and conditions related to his or her learning.
E2.1.9.4. Consulting with other staff members in planning school programs to meet the special needs of children, as indicated by psychological tests, interviews, and behavioral evaluations.
E2.1.9.5. Planning and managing a program of psychological services, including psychological counseling or therapy for children. A qualified psychologist is a clinical psychologist licensed in a State of the United States who has a degree in clinical psychology and additional pediatric training and or experience. Additionally, the DoDDS may certify the psychologist(s) who work(s) in schools.
E2.1.10. Qualified Occupational Therapist. An occupational therapist who has pediatric education or training beyond the basic degree or has pediatric experience and is credentialed under DoD Directive 6025.11 (reference(l)).
E2.1.11. Qualified Physical Therapist. A physical therapist who has pediatric education or training beyond the basic degree or has pediatric experience and is credentialed under DoD Directive 6025.11 (reference (l)) and licensed under DoD Directive 6025.6 (reference (m)).