The Journal of School Nursing2021, Vol. 37(4) 306–315© The Author(s) 2019Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/1059840519861748journals.sagepub.com/home/jsn
Type I diabetes (T1D) is one of the most common childhood diseases and Type 2 diabetes (T2D) is increasing at alarming rates. Given that children spend a great percentage of their time in school, this setting is a critical environment for models of care that lead to better management of this and other health conditions. The School Nurses Managing Diabetes Care ECHO was offered to Colorado school nurses to build their capacity in providing evidence-based management of T1D. The purpose of this effort was to (1) determine whether or not the model could be used as a tool of collaboration and dissemination for school nurses across Colorado and (2) assess the effectiveness of the “School Nurses Managing Diabetes Care” ECHO learning series. Post-series survey results demonstrated a 25% increase in self-efficacy ratings, moving learners from “average among my peers” toward “competent.” Additionally, all respondents planned to make one or more practice changes to improve care for students with T1D. Expanding the use of the ECHO model to implement intensive management of children and youth with T1D is critically important as rates of this and other chronic conditions continue to increase.
diabetes, intensive management, chronic disease, self-efficacy, telehealth, continuing education, workforce development, telementoring, training, e-learning, school nurse
Thirty years ago, the landmark Diabetes Care and Complications Trial demonstrated the importance of intensive management for type 1 diabetes (T1D) to maintain tight glycemic control and prevent diabetes complications such as eye, kidney, and nerve disease (Nathan, 2014). Ongoing longitudinal studies continue to demonstrate the effectiveness of intensive management in preventing T1D-related health complications among children (White, 2015). This approach to T1D care requires frequent blood glucose monitoring and multiple insulin doses, via multiple daily insulin injections or use of an insulin pump. Insulin doses must be carefully balanced with carbohydrate consumption and physical activity to maintain blood glucose levels within a safe range each day. Children with T1D require assistance with intensive management and spend most of their day at school (Pansier & Schulz, 2015). Therefore, school nurses are vital partners in the network of care required for a child with T1D (Cogan, Conway, & Atkins, 2017). As population health leaders who emphasize health promotion and disease prevention while maintaining an overarching focus on social determinants of health, school nurses are poised to implement intensive management of children and youth with T1D.
In Colorado, there are two nursing roles, the school nurse and the childcare health consultant (CCHC). School nurses provide complex coordinated care and oversight for the complex health needs of children in educational settings (American Nurses Association & National Association of School Nurses, 2017) and play an essential role in keeping children healthy, safe, and ready to learn. The CCHC is an emerging national role in nursing and refers to a licensed health professional, specifically a physician or registered nurse, with a background in pediatrics (Healthy Child Care Colorado, 2019). CCHCs typically work with licensed childcare programs, providing monthly visits and developing health plans for children with special health-care needs attending childcare or other early education settings (Colorado Child Care Facility Licensing, 2018). For this article, the term “school nurse” will be used inclusively to encompass the CCHC and school nurse roles.
However, many regulatory factors influence a school nurse’s scope of work. The Colorado State Nurse and Medical Practice Acts outline the required delegation and supervision of necessary health-care tasks by Colorado school nurses who are licensed by the Colorado Department of Education (CDE) as specialized service providers (Colorado Board of Nursing Rules, 2018; Colorado Department of Education, 2019). Unfortunately, there are no requirements for specialty education, such as diabetes management, in the licensure process for school nurses, and no standardized training exists to prepare school nurses for T1D management. Furthermore, none of Colorado’s policies prescribe who should care for the estimated 3,000 students with T1D, of the 950,000 students enrolled in public and charter schools. Colorado public school policy only mandates that a person certified in cardiopulmonary resuscitation (CPR) and first aid be present in the school building at all times.
In addition to minimal regulations, varying funding for health services also results in inequities in care from district to district, which limits the school nurse’s ability to provide intensive management of T1D and adequately support health services for Colorado students. Data reporting of health services in Colorado schools is voluntary (Rules and Regulations Governing Schools in the State of Colorado, 2018), but unofficial data reports have shown that many districts have one nurse serving multiple school buildings. For the 135 Colorado school districts that have been classified as “outlying towns” or “remote” (Colorado Department of Education, 2018) and serve Colorado’s 106,000 rural and frontier students, one nurse could function in several districts and cover a large geographic region.
The student-centered Framework for 21st Century School Nursing PracticeTM states that care coordination, leadership, quality improvement, community health, and standards of practice are essential components of professional school nursing practice (Maughan, Bobo, Butler, & Schantz, 2016). As illustrated in Table 1, these principles can be applied to intensive management of T1D in the school setting, and expertise in these skill sets will assist the school nurse in coordinating the complex health needs of students with T1D at school. School nurses are well positioned to provide intensive management but only if knowledgeable about current treatment methods (Bratina & Battelino, 2010; Holmström, Häggström, & Söderberg, 2018; Latham, 2019), age-appropriate care (Jackson & Albanese-O’Neill, 2016; Kelo, Martikainen, & Eriksson, 2011; Peery, Engelke, & Swanson, 2012), effects of social determinants of health (e.g., health literacy, access to care, health insurance; Schroeder, Malone, McCabe, & Lipman, 2018), and coordination of care (Engelke, Swanson, Guttu, Warren, & Lovern, 2011; McClanahan & Weismuller, 2015).
Although there are a variety of diabetes-specific professional development opportunities for school nurses in Colorado, many nurses are unaware of these resources or have limited access due to time and geographic and financial barriers. Additionally, these workshops frequently utilize diabetes resource nurses to share clinical practice updates, but the primary focus is not on education and training. Such barriers limit access to opportunities for professional development and collegial support and often prevent school nurses from participating in continuing nursing education (CNE) offerings that would increase their capacity to meet the complex needs of children with T1D in school and childcare settings.
Furthermore, autonomously practicing nurses—such as those serving multiple rural school districts and, thus, having limited opportunities for developing collaborative practices within a peer network—may not be aware of these resources. As a result, many school nurses do not receive sufficient diabetes-specific CNE, lack access to professional development and collaboration with colleagues, and are unequipped to support their students with T1D.
Given the complex nature of T1D management and the low access to T1D CNE, there is a grave need to support and equip school nurses better in T1D management. This requires a collaborative effort between school nurses, who have the expertise in school nursing practice, and local health-care providers, who are experts in T1D management in youth. The School Health program at Children’s Hospital Colorado (CHCO), Barbara Davis Center for Childhood Diabetes (BDC), and the Extension for Community Health Outcomes (ECHO) Colorado collaborated to develop a CNE program, entitled School Nurses Managing Diabetes Care. The School Health program at CHCO is a contractual school and CCHC nursing program serving 75,000 urban, suburban, and rural students in and around the Denver region. BDC, located on the University of Colorado Anschutz Medical Campus, is the largest pediatric diabetes provider in Colorado. BDC provides T1D medical care and diabetes self-management education to nearly 4,000 children with T1D and their families and completes about 11,000 clinical visits annually.
Project ECHO uses telehealth technology to virtually connect health-care providers with specialists using interactive multidirectional video conferencing. The aim of ECHO is to improve community health by moving knowledge instead of people in the delivery of evidence-based care for patients experiencing chronic health conditions (Arora et al., 2007; Arora et al., 2010; Arora et al., 2011; Arora et al., 2011; Arora et al., 2014). The ECHO model has been shown to improve access to appropriate care, patient outcomes such as sustained viral response among patients infected with the hepatitis C virus, provider knowledge, and workforce satisfaction across many health topics, regions of the country, and around the world. ECHO Colorado was developed in January 2015 to engage a variety of health providers and organizations across Colorado in a statewide learning network and has since launched numerous learning series covering topics ranging from infectious disease prevention and pediatric complex care to integrated health and quality improvement.
The ECHO model has the potential to increase access to CNE for school nurses by reducing time and travel barriers. Nurses can access ECHO programs from any location, with a computer or other smart device, equipped with an Internet connection and camera. The ECHO learning series was built around the principles of professional school nursing practice (Table 1).
The purpose of this effort was to (1) determine whether or not the model could be used as a tool of collaboration and dissemination for school nurses across Colorado and (2) assess the effectiveness of the “School Nurses Managing Diabetes Care” ECHO learning series in increasing the self-efficacy of school nurses in caring for students with T1D, as well as their overall satisfaction with the learning series, intention to make practice changes, and anticipated barriers to making such changes.
ECHO Colorado’s project evaluation approach was reviewed by the Colorado Multiple Institutional Review Board and determined as not human subject research.
To bridge the educational gaps that existed for school nurses working in public and private school systems throughout Colorado, field experts from the CHCO School Health Program, BDC, and ECHO Colorado partnered to develop a multicohort, 4-week educational ECHO series. Members of the ECHO Colorado team included an instructional designer, project coordinator, evaluator, and marketing and communications professional who were responsible for guiding, coordinating, evaluating, and promoting the curriculum. Members of the CHCO School Health Team and BDC were responsible for providing content expertise. ECHO Colorado engaged the partners in a 12-week development process, which included identifying educational gaps and desired outcomes; recruiting expert presenters, panelists, and participants; and implementing logistics.
Two cohorts of the School Nurses Managing Diabetes Care ECHO learning series were created, each of which included four, 1-hr, weekly sessions. In an effort to ensure accessibility, each cohort was scheduled around the academic calendar—one was offered from mid-February to mid-March and the second cohort was offered in April. Overall learning objectives for the full series included the following:
Session topics for each of the 4 weeks included the following:
In an effort to ensure fidelity to the ECHO model, sessions were designed to support peer-to-peer, practice-based learning through the use of case presentations and previously planned discussion prompts. Short didactic presentations (10–15 min in length) were delivered by field experts who highlighted best practices and foundational learning concepts. Two additional subject matter experts served as panelists to provide varying perspectives on the topic, and sessions were moderated by a trained facilitator who helped guide the weekly sessions to assure an engaging and productive learning environment.
The ECHO series was offered at no cost to the schoolbased nurses. To ensure a quality learning experience that fostered peer-to-peer learning and connections, ECHO Colorado has attempted to keep the number of learners in specific cohorts within a lower range of 20–30 participants to enhance the possibility of each learner’s participation. Due to the high level of interest in this training, waitlists were created for the additional registrants. Those placed on a waitlist were prioritized for subsequent cohorts of the series. Registrants who were accepted to participate were largely selected on a first come first serve basis; however, in some cases, skill level and geographic location were prioritized to ensure statewide representation to facilitate the growth of peer networks and strong alignment between the curriculum and learners’ knowledge and skills. While attendance for the full series was not required, learners were highly encouraged to attend all sessions of the series. Learners who attended at least three of the four sessions and completed the post-series evaluation survey (which included questions required for CNE credit) were offered one CNE credit for each hour they participated. Participation in at least three of the four sessions was set as a requirement by ECHO Colorado for obtaining CNE to incentivize greater participation, but participants could attend any three sessions as their schedules permitted. CNE was administered and offered through the CHCO Office of Continuing Education.
The data for this study were drawn from two tools. The first, ECHO Connect (Thomas, Campbell, Shimasaki, Kazanjian, & Faye, 2018), is ECHO Colorado’s secure, custom-built online database. Connect prompts individuals interested in participating in an ECHO learning series to complete a 26-item questionnaire that includes self-reported demographics (e.g., gender, race and ethnicity, birth year) as well as questions regarding their professional background (e.g., credentials, profession, year started in profession, populations served), prior experience with ECHO, and how they heard about the ECHO learning series for which they are registering. This questionnaire has been developed in collaboration between ECHO Colorado’s evaluation team and partner organizations with the intent of creating an inclusive registration process and unifying the collection of data for funding requirements as well as tracking progress toward program goals of reaching various populations. In addition to these standard questions, three custom registration questions were added for this learning series. These items included school setting, ages served, and region served. Connect is also used during each session of a learning series to track the attendance of registrants.
The second data collection tool used for this study was an evaluation survey. This survey was adapted from ECHO Colorado’s standard 10-item post-series evaluation survey with learning objectives specific to this learning series as well as 6 additional items that were requested by the CNE office. The overall survey primarily consisted of multiple-choice and Likert-type scale questions, with a few open-ended questions as well, and aimed to assess the series’ impact. Table 2 lists the topics and response options for the various questions in this survey. Self-efficacy for learning objectives and serving as a local resource within their workplace or community for the topic of this ECHO series were assessed through a retrospective pretest question design. Other questions assessed respondents’ satisfaction with the series delivery, perception of the value of participating, recommendations for improvement, planned practice changes, and perceived barriers to making those changes.
Data collection. The post-series survey was sent to participants through Qualtrics (2018; Provo, UT) during the final session of the series, and participants were asked to complete it within 2 weeks. Participants were strongly encouraged to complete the survey regardless of the total number of sessions attended and were incentivized by being placed in a monthly drawing to win a US$50 e-gift card, in addition to the survey completion being a requirement for obtaining CNE. Nonresponders were sent up to two reminder e-mails after the initial invitation to complete the survey.
Registration, attendance, and evaluation data for each cohort were first analyzed individually and then aggregated. Data were analyzed using descriptive statistics and expressed as frequencies, medians, and standard deviations. The Shapiro–Wilk test was conducted to assess normality, and changes in median pre- and post self-efficacy scores were compared using the Wilcoxon signed-rank test. Data were analyzed with SPSS Version 25 software (IBM, New York, NY, 2013). A p value <.05 was used to assess statistical significance. Open-ended questions were coded and analyzed through a deductive approach by a trained member of the evaluation team.
One hundred fifteen school nurses registered for the series, and 60 were accepted for participation between Cohorts 1 and 2. Forty-eight registrants (80%) from various Colorado counties (Figure 1) participated in at least one session of the series for which they registered, and across the two cohorts, on average, participants attended 80% of the sessions. This demonstrated greater engagement compared to other learning series for ECHO Colorado in fiscal year 2018, where average participation and attendance rates were 79% and 73%, respectively. However, participation and attendance rates varied between Cohorts 1 (97% and 87%, respectively) and two (63% and 67%, respectively). Twenty-four (50%) participants claimed a total of 88 CNE credits. Participants from the two cohorts represented frontier (2%), rural (20%), and urban (78%) counties across Colorado. County designations were determined based on the U.S. Census Bureau’s identification of “urbanized areas” as those with 50,000 or more people and “Rural” as those not including urban areas (U.S. Census Bureau, 2010). The Colorado Rural Health Center (2018) further classifies “frontier” as counties with a population density of six or less people per square mile.
Most participants identified as White (88%), female/woman (100%), and were between the ages of 40–59 (83%), held a bachelor’s degree in nursing (92%), and had been in their profession for more than 16 years (65%). Participant demographics are shown in Table 3.
Thirty-five (73%) participants across both cohorts completed the post-series evaluation survey. Twenty-three (66%) of those respondents were from Cohort 1, and 12 (34%) were from Cohort 2, resulting in response rates of 79% and 63%, respectively. School nurses reported statistically significant increases in self-efficacy across all measures for managing diabetes in schools (Table 4). The overall change in self-efficacy for participants demonstrated a 25% increase (p < .001, r > .5) from an average baseline score of 3.00 to a postseries score of 3.75, where a 4 represented “average among my peers” and a 4 represented “competent.” Despite the differing response rates, neither the levels of statistical significance nor strengths of effect varied by cohort.
Most respondents agreed or strongly agreed that participation in the series was a valuable use of time (97%), made them better at their job (94%), and improved their professional satisfaction (91%). Furthermore, more than half of the respondents agreed or strongly agreed that their professional isolation diminished (83%), they felt more supported in their job (86%), they had an improved understanding of the subject matter (89%), they felt the materials were presented in a clear way (80%), and they were satisfied with the experience overall (77%).
Responses to the open-ended question regarding what aspects of the learning series participants found to be valuable supported the positive findings of similar questions from the quantitative elements of the post-series survey. The overarching theme most commonly reported was connecting with other nurses throughout the state working in similar environments and hearing about their successes and challenges with their work. These connections allowed for robust discussion where participants could ask questions, actively learn from one another, and share resources—filling a gap of professional support and reducing feelings of professional isolation. One respondent shared,
Although I know I am not the only one to have challenges with diabetic students and their families, it was sure nice to hear from school nurses across the state and ideas that they have tried to combat some of the challenges.
The second most commonly reported theme was receiving expert knowledge. During the opportunities for questions and answers that followed the short presentations by field experts, respondents were able to get their most pressing questions around best practices answered and apply the presentation content directly to their work. One respondent shared,
I appreciate[d] the expertise of the presenters starting with the basics then progressing each week to include the other aspects of insulin management, carbohydrate counting, variables with exercise and developmentally appropriate care. The discussion time went by very fast and was well facilitated to address areas of concern we deal with every day. I was able to use the knowledge learned after the first session in my daily practice and it seemed to get better every week.
Finally, a few people also reported valuing the use of a bidirectional video platform for the delivery of the learning series. They appreciated the ability to join remotely but still see each other as well as the dual modalities of being able to ask questions verbally or through the chat feature. One respondent commented, “The technology worked great from my home computer. The fact that we got to interact and ask questions on camera and also in the chat box was super helpful.”
Through an open-ended question, respondents described planned changes to their work. All respondents indicated at least one change they planned to implement, with changes in student care being the most commonly reported. Many nurses expressed that they previously did not consider the whole patient and focused too heavily on the diabetes diagnosis, regardless of whether or not students were properly managing their blood glucose levels. With that came a heavy focus on things the students were doing incorrectly and often resulted in what nurses admitted felt like lecturing. Respondents planned to reframe their approach, considering the whole child, specifically the unique needs of adolescent students and how hormones impact blood glucose levels, and highlight successes. Additionally, they planned to build better relationships with students by engaging them in educational conversations around diabetes management and proactively checking in with students to ensure they have the necessary support. One respondent described several changes she planned to make:
Being more aware of the changes in adolescents (hormones) and the effects this can have on their blood sugars; closer monitoring/looking for patterns of elevated sugars in my students and communicating better with parents/healthcare providers; obtaining new orders as they are available from parents or healthcare providers; trying to connect on a more personal basis w/students (they are more than their diabetes); being an advocate for these students with other students, staff, and administration.
The second most commonly discussed theme on planned changes was practice change. Many respondents indicated that they were going to start taking steps to improve how they work with others involved in the care of their students. For example, respondents planned to apply newly learned communication strategies with parents and other providers. Additionally, respondents planned to rely more on new connections formed with other school nurses in the ECHO learning series, reaching out to peers as well as primary care providers if challenges or questions arise while caring for children with diabetes.
Challenges are to be expected when implementing changes in care or process in the workplace. Interestingly, 47% of all respondents did not anticipate any barriers to their planned changes. For the 53% who did anticipate challenges, however, lack of support from those supporting the care of the student was the most commonly reported barrier. Others supporting the care included coworkers, management, and parents of students. Less commonly anticipated barriers included lack of resources and insufficient knowledge.
The opportunity to improve the management of diabetes care for students by building the capacities of school nurses has been demonstrated in various studies (Bobo et al., 2011; Breneman, Heidari, Butler, Porter, & Wang, 2015; Fisher, 2006). Similarly, our evaluation findings showed that the School Nurses Managing Diabetes Care ECHO learning series is a promising approach to increasing the self-efficacy of school nurses for managing diabetes care and improving care of students through various practice changes. Respondents reported increases in self-efficacy around key learning objectives, increased professional satisfaction, decreased professional isolation, and intention to apply new learnings to their work—specifically around how they care for students and how they work with other professionals in the care of students. Furthermore, they reported higher self-efficacy for serving as a local resource for managing diabetes in school-age children. These findings suggest that participation in the ECHO learning series helped school nurses become better prepared to deliver evidence-based diabetes care to their students and provide support to other nurses within their school district who are also caring for students with diabetes.
Previous research shows that the ECHO model has been an effective way to decentralize knowledge, so providers across all geographies have access to ongoing professional development education and training, and increase the capacity of the health workforce through a variety of applications (Arora et al., 2007; Arora et al., 2010; Arora et al., 2011; Arora et al., 2011; Arora et al., 2014). However, to our knowledge, the model has not been previously applied to the school nurse population for improving self-efficacy around the management of chronic health-care conditions. Our study supports the notion that the ECHO model is an effective tool for increasing workforce capacity and building professional connections, especially for those who are both geographically and professionally isolated.
Given that children spend significant amounts of time in school, school nurses serve a critical role in managing the day-to-day care of students with diabetes and other chronic health conditions. The limited literature on diabetes education programs specific to school nurses demonstrate the critical need for additional offerings of effective diabetes education as well as the research of such CNE programs (Bachman & Hsueh, 2008; Breneman et al., 2015). With the trend in diabetes continuing to rise (Mayer-Davis et al., 2017), their role will become even more crucial, and thus increasing access to evidence-based diabetes management education is imperative. Through its use of virtual connection, the ECHO model has repeatedly demonstrated its role in filling a very important gap in providing quality education and training. The use of technology and a virtual “grand rounds” approach that allows participants to see and interact with one another, face-to-face, regardless of geographic location, supports the authentic discussions and information sharing previously described. Not only are school nurses busy professionals working in resource-limited environments but Colorado is also a large state that includes many rural areas, making travel for off-site training and education unrealistic for many. The use of the ECHO model gives school nurses access to experts and one another without leaving their offices. Further, this ECHO series facilitated collaboration between school nurses and diabetes health-care professionals, and such teamwork is essential to fostering continuity of care between home and school.
The overwhelming number of registrants for this series speaks volumes to the huge unmet need for Colorado school nurses to pursue professional development opportunities similar to this ECHO learning series. In addition to the quick decision made to run a second cohort, plans to repeat the series again are underway, with Cohorts 3 and 4 scheduled to launch in April and October 2019, respectively. Due to the success of this ECHO learning series, the CHCO School Health Team and ECHO Colorado also designed and implemented several other education and training programs in 2018, including a “School Nurses Managing Neurological Conditions” ECHO learning series and an ECHO Community of Practice series, facilitated monthly throughout the academic year, for school nurse leaders throughout Colorado.
The list of potential future school nurse ECHO series topics appears to have no limits. School nurses will continue to serve as population health leaders, providing highly complex coordinated care to increasing numbers of children where they spend the large majority of their time, their school setting. The need for ongoing CNE offerings in collaborative peer-to-peer learning environments, which support school nurses with these high demands, creates great opportunities to expand the ECHO model, through further application to the school nurse community, as well as other professions that support the health of children in schools.
This study allowed us to assess the potential impacts of the School Nurses Managing Diabetes Care ECHO learning series on nurses’ self-efficacy and intention to change their nursing practice. However, it is uncertain whether or not improvements in self-efficacy were sustained, as no follow-up data were collected. Additionally, while nurses reported plans to change their T1D management at school, we cannot confirm whether the nurses implemented such changes. Future studies on the ECHO model should include follow-up data to assess the long-term impacts of the training. Another potential limitation of this study is that we utilized a retrospective pretest question design to assess changes in self-efficacy. While there are strengths to this question design, such as reducing response shift bias and reducing the risk of missing data, there are also limitations, which include introducing social desirability response bias, recall bias, and acquiescence (Mayer-Davis et al., 2017). One additional limitation is that we required participation in at least three of the four sessions (as it was a requirement by ECHO Colorado for obtaining CNE credit). This could be a limitation for participation at other sites. Lastly, while response rates were quite high (74%), not everyone who participated in the training completed the evaluation survey. However, in comparing demographics, work experience, and attendance rates between survey respondents and non-respondents, no notable differences were found.
As the number of children and adolescents with diabetes continues to increase each year, so too does the likelihood of school nurses having a critical role in managing students with T1D in a school setting. This study demonstrated the effectiveness of the School Nurses Managing Diabetes Care ECHO learning series in increasing school nurses’ self-efficacy, workplace support, professional satisfaction, and intentions to create practice change. Furthermore, given that many professional development opportunities for school nurses are not easily accessible, the ECHO model provides a promising method of supporting geographically dispersed school nurses in gaining the necessary information, strategies for evidence-based practices, and support to effectively care for students with T1D.
John F. Thomas, Erin Bishop, Pamela Brunner Nii, Cari Berget, Lisa Davis, and Christine Perreault contributed to the conceptualization of the manuscript. Suzuho Shimasaki, Erin Bishop, and Pamela Brunner Nii were involved in the data acquisition and analysis and along with Lisa Davis helped in drafting the manuscript as well. All authors gave final approval on the text and agreed to be accountable for all aspects of work ensuring integrity and accuracy.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The Colorado Health Foundation and Children’s Hospital of Colorado.
Suzuho Shimasaki, DrPH, MPH https://orcid.org/0000-0002-5184-1032
Pamela Brunner Nii, BSN, RN, NCSN, AE-C https://orcid.org/0000-0002-0577-5476
John F. “Fred” Thomas, PhD, MSSW https://orcid.org/0000-0001-9495-1787
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Suzuho Shimasaki, DrPH, MPH, is a Evaluation Manager at ECHO Colorado, Colorado School of Public Health.
Pamela Brunner Nii, BSN, RN, NCSN, AE-C, is a Clinical Resource Coordinator, School Health Program at Children’s Hospital Colorado.
Lisa Davis, ND, RN, CCCTM, is a Nurse Consultant & Clinical Nurse IV, School Health Program at Children’s Hospital Colorado.
Erin Bishop, MPH, is a Evaluation Senior Professional at ECHO Colorado, Colorado School of Public Health.
Cari Berget, RN, MPH, CDE, is a Executive Director of ECHO at Barbara Davis Center for Diabetes, University of Colorado.
Christine Perreault, MHA, RN, NC SN, is a Clinical Manager, School Health Program at Children’s Hospital Colorado.
John F. “Fred” Thomas, PhD, MSSW, is a Executive Director of ECHO, Colorado, Colorado School of Public Health, Children’s Hospital Colorado, and University of Colorado School of Medicine.
1 ECHO Colorado, Aurora, CO, USA
2 Colorado School of Public Health, Aurora, CO, USA
3 Children’s Hospital Colorado, Aurora, CO, USA
4 Barbara Davis Center for Diabetes, University of Colorado, Boulder, CO, USA
5 School of Medicine, University of Colorado, Aurora, CO, USA
Corresponding Author:Suzuho Shimasaki, DrPH, MPH, 13055 East 17th Avenue, Mailstop F801, Aurora, CO 80045, USA.Email: suzuho.shimasaki@cuanschutz.edu
