Increasing numbers of children with extensive medical and health related needs are surviving, and through advances in technology, are able to leave their homes to attend school (Task Force on Technology Dependent Children, 1988). The cost associated with providing a child who is medically fragile or technology dependent with a free, appropriate public education (FAPE) under the Individuals with Disabilities Education Act (IDEA, [sections]1400-1485) can cause significant financial hardship for a school district (e.g., Granite School District v. Shannon M., 1992; Detsel v. Board of Education of the Auburn Enlarged City School District, 1987). In addition, the lack of priority funding from the state or federal level to children with extensive education and health needs has created major problems, particularly in urban districts (Handicapped Children's Protection Act: Hearings, 1985). A standard per-pupil cost, without regard to individual differences, is unable to account for the provision of additional related services, including a variety of school health procedures, that may be required for a child who is medically fragile. Cost, although not intended to be a deciding factor in the delivery of services, can directly and indirectly affect the educational programs of children with disabilities.
IDENTIFYING THE POPULATION
During the 20 years that have passed since the implementation of Public Law 94-142, known as the Education for All Handicapped Children Act (EAHCA), the number of children with disabilities who have been identified as qualifying for special education and related services has increased dramatically (Czaja, 1990). Children with extensive medical needs are living and entering the educational system in increasingly greater numbers (Caldwell & Sirvis, 1991; Task Force on Technology Dependent Children, 1988), and children with chronic illness are often surviving into adulthood (Koop, 1982; Newacheck & Taylor, 1992). It has been estimated that the proportion of children with one or more chronic illnesses ranges from 5% to 30% (Newacheck & Taylor). The concept known as the "zero-reject" policy established within EAHCA is intended to ensure that there is a federal right to education guaranteed for all children, regardless of the extent or severity of their disabilities.
Currently, 13 categories of disability are included in the federal law mandating the provision of special education and related services (Assistance to States for the Education of Children with Disabilities Program Rule [sections]300.7(a)(1), (1992). The categorical placement of a child with special health care needs depends on the child's primary disability, as well as state regulations, because the federal law does not currently delineate a separate category for medically fragile conditions that adversely affect educational performance. The Other Health Impairment (OHI) category, as defined in IDEA federal regulations (1992), includes children who have "limited strength, vitality, and alertness, due to chronic or acute health problems .. that adversely affect educational performance" ([sections]300.7(a)(8), Federal Register, p. 44802). Although this definition does not specifically address children who are medically fragile with complicated health needs (Caldwell & Sirvis, 1991), neither does it include the child who has a chronic medical condition that requires accommodation during the school day, but does not adversely affect educational performance.
Children with special health care needs require special health services including interpretation and intervention, administration of health procedures and health care, or use of a health device to compensate for the reduction or loss of a body function (Iowa Rules of Special Education, 1992). For example, these children may require some of the following services throughout the school day: gastrostomy care; nasogastric, parental, or intravenous feeding; tracheal suctioning; continuous monitoring of respiratory status; and renal dialysis, in addition to some of the more traditional health services delivered within the school environment (e. …