Hospital-Based Education for Hospitalized Children: Current Practice and Future Direction

Abstract

School is a normal part of childhood; but for hospitalized children, academic life may become disrupted and substantially deviate from the experiences of healthy peers. Many chronic disorders require frequent hospitalizations, resulting in loss of school days and poor academic achievement.1 The average time students with multiple disabilities are absent from school is 28.9 days each time they are hospitalized.2 Children’s hospitals provide educational services to mitigate learning loss during hospital stays and facilitate school reentry with transition plans. Specific functions of hospital-based school service programs may include course selection, one-on-one bedside or classroom instruction, examination proctoring, and plans for work completion. As such, these programs represent a unique collaboration between the health care and education systems. Despite the long-standing existence of hospital-based education programs and endorsement by the American Academy of Pediatrics,3 there are few publications describing these programs or their efficacy. Therefore, medical providers often have limited understanding of how these programs are modeled, operated, and evaluated. Our goal with this commentary is to provide a description of hospital-based education programs, give recommendations to improve the quality of services, and guide future research.At the federal level in the United States, provision of special education is governed by the Individuals with Disabilities Education Act (IDEA). This law provides federal funding to state and local education agencies to guarantee special education for students who meet 1 of the 13 eligibility criteria (eg, autism, deafness, etc). These children receive an Individualized Educational Program (IEP), which happens in the least restrictive environment. Another important landmark piece of legislations is Section 504 of the Rehabilitation Act of 1973, which is a civil rights statute that ensures services and changes to the learning environment for all children whose disabilities affect a major life function (eligibility criteria for 504 plans are broader than those for an IEP).Neither policy requires the existence of school programs developed by hospitals, but they both make schooling in hospitals a possibility when necessary (if hospitals are the least restricted environment available). A hospitalized child can be first served under Section 504, receiving specialized instruction (eg, extended time on tests, more breaks). If it is not sufficient, an IEP can be created that sets learning goals and modifications of the curriculum.Currently, there are 2 primary models of hospital-based educational services for children. The first is hospital instruction provided by teachers from local public school districts. If the hospital is located in the same district of the child’s home school, the child’s normal teacher can support this child. However, if the hospital is in a different school district, the child needs to withdraw from their home school and enroll in the new school district in which the hospital is located. Alternatively, to avoid this process of withdrawal, the school district of service (where the hospital is located) can provide teaching and exchange vouchers from the school district of residence, which means that all the activities done during hospitalization will be officially recognized when the child returns to the home school.The second model relies on hospitals to develop their own hospital-based school program. When this service is available, hospital-employed teachers provide instruction. The academic goals and curriculum selection, however, are determined in partnership with a community-based teacher, and any credit earned through the coursework is awarded by the community schoolteacher. All coursework is aligned to Common Core State Standards (ie, academic standards for what every student is expected to learn in each grade level) and differentiated and modified to meet the student’s present level of performance. When both models are available, services provided by hospital-employed teachers are preferred, especially for shorter hospitalizations because the process of enrolling a child in a school district is more administratively difficult and time consuming.The most common criterion used to determine which hospitalized children are eligible to receive educational services is length of hospital stay. Yet there is variability among states when establishing the hospital length of stay threshold after which children are eligible to receive hospital education by school district teachers. For example, Michigan’s threshold is 5 days, Florida’s is 15 days, and Texas’ is 28 days. School programs developed by hospitals also have varying requirements, with some institutions starting school services on the first day of hospitalization and others requiring inpatient hospital stay longer than 10 days.Which model is used and the variation in when educational activities begin may depend on how hospitals think about what it means to be in school. An institution may start education activities on the first day of hospitalization because they want to avoid a disruption in the student’s schooling by either continuing the student’s education from their home school or providing the student with work from a curriculum they have established and created at the hospital. However, some institutions believe that for a student to be in school they must be enrolled in an actual school district in which they will earn grades and credits. This process is more time and personnel consuming and could explain why hospitals might start activities later.Next, we propose strategies to improve the quality of education for hospitalized children. These recommendations are based on the limited literature existing on this topic.2–10Hospital schooling is critical to the care of school-aged children whose education is disrupted by frequent or lengthy hospital stays. We have recommended several strategies to improve hospital-based education, but ultimately more studies are required to help establish best practices.We thank Alana Moser, Anna Boucher, Beth Stuchell, Scott Hampton, Kelsey Reeves, and Sarah Steinke for their significant contribution.

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