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.210 

  • Early identification by providers. Any patient healthy enough to participate in educational activities should be seen by hospital teachers or volunteers on the first day of hospitalization, regardless of the diagnosis or length of hospital stay. Various factors (eg, medical condition, length of stay, teacher availability) influence the planning of educational activities and help the medical team identify children who would benefit most from hospital education.

  • Discussion with families. On the first day of hospitalization, medical providers (especially child life specialists, hospital teachers, and school liaisons) should initiate a conversation with their patient and family about schooling during hospital stay. The earlier a child is engaged in hospital education, the greater the chances to promote normalization and introduce structure to their day. The pediatrician can help this process by reaffirming to the family the importance of these activities for the child. The medical team must acknowledge potential barriers (eg, illness severity, potential stress and anxiety attributable to being in the hospital) and strategies to overcome obstacles (eg, modified curricula, breaks as needed).

  • Coordination between medical team and hospital school programs. All pediatric medical providers should be made aware of the importance of hospital school programs when admitting patients and should document the need for a potential student to be seen by hospital teachers in the medical record. This is crucial because hospital teachers spend significant time identifying potential students,4  which is an activity that can be done more efficiently with coordination among the medical team.

  • Support for hospital school programs. Lack of appropriate funding to support educational activities is one of the major barriers to high-quality hospital education.4  Some school districts stop providing funds for hospital teachers when patients exceed specific hospital stays. Therefore, children’s hospitals must be proactive in securing both internal and external financial support. Philanthropy and volunteer programs are critical to maintain hospital education services.

  • Process standardization. Standardized documentation should be established among school districts in states where there is variability in these documents. School districts require extensive paperwork that is time consuming for busy hospital teachers, who already dedicate less than half of their time to teaching students.4 

  • Use of technology. Online education modalities have the potential to improve hospital-based education and should be used to complement traditional classes. The use of technologies with hospitalized children generally increases their potential of learning and improves connectivity with school.7  Online education can help hospitals with limited resources and teachers. The use of online learning during the current coronavirus disease 2019 pandemic has provided new models of education that may allow hospitalized children to remain engaged with their peers.

  • Program evaluation. Systematic mechanisms to evaluate the outcomes of hospital school programs are necessary to guide continuing improvement. There are few publications evaluating the effectiveness of hospital-based education programs to date, and the results are inconclusive.8  A possible strategy to assess the quality of hospital school programs would be to use child and family surveys at the end of hospitalization. Potential quality measures to consider in feedback could include awareness of the existence of hospital school programs, satisfaction, quality of hospital teachers, amount of time per week dedicated to activities, concordance between hospital school and normal school curriculum, number of teachers available per student, and child’s engagement and performance during activities.

  • Transition back to community. As part of transition planning, schools must be made aware of the late effects of some treatments on cognition (eg, radiotherapy) and should be encouraged to provide individualized academic plans. These effects can include working memory, attention, processing speed, and ability to learn deficits.9  To mitigate against these factors, families and school liaison services need to actively participate in school reentry processes10  and have good communication with home school personnel.6  Surveying the child’s teacher on reentry would also provide information to evaluate the effectiveness of hospital school programs.

  • Pressing questions to guide future research. In light of the overall lack of evidence, the following topics should be more fully investigated in future studies to drive continuous improvement of hospital-based education. What is the effectiveness of hospital schooling? Does it facilitate school reintegration? What are the best strategies to facilitate communication between hospitals and schools? When is the optimal time to start educational activities during hospitalization? How should the medical team identify children who would benefit most from hospital education? Does hospital-based education influence medical-treatment engagement and outcomes?

Hospital 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.

Mr Boff collected data and drafted the initial manuscript; Drs McGuire and Raphael reviewed and revised the manuscript; and all authors conceptualized and designed the study, approved the final manuscript as submitted, and agree to be accountable for all aspects of the work.

FUNDING: No external funding.

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.