Homebound Instruction for Children who are Medically Complex
Children with severe disabilities and medical complexity are sometimes unable to attend school. While in some cases the school interruption may be temporary, some children may be unable to attend school at all, while others may have frequent but intermittent absences.
Most children with severe disabilities or medical complexity are eligible for special education services, either based on their disability or the severity of their medical condition (using the special education designation “other health impaired”). Once designated as eligible for special education services, these children are entitled to an education in the least restrictive environment that meets their needs. For some children, that environment may be the home.
Homebound instruction differs greatly from home schooling. Homebound instruction is provided by the public school system at no charge to the family, including all materials and instruction. Home schooling is provided by a parent or guardian using materials of his/her choice, and taught by the parent or guardian. This article will focus on the rights and procedures for homebound instruction provided by a public school system.
Who Should Receive Homebound Instruction?
Because homebound instruction is by its very nature the most isolated setting possible—with no innate access to peers—it should be reserved for children with the greatest levels of medical complexity or medical fragility.
The following situations are common causes for long-term homebound instruction:
- Child with severe immune deficiency or immune suppression
- Child receiving hospice care
- Child with medical technology and/or fragility that makes getting out of bed or being transported medically unsafe or impossible
- Child with chronic disease resulting in severe fatigue
- Child with extremely frequent medical procedures
The following situations are NOT appropriate for homebound instruction:
- Child who requires one-to-one nursing or personal care whose needs could be met with appropriate supports and services
- Children with behavioral problems under most circumstances
- Children with food allergies who can attend safely with changes to the school environment
- Children with mobility or medical equipment, such as a wheelchair or ventilator, who are otherwise medically safe to attend school and be transported
Temporary, Intermittent, or Permanent?
Most children who receive homebound services only receive them temporarily, such as after an illness, accident, or surgery. As such, most programs are designed with this population in mind. Children who are medically complex, however, typically do not fit into this category, and either need services intermittently or on an ongoing basis.
Intermittent services may be provided to children who have frequent absences or intermittent absences. They may be offered in a variety of ways, such as:
- Services only on the days the child is unable to attend school, offered each day the child is unable to attend school
- A blend of in-school and homebound schooling, such as one day a week in school, and four hours of homebound schooling
- Intermittent periods of homebound schooling, such as two weeks out of school with homebound services, following by a month of services in school
Children who are completely unable to attend school may also receive homebound services on a permanent basis.
Legal Requirements for Homebound Instruction
Other than homebound instruction being listed as an option in the continuum of educational placements, there is no federal guidance governing homebound instruction within education laws. Like any placement, however, homebound instruction must be individualized to fulfill a child’s Individualized Education Plan (IEP).
Each state is allowed to develop its own guidelines for homebound instruction. These guidelines vary dramatically, however, both in how homebound instruction is offered, and also in how much instruction is required. For example, many states do not allow homebound instruction to begin until a period of usually 10-20 days of school absence has occurred. In other states, homebound education must be started within 10 days once prescribed by a physician. Some states only require two one-hour sessions a week, while others require two hours per course taken.
In addition to state requirements, each district may have its own policies. Some may only provide homebound after school hours; others may only provide it during school hours. Some may readily provide related services such as speech therapy, while others may not provide any related services at all.
While there have been some local and circuit court decisions relating to homebound education, none of these have been substantial enough to create any sort of federal guideline for homebound instruction. Based on this case law, however, the following homebound instruction standards can be extrapolated:
- Schools are not required to offer any particular amount of homebound instruction. The instruction amount must be sufficient in duration to meet the goals of the IEP. There are no minimums or maximums.
- Schools are required to offer related services to children receiving homebound services, provided by direct providers (such as physical therapists or augmentative communication specialists), in order to meet the requirements of the child’s IEP.
- A parent, guardian, or family-provided nurse/care attendant must be present during the sessions.
- Services are almost always provided at home or at a hospital/inpatient facility.
- The homebound instruction must fulfill the child’s IEP.
- A physician’s referral for homebound education is almost universally required.
- Children requiring special education services in the IEP must receive services from a special education teacher.
In general, the two most difficult stumbling blocks in homebound education are the small number of hours of instruction and the lack of related services. Many school districts have set guidelines for hours of instruction. The hours, however, must be based on the child’s need and his/her IEP, and not school district standards. The school district will need to provide however many hours are required to meet IEP goals. School districts also commonly fail to provide related services and assistive technology services to children receiving homebound services. All children who require assistive technology should have assistive devices provided in the home. Related services, including direct therapies required to access the curriculum, must also be provided in the home as specified in the IEP.
Another common stumbling block is the provision of intermittent services for children who frequently miss school. Many districts require a period of 7 or more days of absence before allowing homebound services to begin. In order to overcome these types of restrictions, the provision of intermittent homebound services should be included in the IEP. For example, a child who misses school frequently due to respiratory issues should have a plan in the IEP that would allow a teacher to come to the home whenever the child misses more than one day of school due to his chronic illness.
Maximizing Homebound Instruction
It is best to keep communication between the school, homebound teacher, and family as open as possible. This will allow the child to receive the best services possible in the home setting.
Children who are well enough to attend school, however infrequently, should be encouraged to do so. Homebound instruction may form the basis of a child’s program; however, the child should be allowed to visit the classroom or attend school, even if it is only one hour a week, if at all possible.
Homebound instruction does not need to be isolating! Children who cannot attend school should be encouraged to participate in classroom activities using technology if at all possible. Services such as Skype may allow a child to participate in many classroom activities using webcams.
Older children who are physically and cognitively able should be permitted to participate in online education programs as part of homebound education, including virtual interaction with teachers and peers.
Finally, the numbers of children receiving longterm homebound instruction is quite small, typically less than 1000 children per state. Because there are so few children receiving this type of schooling, you may need to educate your district on the federal and state requirements for homebound instruction, as well as suggest ways to meet your child’s IEP in a home setting. Always remember that the IEP is individualized, and must be individualized for your child exclusively, whether in the school setting or at home.