Hospital to Home/Community

When a child has an extended hospital stay, a smooth and safe transition back home, to school, and the community is a vital step in a child's recovery process. Proactive supports will help with this transition and address the needs of the child after hospitalization.

Going Home

Children and youth are usually happy to come home from a long hospital stay, but also may have concerns, or the parents may have concerns about the transition home.
Some of the things to consider when going home are:
  • How can the child talk to her friends and family about the experience? Think and talk with your child about this ahead of time so it may not seem so overwhelming when a conversation starts.
  • Are there arrangements with specialists and medical supply/care companies that need to be made? Make sure to make a list of all important contacts and things to do once you get home.
  • Keep all important items like discharge papers, follow up instructions, referrals, contacts and insurance information in a notebook, all together. Some families put together a National Resource Center for Patient/Family-Centered Medical Home-For Families and Caregivers (AAP) for their child that has all this information.
  • Will the child be using a wheelchair? Is their home accessible or at least somewhat accessible? See Easter Seals/Century 21 Easy Access Housing.

Back to School

The foremost goal of transition from the hospital should be to help the child adjust to his or her medical condition and return to the routine of community life including school. Returning to school is a very important and necessary aspect in a student's recovery. Establishing an appropriate transition plan will increase success and foster self-esteem. The transition back to school should begin during the child's hospitalization.
There are many options for transition placement when a child is discharged from the hospital and will need supports for attending school:
  • The child may return home and attend school for partial days, working up to full days when ready.
  • The child may return home and, with accommodations, begin school.
  • The child may return home and receive schooling at home for an extended period of time (Home/Hospital). Most School Districts offer some type of Home/Hospital program. Each district may have different policies and requirements for a child to be approved for these services.
  • Step-Down (e.g. from a medical center to community hospital or facility) When the child's medical condition is stable but the child needs more help with functionality, they may go to a step-down unit or rehabilitation facility where they receive therapy along with schooling provided by the local school district in which the step-down facility resides.

How the Child's Medical Home Clinician Can Help

Your child's primary care clinician can assist with the transition from hospital to home/community in many ways. If your child has significant changes after his long hospital stay, and has needs such as accommodations at school or a community resource, ask if they can help with the transition.
The Medical Home clinician can:
  • Help prepare families to expect and plan for necessary adjustments once their child leaves the hospital.
  • Assist the family in identifying community resources.
  • Assist the family in coordinating appointments with multiple specialists.
  • Communicate with the school principal and school nurse regarding any changes in health status, treatment goals, functional level, medications and/or restrictions, and ensure that information is incorporated into the Health Care Plan, IEP, or 504 Plan. (See sample forms: Schools Information Release Form (PDF Document 49 KB) and Evaluation/Services Recommendation Form (PDF Document 26 KB), and Medical Care Plans / Assessment Forms)
  • Participate in meetings with the hospital transition teams, IEP Team Meetings, and anything related to the child's needs.
  • Assist the parent, school personnel, or discharge planner to assess the child's school environment for needed accommodations related to their medical condition. (See sample school visit evaluation form: TR-School Evaluation Form (Word Document 484 KB))
  • Help to make appropriate suggestions to the school regarding program accommodations such as longer time for test taking, work requirements, length of school day, etc.
Family Focus:
  • Keep in mind that when the child is ready, returning to school represents an important part of healing.
  • Encourage visits and partial day attendance at school.
  • Educate all school personnel involved with the child (teacher, bus driver, school secretary) about their condition. This helps prevent misperceptions and create awareness for signs of things like social isolation, learning, or behavior problems.
  • Keep in mind that the child's performance and participation can be variable and affected by further absences for follow-up appointments and treatments.
  • Remember that the student may now need more structure and assistance than before her hospitalization. New issues may include: reduced optimal performance, difficulty concentrating, and becoming fatigued more easily.
  • Advocate for appropriate special needs and/or accommodations for your child.
  • Include your child in the re-entry plans and/or school meetings when appropriate.
  • During the initial stages of re-entry to school, be aware that social aspects are just as important as academic aspects of the school day. Changes to watch for may include withdrawal, a decrease in confidence, or the appearance of behavioral problems.
  • Seek help from your Medical Home, school counselors, school nurse, and teachers to address any adjustment and/or mental health issues that arise from a change in health status.
  • Communicate with school, doctors, teachers, and the child to help smooth this transition.

Strategies to Help with Transition Before the Student Returns to School

The goal is to address how the child will catch up with schoolwork before returning to school.
  • Ask the child how much information regarding his health can be shared with her class, and if they would like to educate the people at school about their condition.
  • Ask your child's teacher about educating peers regarding the student's condition.
  • Visit the school with your child after school hours to assess the environment (Sample school visit evaluation form: TR-School Evaluation Form (Word Document 484 KB)).
  • Give the teacher your permission to share your child's progress with peers (if the child consents) and encourage communication via phone, email, or visits if appropriate.
  • Establish a plan for transition to school with the School team.*
  • Arrange for missed schoolwork from the child's teachers for your child to work on during recovery.
  • Schedule and monitor homework time.

    *"School team" may refer to the IEP, 504, Health Care Plan, or School Accommodation team.

Strategies to Help Upon Return to School

  • Identify a school case manager and introduce child.
  • Set realistic goals with your child's teacher based on her strengths and needs.
  • Encourage your child's teacher to communicate with you on a regular basis about his progress.
  • If necessary, focus on helping your child develop new learning strategies.
  • Encourage the teacher and the other members of the school team to reinforce progress in a positive light.


Information & Support

For Professionals

TR-School Evaluation Form (Word Document 484 KB)
A 6-page school site visit evaluation form to document your visit.

For Parents and Patients

Hospital-to-School Transition for Children with Chronic Illness
Meeting the New Challenges of an Evolving Healthcare System, an academic report published in Psychology in the Schools, 2007.

Learning and Living with Cancer; Advocating for your Child's Educational Needs
Returning to School, Laws that Help Protect Children who have Educational Needs, How Do I Get Started? Transitions: Advocating for the Young Adult. Produced by the Leukemia and Lymphoma Society

Teens Living with Cancer
Going back to school, advise for teens living with cancer, a website.

Classroom Health Care Plan Example (PDF Document 200 KB)
An example of a health care plan for a child with special health care needs for use in the school/classroom.

Helpful Articles

Elias ER, Murphy NA.
Home care of children and youth with complex health care needs and technology dependencies.
Pediatrics. 2012;129(5):996-1005. PubMed abstract / Full Text
An AAP clinical report, reaffirmed in 2017, which discusses topics for families and providers to consider when transitioning a child from the hospital to home.

Authors & Reviewers

Last update/revision: May 2014
Current Authors and Reviewers:
Author: Barbara Ward, RN BS
Reviewers: Shena McAuliffe, MFA
Gina Pola-Money
Tina Persels
Alfred N. Romeo, RN, PhD
Authoring history
2005: first version: Robin PrattA; Elaine PollockA
AAuthor; CAContributing Author; SASenior Author; RReviewer