Hospital to Home/Community

When a child has a long hospital stay, a smooth and safe shift back home, to school, and the community is vital to healing. Positive supports will help to address the needs of the child after their stay in the hospital.

Going Home

Most of the time, children and youth are happy to come home from a long hospital stay, but they may also have some fears, or the parents may have worries about them coming home.

Some of the things to keep in mind when going home are:

  • How can your child talk to her friends and family about their hospital stay? Think and talk with your child about this so it may not seem so hard when a someone asks.
  • Are there arrangements with providers and health care supply companies that need to be made? Make a list of all contacts and things to do once you get home.
  • Keep all items like discharge papers, follow up, referrals, contacts and health plan information together in a notebook. Some people put together a binder for their child that has all this information (see National Resource Center for Patient/Family-Centered Medical Home-For Families and Caregivers (AAP).
  • Will the child be using a wheelchair? Is his home wheelchair accessible or easily adapted? See Easter Seals/Century 21 Easy Access Housing.

Back to School

The main goal of going home from the hospital should be to help the child adjust to her health care needs and return to daily life and school. Going back to school can be a needed aspect of a child's healing and recovery. Setting up a back-to-school plan will help with success and self-esteem. Plans for returning to school should start during the child's hospital stay if possible.

There are many choices for school placement when a child is released from the hospital and will need supports:

  • The child may return home and ease back into going to school for part of the day, working up to full days when ready.
  • The child may return home and, with accommodations, start school.
  • The child may return home and have schooling at home for a longer period of time (home/hospital). Most school districts offer some type of home/hospital program. Each district may have different rules for a child to be approved for these services.
  • Step-Down (from a hospital to a care facility) When the child is medically stable but he needs more help to function, he may go to a step-down unit or rehabilitation facility where he receives therapy along with schooling provided by the local school district.

How the Child's Medical Home Can Help

Your child's primary care doctor can help with the transition from hospital to home/community in many ways. If your child has changes after her 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 doctor can:

Family Focus

Parents and other family members play a vital role in helping children make a smooth shift from hospital to home. There are many ways you can help your child adjust to starting school again:

  • Keep in mind that when the child is ready, coming back to school is an important part of healing.
  • Start by trying visits and part-time attendance at school.
  • Educate all school personnel involved with the child (teacher, bus driver, school secretary) about their condition. This helps prevent problems and lets them know to watch for signs of things like social isolation, learning, or behavior problems.
  • Keep in mind that your child's ability to get work done and be in classes can be affected by further absences for follow-up medical appointments and treatments.
  • Remember that the child may now need more help and planning than before her hospital stay. New issues may include: problems concentrating, getting tired more easily, and less ability to work.
  • Advocate for appropriate education and accommodations for your child.
  • Include your child in the school re-entry plans and meetings when possible.
  • During the first stages of school re-entry, know that social time at school is just as important as the academic part of the school day. Changes to watch for may include isolation, loss of confidence, or behavioral problems.
  • Seek help from your medical home, school counselors, school nurse, and teachers to address any needs and/or mental health issues that arise from a change in health status.
  • Talk with school, doctors, teachers, and the child to help smooth this transition.

Strategies to Help with Transition Before the Child Returns to School

It is helpful to plan ahead for your child’s return to school. The ideas below can help guide this planning process:

  • Ask the child how much information about his health he wants to share with his class, and if he would like to educate the people at school about his condition.
  • Ask the teacher(s) if they would help to educate classmates about your child's condition.
  • Visit the school with your child after school hours to look at the environment (see 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 wants that) and let them know they can call, text or visit if appropriate.
  • Set up a plan for school re-entry with the School team.*
  • Get missed schoolwork from the child's teachers for your child to work on during recovery.
  • Plan and help with homework time.
    *"School team" may refer to the IEP, 504, Health Care Plan, or School Accommodation team.

Strategies to Help When Returning to School

The steps below can help you and your child with the shift back to school:

  • Find a few trusted adults
  • Set realistic goals for your child based on her strengths and needs.
  • Ask your child's teacher to text or email you to let you know how things she is doing.
  • If needed, help your child with new ideas for studying and learning.
  • Ask teachers and the other members of the school team to reinforce progress with positive support.


Information & Support

For Parents and Patients

Teens Health: Balancing Schoolwork and Hospital Stays
Provides a good guide for teens to read on managing school work while in the hospital.

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

Bringing a Child Home From Psychiatric Hospitalization
Addresses psychiatric hospitalization in children.

Classroom Health Care Plan Example (PDF Document 200 KB)
Good link for parents; gives an example of a school health care plan for a medically fragile child.

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

Initial publication: December 2005; last update/revision: November 2019
Current Authors and Reviewers:
Author: Medical Home Team
Reviewer: Tina Persels
Authoring history
2014: revision: Shena McAuliffe, MFAR
2014: revision: Gina Pola-MoneyR; Tina PerselsR
2008: revision: Alfred N. Romeo, RN, PhDR
2005: first version: Barbara Ward, RN BSA; Robin PrattA; Elaine PollockA
AAuthor; CAContributing Author; SASenior Author; RReviewer

Page Bibliography

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.