Program Quality Assurance Services
Compliance and Monitoring
Question and Answer Guide on the Implementation of Educational Services in the Home or Hospital
603 CMR 28.03(3)(c) and 28.04(4)
Issued February 1999
Revised February 2005
1. What is the Intent of the Massachusetts Regulations on Educational Services in the Home or Hospital?
The Massachusetts regulation requiring educational services in the home or hospital is 603 CMR 28.03(3)(c). It reads as follows:
Upon receipt of a physician's written order verifying that any student enrolled in a public school or placed by the public school in a private setting must remain at home or in a hospital on a day or overnight basis, or any combination of both, for medical reasons and for a period of not less than fourteen school days in any school year, the principal shall arrange for provision of educational services in the home or hospital. Such services shall be provided with sufficient frequency to allow the student to continue his or her educational program, as long as such services do not interfere with the medical needs of the student. The principal shall coordinate such services with the Administrator for Special Education for eligible students. Such educational services shall not be considered special education unless the student has been determined eligible for such services, and the services include services on the student's IEP.
The intent of this regulation on home or hospital instruction is to provide a student receiving a publicly funded education with the opportunity to make educational progress even when a physician determines that the student is physically unable to attend school. While it is impossible to replicate the total school experience through the provision of home/hospital instruction, a school district must provide, at a minimum, the instruction necessary to enable the student to keep up in his/her courses of study and minimize the educational loss that might occur during the period the student is confined at home or in a hospital.
Although the regulation on home/hospital instruction is included in the Special Education Regulations (603 CMR 28.00), home/hospital instruction is not considered "special education" unless the student has been found eligible for special education. In other words, home/hospital instruction typically is considered a regular education service, since it is in the interest of both the individual student and the school to make it possible for the student to keep up with schoolwork while s/he is unable to attend school for medical reasons.
The Special Education Regulations also include a provision relating specifically to students who are likely to be confined to home or hospital for medical reasons for more than 60 school days in any school year. Please see regulation 603 CMR 28.04(4), discussed in Question #4, below.
Please note that the requirements and guidance discussed in this Question and Answer Guide are separate and distinct from those relating to the approval of parent requests for "home education" or home schooling programs, which are governed by General Laws Chapter 76, § 1. The Department of Elementary and Secondary Education's Home Education Advisory provides guidance on the Massachusetts law governing home schooling programs.
2. Who is Entitled to Educational Services in the Home or Hospital?
Public school students. A public school student who, due to documented medical reasons, is confined to home or a hospital for not less than fourteen (14) school days during the school year, is entitled to receive home/hospital educational services as described under 603 CMR 28.03(3)(c). In this context "public school student" means a student who is enrolled in a public school district or a charter school, or a student who is being educated with public funds in an educational collaborative or an approved private day or residential special education school. (Please see Question #8, below, for more detail about students in approved private day and residential special education schools.) The requirement for a school district to provide home/hospital instruction to a public school student who is being educated at public expense is not dependent upon the student's eligibility for special education.
Private school students. A student who is enrolled in a private school at private expense ("private school student") is entitled to receive publicly-funded home/hospital instruction as a special education service if s/he has been found to be a student with a disability who requires special education. Mass. General Laws Chapter 71B, § 1defines "school age child with a disability" as follows:
a school age child in a public or non-public school setting who, because of a disability consisting of a developmental delay or any intellectual, sensory, neurological, emotional, communication, physical, specific learning or health impairment or combination thereof, is unable to progress effectively in regular education and requires special education services, including a school age child who requires only a related service or related services if said service or services are required to ensure access of the child with a disability to the general education curriculum. G.L. Chapter 71B, § 1 (emphasis added).
A private school student who has been evaluated and has been found eligible for special education is entitled to receive home/hospital educational services as outlined in Question #9, below. For both public school students and private school students, the justification for any needed home or hospital instruction must be documented by a student's personal physician. A school district that receives a request for home instruction from someone other than a physician, or from a physician who is not personally responsible for a student's care, is not obligated to provide instruction under 603 CMR 28.03(3)(c). In this case, the responsible school district should inquire further with the student's parent or guardian to determine the student's status and any additional information or action that is needed. For example, the school district may need to proceed under the compulsory attendance law if it determines that a student between ages 6 and 16 is not attending school, is not being otherwise educated in a manner approved by the school district, and is not medically unable to attend school.
Determining eligibility. As required under M.G.L. c. 71B, § 2, if a parent of a private school student requests an evaluation to determine the student's eligibility for special education and presents the school district with a physician's statement, then the school district must immediately review the physician's statement to determine if there is sufficient information available to consider if the student has a "health impairment" according to the definition provided under 603 CMR 28.02(7)(i). If there is sufficient information in the physician's statement, then the school district should convene the Team within 15 days to make an expedited determination of eligibility and begin provision of services. Please refer to Administrative Advisory SPED 2003-1 for additional information about these requirements.
3. How Can Home or Hospital Education Services Be Accessed?
Once the student's personal physician (for example, a pediatrician, internist, medical specialist or psychiatrist) determines that a student's medical condition will require either hospitalization or home care for not less than 14 school days, the physician must notify the school district responsible for the student in order to begin the home/hospital instruction process. The student's physician must complete a Department of Elementary and Secondary Education form 28R/3 (or equivalent signed statement) and submit it to the student's building principal or other appropriate program administrator. At a minimum the physician's signed notice must include information regarding:
- the date the student was admitted to a hospital or was confined to home;
- the medical reason(s) for the confinement;
- the expected duration of the confinement; and
- what medical needs of the student should be considered in planning the home or hospital education services.
Students with chronic illnesses who have recurring home/hospital stays of less than 14 consecutive school days, when such recurrences have added up to or are expected to add up to more than 14 school days in a school year, are also eligible for home or hospital educational services if they are requested and the medical need is documented by the physician.
Home and hospital educational services under 603 CMR 28.03(3)(c) must begin without undue delay after the school district receives written notice from the student's physician that such services are necessary. Please note that there is no required 14-day waiting period before home or hospital instruction can commence if it is likely that the student will be absent from the school-based program for 14 school days or more in the school year.
Whenever a student is likely to miss 14 school days or more for health-related reasons, the Department strongly recommends that the school district expedite the delivery of educational services as well as any evaluation or Team meetings that may be necessary, in order to minimize the negative impact on the student's educational progress. (See also Question #10, below.)
4. What Requirements Apply if the Student is Likely to Be Confined to Home or a Hospital for More Than 60 School Days?
If, in the judgment of the student's physician, a student with an IEP is likely to remain at home, in a hospital, or in a pediatric nursing home for medical reasons and for more than sixty (60) school days in any school year, the Administrator of Special Education is required, without undue delay, to convene a Team meeting to consider evaluation needs and, if appropriate, to amend the existing IEP or develop a new IEP suited to the student's unique circumstances. (See 603 CMR 28.04(4).) The Department recommends that the Administrator of Special Education convene the Team meeting within 10 school days after the school district is notified that the student is likely to remain at home or in the hospital for more than sixty days. This provision applies to all eligible students, including private school students who have been determined to need special education.
5. How Should Home or Hospital Services Be Delivered?
School districts may provide home/hospital services in a number of ways, including:
- providing the services directly to the student using district employees;
- contracting with the hospital to provide the needed services;
- contracting with another school district to provide the services; or
- contracting with another agency to provide the services.
Home/hospital instruction is typically one-to-one or small group instruction that is provided on an individualized schedule, for less than a full school day or a full school week. The school district should determine the number of instructional hours per day or per week based on the educational and medical needs of the individual student. School districts may not preset the number of instructional hours per week provided to students who must remain at home or in the hospital; the decision must be individualized. Based on the student's medical status, the student's physician may determine that the number of instructional hours should be reduced. In addition, the amount of instructional time deemed necessary by a district may be guided by the instructional approach used in a one-to-one home or hospital setting as compared to the instructional approach normally implemented in the student's school-based program. However, such a reduction in instructional time must be based on the educational benefit received by the student given the reduced teacher-student ratio. Service delivery, including the time of day the services are to be delivered, should be determined in the best interests of the student and in consideration of the medical circumstances of the student.
When planning and delivering home or hospital educational services, the school district should carefully consider all aspects of a student's educational program while attending school, including any current IEP services, Section 504 plans and instructional accommodations, as well as the student's general education services.
6. Is the Academic Content of Instruction and the Certification of Staff Any Different for Home or Hospital Instruction Than for School-Based Instruction?
Instruction that is provided in the home or hospital for public school students under 603 CMR 28.03(3)(c) must include the same academic content as that provided in the student's regular school-based program. While teacher certification requirements apply to the teachers who are providing the instruction, the teachers do not have to be certified in all subject areas. However, in all cases the school district must be able to demonstrate that the assigned staff member effectively provides the necessary instruction to the student. Teachers who provide home/hospital instruction to public school students must coordinate the instructional content, approach and student progress with the student's teachers at school.
For both public school students and private school students, special education and/or related services that are provided in a home or hospital setting under this provision must be delivered (or closely supervised) by staff certified or appropriately licensed to deliver such services.
7. May A School District Require That a Parent or Other Responsible Adult be in the Home While the District's Instructor is Working With the Student?
If a district requires that an adult is present during homebound instruction, the district should take reasonable steps to ensure that this policy does not conflict with its obligation to provide instruction. A district could likely avert a potential conflict by arranging for instruction at a time (such as late afternoon or evening) when an adult would be at home with the student. If a district were unable to send an instructor at a time when an adult was at home, it would be permissible for the district to send a staff member to accompany the instructor. If a district is unable to arrange for instruction during hours when an adult will be at the home or to send a staff member to accompany the instructor, the district should propose a reasonable alternative to the student's parent that would ensure that the student receives instruction while satisfying the district's legitimate concerns about safety and liability.
8. Under what Circumstances are Educational Collaboratives and Public and Private Day and Residential Special Education Schools Approved Under 603 CMR 28.09 Required to Provide Home or Hospital Instruction?
If the school district continues to pay the costs of the placement in order to hold the enrollment status of the student in a educational collaborative program or a public or private special education school during the student's confinement to home or a hospital, the respective collaborative or public or private school must provide at no additional cost to the school district appropriate educational and special educational services. These services must be provided consistent with requirements of 603 CMR 28.03(3)(c) regarding educational services in a home or hospital, subject only to the limitations outlined in Question #5, above.
If the student is not expected to remain in the placement after the student's confinement to home or hospital, the school district must ensure in another way that the student receives appropriate educational and special educational services or, if appropriate, reconvene the Team consistent with 603 CMR 28.04(4) and consider evaluation needs and/or revisions to the IEP taking into account the services the student needs while s/he is unable to attend school for medical reasons.
9. How Do These Requirements Apply to a Student Who is Enrolled in Private School at Private Expense and Needs Home/Hospital Instruction for Medical Reasons?
As is stated above in answer to Question #1, although the regulation requiring home/hospital instruction is included in the Special Education Regulations (603 CMR 28.00), home/hospital instruction is not considered "special education" unless the student has been found eligible for special education. State law (G.L. Chapter 71B) requires school districts to provide special education to eligible students who are attending private school at the parent's expense or other private expense ("private school students"). Since home/hospital instruction can be a regular education or special education service, this has led to some confusion about the appropriate provision of home/hospital instruction for private school students.
If the private school student already has an IEP under which the school district is providing special education services, then during the 14+ school days that the physician says the student will be out of school for medical reasons, the school district must provide the specially designed instruction and/or related services described on the student's current IEP, modified as necessary to accommodate the student's medical needs. If the student's medical condition is likely to affect the ability of the student to maintain effective school progress, the student's parent may request that the Administrator of Special Education convene a Team meeting to consider further evaluation of the student and, if appropriate, to amend the existing IEP or develop a new IEP. Modifications to the IEP can include home or hospital instruction. The Administrator of Special Education is required to convene a Team meeting without undue delay for any student with an IEP who, in the judgment of the student's physician, is likely to remain at home or in a hospital for more than 60 school days in any school year. This requirement is found in the Special Education Regulations at 603 CMR 28.04(4) and is discussed in Question #4, above.
If the private school student does not have an IEP and will be confined to home or a hospital for medical reasons, s/he may be eligible for special education services if the student's medical condition is determined to be a health impairment that adversely affects the student's educational performance. Under these circumstances, the parent is entitled, at any time, to request and receive an evaluation of the student by the public school district to determine if the student's medical condition meets special education eligibility requirements. If a physician indicates to a school district that the student has a medical or health condition that is likely to lead to extended school absence(s) or an inability to maintain effective educational progress, the school district shall treat such information as a referral for an evaluation to determine eligibility for special education. In such case, the school district shall, within five school days, send written notice to the student's parent seeking consent for such evaluation to occur (603 CMR 28.04(1)(a)). A Team may find a student eligible for special education based on a chronic or acute health impairment or other disability, as defined in 603 CMR 28.02(7), that adversely affects the student's educational performance. Please see Question #10, below.
Under Massachusetts law, a private school student who has been determined to be a "school age child with a disability" as defined in G.L. Chapter 71B, § 1, is entitled to receive publicly-funded special education services in accordance with an IEP developed by the school district of residence. The school district may not refuse to evaluate the student because s/he is enrolled in private school or because s/he is currently out of school for medical reasons. The Department recommends that the Administrator of Special Education make every effort to expedite assessment(s) and the Team meeting so that services may be provided in a timely fashion. If the student is evaluated and determined to be a student who is eligible for special education, the student will be entitled to receive home/hospital instruction according to the IEP.
If the private school student does not have an IEP and the parent does not wish to refer the student for a special education evaluation, the parent may contact the school district of residence, providing documentation from the student's physician that the student is confined to home or hospital for medical reasons for not less than 14 school days during the school year. The school district may, at its discretion, provide home/hospital instruction to the student, using the district's resources to provide the instruction, but it is not required to do so unless the student is evaluated and found to be eligible for special education. Please see Question 2 above for additional information on determining eligibility of private school students based on a physician's statement.
Please note that the public school district is under no obligation to be familiar with nor to use the private school's curriculum, textbooks, or related education materials, but shall provide home or hospital services designed to maintain the private school student's progress in general curriculum areas when such services have been included on the IEP. Consequently, if a private school student will be absent from school for medical reasons for an extended period of time, the student's parent should always contact the private school to find out what tutoring services or other home/hospital instruction the private school will provide to help the student keep up with his or her schoolwork. The administrators and teachers in the private school are most knowledgeable about the private school's curriculum and the coursework that the student is covering in class, and they are in the best position to design and provide tutoring or other home/hospital instruction that will enable the student to keep up with school assignments. Depending on the circumstances, the private school itself may have an obligation to provide accommodations or services to the student under federal civil rights laws, Section 504 of the Rehabilitation Act and the Americans with Disabilities Act, or under the contract of enrollment between the school and the parents.
10. Are Students With Chronic or Acute Health Issues Always Eligible for Special Education?
The answer depends on the facts of the individual case. Any student with a medical or health condition that is likely to lead to extended school absence(s) or inability to maintain effective educational progress is a reasonable candidate to be referred to the public school district for initial evaluation to determine special education eligibility. Such referrals should take place as soon as it is known that a student's health condition is chronic or acute and is likely to have a negative educational impact, rather than delaying referral or action until the student is absent for significant periods of time or has begun to experience educational failure.
If assessment information indicates that the student's educational progress will be adversely affected as a result of a chronic or acute medical condition that is not temporary in nature, then the Team will likely determine that the student is eligible for special education. An eligibility determination is an individualized decision that depends on the facts of each case. In most cases, if the Team determines the student is eligible, the type of disability as recognized by federal and state special education law will be a "health impairment" (see 603 CMR 28.02(7)(i)). In some cases, the assessments may indicate other types of disability, such as "emotional impairment" or "neurological impairment."
If the student has been evaluated and found eligible for special education, the Team will write an IEP describing the special education and related services that the student needs and the school district will provide. If the student will be out of school for medical reasons for an extended period of time, it is appropriate to include on the IEP educational tutoring as a related service that the student needs in order to access the general curriculum while s/he is in the home or hospital setting. The IEP may be tailored to address expected time periods when the student is unable to attend school, if that is deemed appropriate to meet the unique needs of the individual student.
Additional questions or concerns about the provision of home or hospital educational services for students who are unable to attend school should be directed to the Department of Elementary and Secondary Education, Program Quality Assurance Services, at (781) 338-3700.