Special Education: Additional Federal Actions Could Help Address Unique Challenges of Educating Children in Nursing Homes
Highlights
What GAO Found
Children in nursing homes represent a relatively small group of children whose medically complex conditions often present unique educational challenges. Of the nearly 5,000 school-age children in nursing homes nationwide, about 40 percent needed a feeding tube for nutrition and one-third needed oxygen therapy to help them breathe, according to GAO's analysis of 2012 data—the most recent data available—from the Department of Health and Human Services (HHS). Consistent with 2012 data, GAO observed on recent site visits that these children also had conditions that affected learning. For example, many children GAO observed at the nursing homes were nonverbal and minimally responsive. Because of their complex medical needs, these children often stayed in nursing homes for long periods of time—about one-third of them for more than a year, according to GAO's analysis of HHS data.
States GAO visited required nursing homes to refer children to school districts for educational services, and in nursing homes GAO visited, staff typically collaborated with school district officials to help them understand the children's needs. Because of the children's medical fragility, education services were delivered primarily in classrooms at the nursing homes or one-on-one (often bedside), with a few children transported to local schools. Teachers that GAO observed used assistive technology and other methods to aid instruction.
State and local school officials reported challenges to serving children living in nursing homes, including curricula development and teacher training. In GAO's nationwide survey, 31 states indicated having adequate training for teachers was a challenge. According to school officials GAO interviewed, teachers may not be fully prepared to teach children with profound disabilities, and several teachers said they could benefit from the experiences of other teachers about how best to serve these children. While the Individuals with Disabilities Education Act (IDEA) recognizes the importance of information sharing to improve educational results for children, current technical assistance efforts supported by the Department of Education (Education) do not include mechanisms for teachers to share best practices about how to serve children with significant cognitive and multiple disabilities. Such information sharing about effective approaches and strategies could help teachers of children in nursing homes be more fully prepared to provide children with education commensurate with their unique needs.
Education and HHS have different, yet complementary, monitoring responsibilities with respect to children in nursing homes. Education monitors state compliance with the IDEA requirement to provide a free appropriate public education in the least restrictive environment, and HHS oversees state nursing home inspections. Although collaboration between agencies with a common interest is a key practice, these agencies do not coordinate their monitoring efforts with respect to the education of these children. The relatively small size of this population makes it difficult for Education and states to gather information on whether these children receive education that meets IDEA requirements. Coordinated efforts between the two agencies could help close any potential gaps in Education's monitoring and help ensure that all children in nursing homes receive an education.
Why GAO Did This Study
Although nursing homes typically care for elderly or disabled adults, some children with disabilities also live in these homes. Because these children live away from their families, they may be less connected to local schools and may not receive the education benefits to which they are entitled. GAO was asked to study the delivery of education to children in nursing homes.
GAO examined (1) the characteristics of children in nursing homes, (2) how such children are referred for and receive education, (3) the challenges in delivering services to these children, and (4) monitoring of the education of children in nursing homes. GAO analyzed national nursing home data on children, surveyed all state special education directors, reviewed relevant federal laws and regulations, and interviewed federal officials. GAO also visited nursing homes and school districts in three states selected to include a large percentage (42 percent) of children in nursing homes nationwide.
Recommendations
GAO recommends that Education develop information sharing mechanisms for teachers of these children and that Education and HHS strengthen their monitoring efforts. Education agreed with the first recommendation. For the second, Education and HHS agreed to further collaborate, but expressed concerns about creating an oversight structure. However, GAO recommends using existing means of oversight.
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Department of Education | To enhance the education that children in nursing homes receive and to better support the professional development of special education teachers who serve these severely disabled children, the Secretary of Education should develop mechanisms to facilitate information sharing among teachers of students in nursing homes. For example, Education could facilitate the establishment of a medium, such as a list serve, for teachers of these children to share information, including best practices, on how to best serve these students. |
In April, 2016, Education issued guidance for states and school districts about providing special education and related services to children with disabilities in nursing homes, including information on special education requirements, best practices for special education teams in schools, the need for appropriate qualifications and training for teachers of these students, and existing resources through Education's technical assistance centers.
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| Department of Education | To provide additional oversight of this vulnerable, low-incident, and largely hidden population of children with disabilities living in nursing homes, and to minimize potential monitoring gaps, the Secretaries of Education and of HHS should jointly explore opportunities to use the Centers for Medicare & Medicaid Services (CMS's) existing oversight mechanisms of nursing homes to help Education better ensure the education of such children. For example, Education and CMS could work together to encourage state nursing home surveyors--as part of their on-site reviews of medical and quality of life standards--to confirm that school-age children in nursing homes are receiving education services, and, if not, take appropriate follow-up steps with the nursing home and school district as needed. In another example, Education could offer training to enhance relevant CMS employees' understanding of IDEA requirements. Working with Education, CMS could encourage state health agencies to share information with state educational agencies when surveyors learn of school-age children in nursing homes. |
In a March 2017 meeting, HHS, Education, and GAO discussed and explored possible opportunities to use existing oversight mechanisms to help Education better ensure the education of children with disabilities living in nursing homes. During that meeting, HHS agreed to review information that Education had provided to states and school districts about IDEA and Individualized Education Program requirements for children in nursing homes. Education also noted that the department had already established a collaborative relationship with HHS to educate them on certain aspects of the Department's IDEA regulations. Education said that it will continue to work with HHS and that it will encourage state education agencies and school districts to follow up on any referrals from state health officials to ensure that all children residing in nursing homes are evaluated for and receiving appropriate special education services for which they may be eligible.
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| Department of Health and Human Services | To provide additional oversight of this vulnerable, low-incident, and largely hidden population of children with disabilities living in nursing homes, and to minimize potential monitoring gaps, the Secretaries of Education and of HHS should jointly explore opportunities to use the Centers for Medicare & Medicaid Services (CMS's) existing oversight mechanisms of nursing homes to help Education better ensure the education of such children. For example, Education and CMS could work together to encourage state nursing home surveyors--as part of their on-site reviews of medical and quality of life standards--to confirm that school-age children in nursing homes are receiving education services, and, if not, take appropriate follow-up steps with the nursing home and school district as needed. In another example, Education could offer training to enhance relevant CMS employees' understanding of IDEA requirements. Working with Education, CMS could encourage state health agencies to share information with state educational agencies when surveyors learn of school-age children in nursing homes. |
In a March 2017 meeting, HHS, Education, and GAO discussed and explored possible opportunities to use existing oversight mechanisms to help Education better ensure the education of children with disabilities living in nursing homes. During that meeting, HHS also agreed to review information that Education provided school districts about IDEA and Individualized Education Program requirements for children in nursing homes. HHS further noted that the agency had collaborated with Education about these children in 2014 and stated that they were open to more collaborations in the future.
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