Caring for Children and Youth With Special Health Care Needs During the COVID-19 Pandemic

Children and youth with special health care needs (CYSHCN) are defined as those who have or are at increased risk for chronic physical, developmental, behavioral, or emotional conditions and who also require health and related services of a type or amount beyond that required by children generally.

• Ensuring equity for CYSHCN at all levels should be a priority for pediatricians and all service sectors. Community and public health strategies should ensure prioritization of needs of CYSHCN, including mitigation of community transmission, individual protection against disease, protection of workforce, and access to all needed services, including school and child care. CYSHCN are more likely to have ongoing disruption to health care, education, and community life as a result of the COVID-19 pandemic. Consequences may include delayed development, reduced learning, and mental health challenges. Interruptions to services disproportionately affect subpopulations of CYSHCN, such as those of younger age, those with medical complexity, and those with behavioral health conditions, in different ways. Inequities attributable to poverty, racism, immigration status, ableism, health conditions, geography, health care access, educational access, child care access and other factors make these disruptions particularly dangerous for some CYSHCN.
• Subgroups of CYSHCN, specifically children with medical complexity as well as children with certain chronic conditions such as prematurity, obesity, type 1 diabetes, neurodevelopmental disability and medical complexity, are more likely to have a diagnosis of severe acute biological effects of SARS-CoV-2 infection requiring admission to the hospital or intensive care unit. Black and Latinx children with chronic conditions experience a disproportionate burden of hospitalization. Data on the risk of infection, as well as detection of its acute and chronic effects, continue to evolve with different SARS-CoV-2 variants. All children and youth are at risk for developing special health care needs following SARS-CoV-2 infection. , Long-term effects from SARS-CoV-2 infection may be significant, regardless of the initial disease severity. AAP Interim Guidance for Post-COVID-19 Conditions in Children and Adolescents provides additional information.

What is the overall approach to minimizing the risk of infection while meeting the ongoing needs of CYSHCN during the pandemic?

The most important approach to minimizing the risk of infection is mitigation of community transmission, utilizing policies that decrease spread. Important approaches include promotion of immunization for all eligible CYSHCN, family members and community members (and others who come into close contact with CYSHCN) and use of face masks indoors when community levels of COVID-19 are medium and high, including use of face masks in schools.

To reduce direct exposure risk, particularly when community levels are high, combine the following 3 strategies:

1. Multi-layer risk reduction, conceptualized as an application of the Swiss Cheese Model to provide extra protection for CYSHCN from SARS-CoV-2 infection through multiple layers of protection (ie, slices), because each layer has limitations (ie, holes), the size of which depend on policy and human behavior. Potential layers of risk reduction include:
   • Vaccinate (including boosters) all eligible children and adults, especially all eligible individuals who have contact with CYSCHN, including, but not limited to, family members, household contacts, health care workers and education workers (see immunization section for details). At this time, CYSHCN 6 months of age and older are eligible for the COVID-19 vaccine.
   • Minimize a CYSHCN’s environmental exposure risk by avoiding unnecessary closed spaces, crowded places and close contact (the 3 C’s) and spread through hands and surfaces, particularly if they are unvaccinated and/or community levels of COVID-19 are medium or high. Avoid closed spaces and especially those with poor ventilation where physical distancing guidelines (ie, 3-6 foot rule) may be insufficient.
   • CYSHCNs should use face masks in areas with medium and high community levels of COVID-19, especially when the risk of exposure is higher and when individuals are unvaccinated. Face masks are essential to protecting CYSHCN. Nearly all CYSHCN, 2 years and older, can successfully use face masks that securely cover the nose and mouth. Children with tracheostomies can also benefit from a mask covering their stoma. Practice, modeling and consistent use by the child and caregivers will increase success. There are few valid medical exceptions. Close contacts of CYSHCN can also consider using face masks to limit spread. Use face masks with particularly heightened consistency and vigilance in situations in which spread is more likely, such as close contact, closed spaces and crowded locations (see PPE section for details), particularly in areas with high community levels of COVID-19.
   • Address inequities and optimize health coverage. Housing, income and other supports reduce the structural risk of infection spread. Health coverage should support multiple ongoing CYSHCN needs across the continuum of care, including testing for SARS-CoV-2 infection, counseling on risk reduction and coordination of accommodations to safely meet the needs of CYSHCN during the pandemic. Equitable policy in both the short- and long-term will reduce disparities in the health of CYSHCN related to the pandemic and beyond (see case management and health coverage sections for details).
2. Creative, flexible and responsive accommodation to safely achieve inclusion by overcoming the barriers introduced by the multi-layer risk reduction strategies in meeting the ongoing needs of CYSHCN in health care, education, child care and community life (see respective sections for details). For example, moving activities outdoors with context-specific risk mitigation strategies (eg, physical distancing and use of face masks) can substantially reduce, but not eliminate, risk of SARS-CoV-2 infection. In areas with medium and high community levels of COVID-19, consistent and universal use of face masks can allow inclusion of CYSHCN in activities.
3. Shared Decision Making to resolve difficult decisions in health care, education, child care and community life, balancing risk reduction with other ongoing needs specific to the child and caregivers (especially, but not limited to, families), and respecting and valuing the concerns of multiple stakeholders (health care providers, educators, school nurses and others) to achieve consensus for needed accommodations. Practical steps include:
   • Develop shared goals and objectives.
   • Identify personal and cultural preferences, priorities and concerns of all parties actively involved.
   • Collaboratively review risk reduction strategies and creative, flexible and responsive accommodations under consideration, specific to the needs and risks of the child and contacts.
   • Determine which individual(s) are responsible for carrying out the actions required to achieve the shared goals.
   • Acknowledge policies to inform these decisions during the pandemic continue to evolve as evidence gets stronger, with the importance of combating misinformation.
   • Revisiting policies at regular intervals based on community levels of COVID-19, in alignment with CDC updates.

It is important to recognize the importance of reducing spread of not just COVID-19 but also other respiratory pathogens such as respiratory syncytial virus and influenza.

Specific Considerations

How should immunization proceed for CYSCHN during the pandemic?

CYSCHN should continue to receive all recommended vaccines during and after the COVID-19 pandemic. Specific considerations include:

COVID-19 Immunizations

Information about COVID-19 vaccination is available in the AAP policy. The AAP recommends that all children and adults who meet criteria, as recommended by the CDC Advisory Committee on Immunization Practices, receive the COVID-19 vaccine. Some infants, children and adolescents who are immunocompromised may be eligible for an additional primary series dose of the vaccine. All who are eligible are urged to get a booster dose for additional protection. Policy makers should consider the unique needs of CYSHCN as well as their families/caregivers, educators, therapists and other individuals involved with the care of CYSHCN when making determinations about access to the vaccine. Clinics providing care for CYSHCN eligible for the vaccine should facilitate distribution, with particular focus on those CYSHCN/families who have barriers to access such as transportation, location, language, etc, or with out-of-home placement. Efforts addressing vaccine hesitancy should be present and accessible in communities where CYSHCN may reside and/or obtain services and pay particular attention to delivering factual information in a trustworthy manner (eg, family-centered, relationship-based manner) and through methods and language most comfortable to the family. Vaccine distribution and access should be supported for all eligible children and adolescents, with particular attention to those at risk for severe biological effects of SARS-CoV-2 infection. Providers who have COVID-19 vaccine in their offices should specifically reach out to CYSHCN to encourage vaccination.

Influenza Immunizations

In alignment with AAP recommendations, pediatric clinicians should support CYSHCN in receiving routine influenza immunization starting at 6 months of age. Influenza immunization is particularly important during the COVID-19 pandemic, because some CYSHCN are at an increased risk for influenza complications. In addition, all those in the family of a CYSHCN as well as those caring for the CYSHCN in or outside the home (including therapists and teachers) should receive the influenza vaccine, in alignment with AAP and CDC recommendations.

How should CYSHCN use face masks?

Interim guidance from the American Academy of Pediatrics (AAP) on PPE in ambulatory care settings and face masks is available for more information.

CYSHCN 2 years and older can safely wear face masks that securely cover the nose and mouth, with rare exceptions. These face masks should be used in public spaces indoors at all times and outside when physical distancing cannot be maintained, especially during times of medium or high community levels of COVID-19. Cloth face masks are less effective against COVID-19, and the best protection is given by well-fitting N95/K95/KF94 masks, followed by well-fitting surgical/procedure masks. A family plan with home use of face masks also may be particularly valuable in households that include adults and CYSHCN known to be at risk for severe biological effects of SARS-CoV-2 infection. The cognitive vigilance required to use face masks consistently over a long period is challenging. The appropriate use of face masks should be prioritized 1) for CYSHCN who are unvaccinated and known to be at high risk for severe biological effects of SARS-CoV-2 infection, particularly CYSHCN who have contraindications to receiving COVID-19 vaccine; 2) when environmental exposure risk is elevated with crowds, closed spaces, and close contacts, particularly in areas with medium or high community levels of COVID-19; and 3) in homes and especially in the same room with other household members or visitors when intrahousehold spread is an increased concern. Families can promote the practice of face mask use at home to enable CYSHCN to become accustomed to situations where face masks are more necessary.

In schools, child care centers and other institutions where universal indoor face mask use is no longer required, use of face masks continues to be beneficial, because viral variants have evolved to be more infectious, and thus, use of face masks should be encouraged to reduce the risk of infection, especially when community levels of COVID-19 are elevated. Caregivers, CYSHCN, child care center personnel, education workers, therapists and other individuals may require additional counseling on the use and selection of face masks to promote inclusion and ensure the safety of all contacts in a variety of situations. Attention to fitting and seal is necessary for all but may require particular attention for some CYSHCN, such as those with craniofacial conditions.

In cases in which lip reading is essential, contacts should use face masks with transparent windows and/or use augmentative communication strategies, such as voice-to-text mobile applications.

The subgroups of CYSHCN known to have a higher risk for severe biological effects of SARS-CoV-2 infection, as well as their caregivers and close contacts, may require similar access to the types of PPE used by health care workers. The PPE should be appropriate to the medical condition of the child and the needs of caregivers and close contacts. Close contacts should have access to appropriately fitted N95 respirators and eye protection for aerosol-generating procedures (ie, airway suctioning, airway clearance procedures, tracheostomy changes, noninvasive ventilation, manual ventilation and nebulizer treatments). In some situations, child use of an appropriately sized face shield may help protect contacts.

When should CYSHCN be tested for SARS-CoV-2 infection?

AAP interim guidance on testing is available for more information, including information on use of molecular (ie, RT-PCR) and rapid antigen testing.

The AAP supports the implementation of public health surveillance that tests at a population level to identify local outbreaks of COVID-19, in partnership with health care providers and local public health departments. Among CYSHCN at higher risk for severe biological effects of SARS-CoV-2 infection who require close contact services, regularly screen for symptoms among contacts and test if there is exposure or if symptoms occur. Consider periodically screening their asymptomatic caregivers, home care personnel, child care personnel, education workers, therapists and other close contacts in locations with sufficient testing capacity. See CDC Guidance for further information on expanded screening.

How should health and related service providers support CYSHCN during the pandemic?

Guidance for coding services in the pandemic is available here.

Outpatient Settings

During the pandemic, health care providers should consider proactively reaching out to families of CYSHCN, especially those who have not recently engaged with the health care system, to ensure child and caregiver well-being. It is optimal for the medical home to partner with the family in managing and coordinating the multiple ongoing health needs of CYSHCN during the pandemic.

• Use telehealth when needed, particularly during times of high community transmission of COVID-19 or other respiratory viruses such as influenza and respiratory syncytial virus. Recognize and take steps to address inequities in internet connectivity and devices as well as digital fluency, and engage in shared decision making with families/caregivers and CYSHCN to support appropriate delivery of care via telehealth within the medical home model. Collaborate with visiting and private duty home care personnel for assessments through telehealth, including weights, vital signs, physical examination findings and home assessments. Provide equal access to translation services, including non-English languages and American Sign Language. See AAP policy on telehealth care.
• Use home-based laboratory draws and diagnostic imaging whenever possible.
• In certain situations, health care providers may consider the need for pre-exposure prophylaxis in immunocompromised pediatric patients or those who may have contraindications for vaccination. More information is available in the AAP interim guidance on Management Strategies for Children and Adolescents with Mild to Moderate COVID-19.
• Schedule interdisciplinary care planning and health maintenance visits, utilizing telehealth when needed and/or to facilitate team-based interdisciplinary care. Depending on the needs of individual patients, multiple visits may be necessary to:
  • Counsel about SARS-CoV-2 and multi-layer risk reduction (eg, 3 C’s, PPE, hand hygiene, surface cleaning, screening) – see respective sections for details, and needed accommodations in health care, education, child care and community life. Use Shared Decision Making framework for difficult decisions.
  • Develop emergency and advanced care plans for situations in which a child or household member is exposed, infected or hospitalized, including access to antiviral treatment or monoclonal antibody if available and eligible. Regularly update schools of relevant plans to ensure continuity of care.
  • Address ongoing health care needs for health maintenance, chronic condition care plans (ie, asthma, seizures, dysautonomia), prescription refills, home care, rehabilitation/habilitation, durable medical equipment, medical supplies and other needed care.
  • Address care typically provided during the school day for CYSHCN not receiving in-person services in school.
  • Plan for optimal timing of specific in-person visits, including vaccinations.
  • Refer to supports and resources (see case management and health coverage sections).
• Specific considerations for when in-person encounters are necessary and/or desired:
  • Consider encouraging face mask use by patients and their families even when not required, especially during surges of viral respiratory illness of any type in a community. Offer high-quality masks within health care settings for children, youth and families/caregivers.
  • Consider use of PPE by health care personnel and staff to protect CYSHCN who need extra protection even if the health care facility does not require universal use of face masks. Health care personnel should honor requests made by families to wear a face mask, even when it is not required.
  • Ensure safe transportation options to facilitate in-person encounters, especially for CYSHCN whose public transit options are limited by the pandemic.
  • Make creative, flexible and responsive accommodations in workflow and other practices for complex needs (ie, examinations in vehicles, early appointment times, immediate rooming).
  • Arrange separate areas (ideally with negative pressure flow) for aerosol-generating procedures (ie, airway suctioning, airway clearance procedures, tracheostomy changes, noninvasive ventilation, manual ventilation and nebulizer treatments).
• Provide support and subspecialty referrals, if needed, for children with long COVID-19 symptoms. AAP interim guidance for Post-COVID-19 Conditions in Children and Adolescents provides additional information.

Mental Health

The recent declaration by the AAP and others of a national emergency in children’s mental health highlights that both CYSHCN and their caregivers may have substantial mental health needs during the pandemic, economic decline and social unrest. Beyond the components called for in the declaration on October 19, CYSCHN and their caregivers will benefit from the following specific recommendations:

• Assess for mental health needs in CYSHCN and caregivers. Proactively manage, co-manage and make appropriate referrals, taking into account the possibility of long waiting times for counseling/therapy. Use telemedicine approaches as appropriate. These practices may be particularly important for certain subgroups of CYSHCN who may have higher mental health needs, including children with a diagnosis of autism spectrum disorder, attention-deficit/hyperactivity disorder, anxiety, depression or mood disorders. Additional information about telehealth is available here.
• Support mental health/wellness of CYSHCN and their caregivers with proactive guidance to plan safe, inclusive social/recreational opportunities.
• Connect families to peer supports such as Family-to-Family Information Centers.
• Assess the need for, safety of, and availability of respite services, such as in short-term stay units, if available.

Inpatient/Long-term Care/Post-acute Care Settings

• Ensure adherence to CDC guidance on infection control in health care settings. Increased risk-mitigation strategies during times of surges of any respiratory viral illness may help to minimize risks to CYSHCN, particularly children with medical complexity, not only from illness but also from reduced or delayed access to needed care.
• Crisis standards of care must not discriminate against CYSHCN and people with disabilities in the allocation of scarce resources, such as pediatric hospital beds. See guidance from the HHS Office of Civil Rights.
• Adopt family presence policies that balance safety and PPE conservation with the unique needs of CYSHCN, who may require a caregiver to stay with them at all times. Young adults (older than 18 years) with disabilities or other special health care needs may need a family member/caregiver present in the inpatient setting as part of reasonable accommodations in alignment with the Americans with Disabilities Act.
• Pay careful attention to interfacility transfer and discharge processes to ensure children and caregivers avoid exposure during transitions in care. See AAP interim guidance on interfacility transport.
• Promote information about COVID-19 and influenza vaccination to inpatient, long-term care and post-acute care setting providers.

Home Care Settings

• Explore the feasibility of home modifications specifically to improve ventilation.
• Adopt procedures and accommodations to prevent SARS-CoV-2 transmission into the household (ie, universal masking, testing procedures, personnel scheduling).
• As needed, refer families to resources for housing support and internet service and electronic devices.
• Promote information about COVID-19 vaccination to home care providers. Carefully consider risks related to allowing unvaccinated home care providers into home care settings for CYSHCN, and work with trusted health care providers to discuss and promote COVID-19 vaccination among home care providers.

Rehabilitation/Habilitation Therapies

Systems of health care and/or education (ie, Early Intervention, schools) may provide services such as physical, occupational, speech and other therapies. These therapies are medically necessary, are critical for early childhood development and school-age education, and often dictated by requirements of the Individualized Family Service Plan or Individualized Education Program (IEP). In some cases, Medicaid finances school-based therapies.

• Continue therapies regardless of in-person school attendance during the pandemic, including accommodations for in-person therapies.
• Virtual therapy services may be considered as an alternative or adjunct to in-person therapy services, but prioritization should be given to the most effective modality, agreed upon through shared decision making.
• Use appropriate PPE for in-person therapy services and give preference to larger, better-ventilated spaces.
• Address current therapy needs and need for compensatory services because of prior or ongoing lack of services.

Durable Medical Equipment/Medical Supplies/Pharmacy

• Adopt streamlined processes for approval and home delivery of durable medical equipment (DME), medical supplies and pharmaceuticals.
• Make accommodations to move equipment from the school to home as needed for home-based instruction or services.
• Give allowances for extra supplies.

Transportation

• Prioritize and advocate for single-patient/family transportation options such as vans for education needs and accessible taxis or ambulances for medical encounters. Private transport is especially important for children in areas with high community levels of COVID-19 who have challenges using face masks or in settings where other people will not be physically distanced or use face masks.
• Encourage the use of a child’s own car seat or assigned seat with distancing.
• Promote opening windows when possible. If using transportation with multiple individuals in an enclosed space (ie, buses to support education, medical or community life), use strict capacity limits and universal use of face masks if in an area with high community level of COVID-19.

Care Coordination and Case Management

Care coordinators and case managers should proactively continue reaching out to CYSHCN, especially those who have not recently engaged with the health care system, to review needs and make appropriate referrals for supports. Families of CYSHCN have increased financial burdens generally and, thus, may need additional supports during the pandemic, including unemployment benefits, Administration for Children and Families resources (including Temporary Assistance for Needy Families) and Supplemental Security Income, which provides cash assistance to many families of children with disabilities and chronic illnesses. CYSHCN are at higher risk for malnutrition and may be at elevated risk of food insecurity from the pandemic, so families should be connected to programs to address food insecurity, such as the Supplemental Nutrition Assistance Program (SNAP) and Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Insurance coverage for medical foods may help in specific clinical circumstances. Some CYSHCN are at higher risk for child abuse and maltreatment generally and may be at even greater risk during the pandemic. These resources may support families and other stakeholders. Family support organizations are critical partners in systems navigation and connecting families to appropriate services and support during the pandemic.

How should payers of health care support CYSHCN during the pandemic?

The AAP policy statement Principles of Financing the Medical Home for Children should be the starting point for health coverage for CYSHCN during the pandemic. Enhanced payment for care delivery based on the complexity of care and payment for coordination of that care is essential to support substantially increased needs during the pandemic (see Health Care Needs Section). A pandemic may also lead to disruptions in coverage because of income reductions and job loss, resulting in loss of employer-sponsored health insurance. Coverage options are available as described below

• Public coverage options, such as Medicaid, should streamline the process of enrollment with policies such as presumptive eligibility.
• Medicaid programs should provide all necessary services to children as mandated by the Early and Periodic Screening, Diagnostic, and Treatment provisions of Medicaid law. Payment for all services must be sufficient to ensure the provision of all required services during the pandemic.
• States should use health insurance premium payment programs to support and maintain employer-sponsored health insurance for children eligible for Medicaid (including those who receive Medicaid through home and community-based service programs like waivers). These programs can help families afford current options and, in some cases, pay for COBRA coverage in the event of job loss.
• All payers should cover telehealth for all health providers, including primary care, complex care teams, rehabilitative and habilitative therapists, subspecialty providers, behavioral health specialists, home care providers and others with coverage at parity for in-person services. Cross-state licensing reciprocity is necessary to help children who cross state lines for care. Given the multiple stakeholders involved in the care of many CYSCHN, payers should pay for group telehealth encounters.
• All payers should provide enhanced payment to providers across the continuum of care to account for substantially increased expenses such as PPE and increased need for typically unpaid non–face-to-face care coordination and planning during the pandemic.
• Payer case management and utilization review entities should maximize the access of CYSHCN to services needed during the pandemic and grant flexibility in meeting unique family needs across the continuum of care.
• Payers should presumptively cover habilitative and rehabilitative services for CYSHCN without formal diagnoses, because the pandemic limits the ability to perform the necessary diagnostic assessments.
• Home care during a pandemic is essential for many CYSHCN, and the AAP policy statement Financing of Pediatric Home Health Care should be a starting point for home care coverage.
  • Cover home-based laboratory draws and diagnostic imaging.
  • Pay for PPE, rehabilitation/habilitation therapies and telehealth/telemonitoring. To minimize the number of providers coming into the home, use flexible staffing policies such as overtime allowance.
  • Use home and community-based services such as waivers and other options to provide targeted services and Medicaid coverage for eligible populations. Such programs should provide home modifications to improve ventilation in-home care settings, payment for PPE, telehealth devices and internet connectivity. Provide services to all who need them without waiting lists. Use streamlined approval processes.
  • Expand options to compensate family caregiving to provide in-home supportive services.

How should schools accommodate CYSHCN during the pandemic?

In-person learning should be prioritized for CYSHCN through implementation of multi-layer risk reduction in schools. Information on safe schools is available via the AAP interim guidance. Schools should prioritize special considerations for in-person learning for CYSHCN, including surveillance of community levels of COVID-19, on-site SARS-CoV-2 testing, use of face masks, reasonable accommodations and mental health support. Education is particularly critical for the development and well-being of CYSHCN, and communities must prioritize CYSHCN by taking all steps necessary to suppress community transmission of SARS-CoV-2 and giving school districts the resources needed to conduct education safely during the pandemic. Inequities are particularly salient in education. Decisions at the community and individual level must take into account the community level of COVID-19 and the risk of transmission to household members who may be at higher risk for severe acute biological effects of SARS-CoV-2 infection, such as older individuals and individuals with certain chronic conditions, as well as reasonable assessments of the resources required to implement plans.

Although surges in case numbers may lead to discussion of virtual learning options for those who are at higher risk for severe acute biological effects of SARS-CoV-2 infection, it is important to recognize that safe in-person instruction still should be the priority. Shared decision making among families, health care providers and educators is the likeliest pathway to come to a joint decision as to the optimal educational environment and needed reasonable accommodations. Pediatricians can support patients/families by facilitating a thorough and balanced understanding of the known benefits and risks of in-person attendance and virtual learning. Based on the student/family’s priorities, the team (including student/family, school nurse, school administrator, teacher and pediatrician) should work to develop creative, flexible and responsive accommodations to allow those priorities to be met safely. Parent training and information centers can provide support regarding education issues, including IEPs and 504 Plans.

In accordance with the Individuals with Disabilities Education Act (IDEA), IEPs must be updated annually, regardless of learning/attendance modality (virtual, hybrid, in-person). Families/caregivers of CYSHCN should be supported in adjusting IEP plans and goals as needed, including needs for compensatory education and services, even if this occurs more frequently than on an annual basis.

With in-person instruction, schools should:

• When community level of COVID-19 is medium or high, maintain universal use of face masks and physical distancing in accordance with AAP and CDC recommendations, particularly as students maintain in-person learning, to accommodate needs of CYSHCN.
• Consider additional measures to protect students with disabilities who need extra protection (eg, masking by adults and students around them, portable air filtration), even if the rest of the school has relaxed standards.
• Educate staff on the proper use of PPE and supply the staff with optimal PPE to protect students and staff, with particular attention to close contact situations such as therapies, diapering, feeding and medical procedures (see PPE section for details).
• Give children and adolescents more likely to have severe biological effects of SARS-CoV-2 infection preference to receive in-person instruction and participate in inclusive activities in larger, better ventilated and less crowded indoor spaces or outdoor spaces, with heightened attention to PPE, surface cleaning and hand hygiene practices.
• Support additional academic, mental and behavioral health needs of students and staff related to the pandemic.

If virtual instruction is considered, schools should:

• Collaborate with families to understand the reason virtual instruction is being requested and consider modifications to the in-person instruction model that might allow for in-person instruction.
• Arrange access to adequate internet bandwidth, connection speeds and individual devices for instruction and training for families on use, particularly those with less digital fluency.
• Provide options for aides (in person at home or virtual) or home nursing, preferably through the IEP, to assist CYSHCN with virtual learning. 
• Offer virtual therapy sessions and make arrangements for home-based therapies.
• Allow those choosing virtual learning to participate in some in-person activities (ie, therapy, outdoor events) on an individualized basis.
• Offer synchronous or asynchronous options to acknowledge the other demands on students and families.
• Provide options for food delivery and refer to supports to address food insecurity and other needs (see case management section).
• Support additional mental and behavioral health needs of students and staff.

How should child care settings accommodate CYSHCN during the pandemic?

Information on child care is available via the AAP interim guidance. CYSHCN may receive child care in a variety of settings, including general child care, special needs child care programs, medical child care programs and in-home caregiving. As with school reopening decisions, Shared Decision Making is essential to make child-specific decisions about the risks and benefits of various child care options. CYSHCN may need updated Individualized Health Care Plans in the pandemic. Resources for child care options are available here.

How should communities accommodate CYSHCN during the pandemic

Communities should be understanding and continue with accommodations for those CYSHCN and families who continue to use face masks and take precautions. Examples of these accommodations may include:

• Employers
  • Give parents and other family members of CYSHCN flexibility in working from home and leave policies, because these families may have added barriers to child care.
  • Advocate for families to get needed coverage across the continuum of care for CYSHCN from employer-sponsored health insurance plans. Benefits exceptions facilitated by human resource professionals can help families with needed supports.
• Community businesses
  • Comply with the Americans with Disabilities Act in outdoor dining to allow wheelchairs to pass through.
  • Set priority hours for grocery shopping and food pantry retrieval as well as prioritization for delivery programs.
• Utilities and internet providers
  • Assist with maintenance of service in the event of family financial difficulty to maintain electricity for medical equipment, appropriate climate control for medical needs and remote connection to health care and education services.
  • Provide extra allowances for bandwidth usage because of telehealth and remote learning, especially for low-income families.
• Housing owners/landlords
  • Consider accommodations to improve ventilation, especially when home care providers are coming and going to meet the needs of CYSHCN.
  • Use payment plans and other methods to avoid evictions that compromise home care.
• Transportation entities
  • Accommodate CYSHCN and their families who rely on public transit with accessible, capacity-limited options and enhanced access to programs that allow individual/family transportation for people with disabilities.
• Park districts
  • Help families reserve accessible, physically distant outdoor space for safe recreation.
• Community organizations and faith communities
  • Help CYSHCN and their caregivers through accommodations that promote safe inclusion in recreation and worship. Families can often benefit from help with errands and financial assistance as well.

Additional Information  

• Providing Acute Care in the Ambulatory Setting During the COVID-19 Pandemic
• Newborn Screening During the COVID-19 Pandemic
• Use of Personal Protective Equipment (PPE) for Pediatric Care in Ambulatory Care Settings During the SARS-CoV-2 Pandemic