Hospitals and healthcare systems that engage in active community outreach are finding it's a natural fit to open clinics in schools, where they can best reach underserved young patients.
With cooperation from schools and other community-based organizations, providers can bolster healthcare services for children and adolescents, from primary care to reproductive services and mental health counseling.
The number of school-based and school-linked health centers nationwide increased to more than 600 in 1994 from 327 in 1991, according to Washington-based Advocates for Youth. By comparison, only 31 centers were in operation in 1984.
One such center is hosted by Children's Hospital Medical Center in Cincinnati. Located in Rockdale Elementary School, just two blocks from the hospital, the clinic serves 750 students in preschool through sixth grade.
About 97% of the children are at poverty level and below, said Sheila Smith, assistant vice president for patient services. Smith coordinated the clinic's start-up, in cooperation with a city program called School Partnerships.
Since it opened in January 1995, the clinic has immunized 150 students and served about 300 students at health screening fairs. Two to 15 students visit the clinic each day, Smith said.
The hospital has been careful not to replicate services offered through its own facility, the public health department, local health clinics or private practice physicians, Smith said.
In addition, the medical center is developing a plan to coordinate pediatric services for school-aged children throughout Cincinnati, Smith said.
The average operating budget for school-based health centers sponsored by hospitals was just over $150,000 for the 1992-93 school year, according to Advocates for Youth. That translated to an average cash cost of $154 per student. Providers often obtain grants to offset the clinics' costs.
About 64% of clinics are school-based, meaning they're located on school grounds. School-linked centers, which constitute about 7% of clinics, have off-campus locations. The remaining 29% of centers are based on-campus but also serve students from other schools.
One criticism leveled against school-based clinics, especially in rural areas, is that they take business away from local pediatricians.
But that doesn't have to happen, said Robin Hatziyannis, a spokeswoman for Advocates for Youth, which tracks school-based and school-linked health centers. "People who are high-risk are probably not seeking medical care at all," she said.
Recent research supports this theory. Researchers at the University of Colorado School of Medicine and Children's Hospital in Denver found that 90% of Denver high school students who used school-based healthcare visited a medical provider once a year. Nationally, 77% of insured adolescents and 58% of uninsured adolescents visit medical providers each year. The four-year study of 3,800 students was published in the March issue of Pediatrics, the journal of the American Academy of Pediatrics.
The increased use did not signify overuse of services, researchers observed. Instead, centers fill a void by giving adolescents access to low-cost, confidential healthcare.
"These are kids who would otherwise not see a physician unless they were seriously ill," said Judy Tarr, chief executive officer of Miles Healthcare, a Damariscotta, Maine-based system that runs Miles Memorial Hospital.
Miles works with a local school that serves 450 high school students from several surrounding towns. Since a school-based clinic opened there in January, more than 1,000 students have visited.
About three years ago, Miles incorporated a commitment to preventive medicine and wellness in its mission statement. Launching the clinic was its "first major step in that direction," Tarr said.
Miles received a two-year, $110,000 grant from the Bureau of Health within Maine's Department of Human Services, she said. The hospital also contributes about $34,000 a year worth of services in kind, such as administrative services and time donated by physicians and therapists.
In addition, the school funds the nurse's salary and other expenses totaling $70,000 annually, Tarr said.
Miles' clinic, like about 29% of all school-linked and school-based centers, serves a rural area. Some 59% of clinics are in urban areas. The remaining 12% are in suburban areas.
Detroit Riverview Hospital recently opened its third clinic, at Butzel Middle-Elementary School, which is about a quarter of a mile away. "It's right in our back yard," said Richard Young, administrator of Detroit Riverview.
The hospital received a three-year, $100,000 grant on behalf of the Kettering/Butzel Health Initiative, Young said. The community-based planning coalition had assessed the need for better access to healthcare for children and adolescents in Detroit.
The clinic is staffed during school hours with a nurse practitioner, a social worker and clerical staff. The hospital's chief of pediatrics, Gerard Mosby, M.D., is the clinic's medical director.
In the neighborhood served by both the school and the hospital, the median household income is $12,000. Some 63% of the 1,000 children at Butzel live in poverty.
The grant doesn't meet all the clinic's expenses, but the hospital does receive some fee-for-service revenues from the venture, he said.
"We're in a particularly challenged area of Detroit, so everything we do is challenging," Young said.