clinics compared the costs for the school services with the estimated cost in the absence of the school clinic (Brindis et al., 1995). Variables used included reduced emergency room use, pregnancies avoided, early pregnancy detection, and detection and treatment of the common STD, chlamydia. The ratios of savings to costs ranged from $1.38 to $2.00 in savings per $1.00 in costs, suggesting that the school clinic services were a good investment.
The Johns Hopkins University Child and Adolescent Health Policy Center has recently published a report that analyzes the existing research on SBHCs and summarizes their strengths and weaknesses in improving access to primary care for adolescents (Santelli et al., 1995). This report defines primary care as having the following characteristics: ''first contact, continuous, comprehensive, coordinated, community-oriented, family-centered, and culturally competent." The potential strengths and weaknesses of SBHCs in providing primary care identified by the report are outlined in Table 4-6.5
Many fundamental questions remain unanswered about SBHCs and other extended services. One of the most basic regards the relative advantages and disadvantages (in terms of quality, cost, and effectiveness) of providing primary care and social services at schools compared to providing these services at other sites in the community—for example, private physicians offices, other managed care providers, community clinics, or youth centers—or compared to not providing these services at all, as a function of the needs and characteristics of students and the community. A related question has to do with how the quality and effectiveness of SBHCs and other extended services should be defined and measured.
If SBHCs are indeed found to be a promising approach for many communities, then a broad research agenda will be needed to examine the implementation and dissemination of effective models. Greater understanding is needed about the best strategies for managing, staffing, and integrating the SBHC with the overall school program. Questions that must be addressed include: How does this activity get off the ground?