tal health agency) showed significant improvements in attendance and reductions in the numbers of students retained (left back) to close to zero (Dolan and Haxby, 1992). A strong school-based case management program in Fresno, California, conducted in conjunction with the county department of social services, showed a 40 percent reduction in unexcused absences, a decrease of 70 percent in referrals for misbehavior, and a substantial increase in parental involvement (Center for Future of Children, 1992).
The Metropolitan Health Department of Nashville, Davidson County, Tennessee, reported that its One Stop Shopping Family Resource Center provided easier access to prenatal care, pediatric services, and school health (Maternal and Child Health Bureau, 1993). The immunization rate for enrolled 4- to 5-year-olds was 98 percent in 1993, and 150 families were in intensive case management.
A few studies have been conducted to document the design and implementation of SBHCs. A unique survey of 90 clinics in 1991 focused on planning strategies and barriers to implementation (Rienzo, 1994). Key variables that influenced the capacity of SBHCs to offer comprehensive services (number of clinical and outreach services provided) included the presence of a strong coordinator, the use of information such as needs assessments for gaining support in the community, and obtaining funding from national sources, particularly foundations. The ideal coordinator was described as a "workaholic," with the ability to acquire funding and expertise in adolescent care. The more successful programs carefully organized planning committees and community advisory boards, and relied on committed school administrators to facilitate "navigation" through the approval process. Barriers to implementation included insufficient funding (66 percent) and problems with staff training and turnover (33 percent), issues that are related at least in part to the matter of funding. Many programs initially confronted organized opposition and dealt with controversy through public hearings. As a result, several changed their policies in regard to birth control and abortion counseling; birth control was limited in 28 percent of the cases and abortion counseling proscribed in 9 percent.
One study documented the importance of providing services on school property (school based) rather than nearby (school linked). A health center was removed from school grounds in Quincy, Florida, during the tenure of a conservative governor, who refused to allow public funds to be used for school-based clinics (Center for Human Services Policy and Administration, 1990). The level of service activity declined