Inside Anton Grdina elementary and middle school, a bulletin board covered in yellow construction paper announces big news. 

“Medical Health Clinic: COMING SOON!!!” 

That clinic is now open, staffed by a nurse practitioner, nurse and community health specialist employed by MetroHealth. The clinic is one of three that opened inside schools in the Cleveland Metropolitan School District this fall. Two other on-site clinics began operating inside Cleveland schools last year, while a third has been open since 2013. 

The new clinics were built with federal COVID-era money that the city of Cleveland and the state of Ohio received and dedicated to in-school health facilities years ago. The effort has broad support from a coalition of Clevelanders, including hospitals, the Cleveland Teachers Union and local philanthropists. 

Here’s why: Supporters believe the investment will make healthcare more accessible for students and families who need it most. Advocates also see the possibility for the clinics to make a dent in student absenteeism, a significant challenge for CMSD post-pandemic.

“These programs are designed centering the barriers that families face,” said Katherine Bissett, the director of initiatives at the Ohio School-Based Health Alliance, which advocates for the expansion of school health care. “…And part of that is that they’re really one of the only pediatric providers that is able to see kiddos unaccompanied, because that’s a huge barrier for families being able to get their kids care.”

Now, with the effort expanding, CMSD and its healthcare partners can put their hypothesis to the test. But will the clinics improve health and educational outcomes?

As of right now, officials are still working with a researcher to gather data about whether the first three clinics and other district health initiatives have improved student health or education outcomes, according to Michele Pomerantz, Cleveland’s Chief of Education. Anecdotally, a spokesperson for the district said it’s seen “satisfied parents because of the initiative to provide a more accessible means of care.”

Challenges to success remain. The first batch of clinics “might not have seen the kind of traffic that we’re looking for,” said Shari Obrenski, president of the Cleveland Teachers Union. Last year, the three open clinics saw about 790 visits from students, families and staff, according to MetroHealth, though they only operated one to two days a week. And the average rate of students whose parents have filled out paperwork to allow them to be treated at the health centers is below thirty percent in schools with a clinic.  

Leaders are gung-ho to pitch the program to more parents. MetroHealth, which operates five of the six clinics, employs community health workers that help get more parents to sign the right forms. The city of Cleveland budgeted $1.7 million in pandemic dollars to raise awareness of the school health program among CMSD students and families.

The goal is to help parents understand, “especially after COVID and the vaccine and everything else … that we are not here to take over your child’s health, but as a partner with you,” Pomerantz said. 

How in-school clinics work at CMSD

The clinics are not meant to replace school nurses or other school health staff, who will still work for the district. After the pandemic, the district assigned a full-time nurse to every school building.

Instead, the clinics employ healthcare providers that have more capabilities than a school nurse, like a nurse practitioner or doctor who can diagnose and prescribe medicine. MetroHealth runs five of the clinics, which have medical staff on-site two days a week, while Cleveland Clinic Children’s Hospital operates one at John F. Kennedy High School that will be open five days a week at the end of September.

At the MetroHealth clinics, kids can get primary care – well-child visits, vaccines, sports physicals, sick visits, blood work – and behavioral health screenings that would typically take place in a pediatrician’s office. There is limited counseling available, too, as well as dental cleanings and some more serious dental work.  

The offerings at the in-school health center run by the Cleveland Clinic are fairly similar, though it will also offer vision screenings and a psychiatrist on-site three days a week. 

Still, the clinics are expected to work closely with school nurses and receive referrals from them, said Josh McLaughlin, the director of school health at MetroHealth. For example, if a child has a sore throat, nurses could send them to the clinic to get tested for strep to determine whether they need to go home, said Dr. Roopa Thakur, the medical director of the Cleveland Clinic School-Based Health Program.  

So far, the new healthcare providers coming into the schools have been “extremely respectful” of existing school staff, Obrenski said. But small, yet important, questions are still not totally clear, she added. Like, are teachers supposed to take a student to the clinic? Who is responsible for getting students scheduled in the clinic? 

“It’s adults’ inside baseball, us trying to work out what that looks like so that operation is seamless,” Obrenski said. “And I will say, I think that there is a potential that it may look different from site to site because the needs aren’t necessarily the same.”    

Though parents aren’t required to be on-site when a child is seen at the school clinic, they’re a big part of school healthcare. Parents must fill out a consent form for their child to use the clinic. And both McLaughlin and Thakur said that providers call children’s parents each time they are seen in the clinic to get approval again. Parents can also attend the appointment with their kid, if they want, or get a summary sent home afterward.

The clinics at MetroHealth are free and without co-pays for families, though the hospital does bill Medicaid or insurance companies if it can. Philanthropic and state grants help cover other costs. And, students who are seen in the clinics are protected by health privacy laws. 

“Your doctor is not going to walk over to your high school teacher and tell them the results of your blood draw,” Bissett said. “There’s a wall there inside.”

Why in-school health clinics?

Local organizations like Case Western Reserve University and hospitals have been offering free or reduced-cost healthcare services to CMSD students for years, from dental exams to eye exams. For more than a decade, both Cleveland Clinic and MetroHealth offered students primary care mostly via mobile clinics that could travel to different schools.

During the 2017-18 school year, the district evaluated MetroHealth’s school health program, which consisted of mobile clinics and one school-based health clinic at the time. It found that kids whose parents allowed them to receive healthcare from the program had fewer absences than those who didn’t, a statistically significant difference. Their grades were also higher.  

Since then, there’s been a push at the local and state level to go beyond mobile clinics and further integrate health into school buildings. 

In 2020, Say Yes Cleveland – a local scholarship program supported by local philanthropists and businesses – as well as CMSD and local community health providers came together to create the Integrated Health Initiative to expand school-based healthcare. 

After the pandemic, the group encouraged the city of Cleveland to route $3.7 million of the city’s COVID recovery dollars to the Cleveland Foundation to build three new clinics in schools. The push followed a report, published by community groups such as the Cleveland Foundation and the George Gund Foundation, that identified rising absenteeism and mental health issues among Cleveland students post-pandemic.  

Around the same time, Governor Mike DeWine also started leaning into school-based healthcare. In 2022, he funneled about $26 million of COVID recovery funds into new or expanded school-based health centers across Ohio, including the three clinics in Cleveland schools that opened last year. The legislature also supported the school-based healthcare effort with $15 million in the 2024-25 state budget. 

“We’ve really seen this model spread across Ohio in the past five years,” said Reem Aly, executive director of the Ohio School-Based Health Alliance.

The movement to put clinics in schools is supported by a growing body of research that finds school-based health clinics positively impact student health – from the increased likelihood of receiving well-child and mental health visits to higher rates of completing vaccine schedules. In Cincinnati, risk of hospitalization and emergency room visits due to childhood asthma dropped after school health centers opened. 

Research also shows the health centers can improve educational outcomes, specifically absenteeism. A study in rural New York found students in districts with school-based health centers had a 12% greater chance of not being at risk for chronic absenteeism.  

CMSD wants its in-school clinics to impact absenteeism, said Pomerantz, with the city of Cleveland. Chronic absenteeism in CMSD peaked at 64% following the COVID pandemic. 

“When a child is sick and they have to leave school, they’re missing that lesson of that day,” Pomerantz said. “Their mother has to come pick them up. Then the class keeps moving.”

Challenges persist

Opening a health-care center inside a school is one step. But getting kids and staff to use it is another. 

That’s the next obstacle district and healthcare leaders are contending with, since usage of the clinics was relatively low last school year. 

The clinics that opened in CMSD schools last year saw between 8 and 9 visitors a day, said Katie Davis Bellamy, chief operating officer at MetroHealth Community Health Centers. MetroHealth aims to set 12 pre-scheduled visits a day and leaves room for walk-in appointments. The number of daily visits the clinics see is important for their financial sustainability, since the centers get reimbursed by insurance for their services.  

That’s one of the reasons the MetroHealth clinics are operating two days a week in schools this year, as they determine what sort of demand they’ll see, Bellamy said. 

“Ideal world, we’d love to be there five days a week in all of the clinics,” Bellamy said. “But we want to make sure that we have that utilization for our clinics.”

Bellamy said the major challenge is awareness. Bernetta Wiggins, executive director of CMSD’s Integrated Health Department, agreed. She said that recent surveys show not many parents know about the health clinics – so she attributes the low numbers to insufficient marketing. 

But Wiggins said the district is ramping that up, sharing information about the clinics at health fairs, back-to-school events and with parent ambassadors, who help support outreach to other parents and families. One back-to-school event yielded more than 100 new consent forms, according to a spokesperson with MetroHealth.  

Cleveland budgeted $1.7 million in ARPA funding to help promote the health program, though it’s unlikely to use that entire amount, according to a spokesperson for the city. Some of those dollars were used to hire the Cobalt Group, a community advocacy and strategy group, to help raise awareness. 

That includes increasing the number of students who have a signed consent form, which is essential for them to get health care in the clinics. 

In schools with new and existing clinics, an average of about one-quarter of students have their forms signed. 

At first, the district thought that this low number meant parents weren’t interested. “But as we talk to the parents,” Wiggins said, “The desire is there. … They want the services.”

Clinics around the state deal with similar challenges, a statewide census of school health centers across Ohio found. The average rate of students with a consent form on file was 44% in the 2023-24 school year. Bissett said that’s not necessarily an indication of the demand.

“We know there are school-based health centers that are bonkers busy with a consent rate of 30% students,” Bissett said. “And that could be because they’ve got a really big school building. That could be because the kiddos have a lot of unmet needs.”

MetroHealth is doing what it can to drive up participation. Its community health workers pass out consent forms in parent pick-up lines and attend back-to-school events, Bellamy said. But she believes one of the biggest ways to gain trust will be just showing up in the schools, week after week. 

“It’s that consistency — so that they know that they can trust and build a relationship, and then they can tell more people about your services,” Bellamy said. “So it does take time, but I think we know that the benefits are there.”