Municipal child health services: a ten-year reorganization

There has been increasing interest within the medical community in developing primary care programs in teaching hospitals that meet the medical needs of a community. The Cambridge Hospital system provides a working model for such a mutually beneficial interaction. Based on principles of administrative centralization and utilization of the pediatric nurse practitioner, the neighborhood health centers operate as part of a cost-effective series of concentric circles. Administrative centralization within the Department of Pediatrics at the Cambridge Hospital has permitted the elimination of duplicate medical services and the development of a responsive community health service. The pediatric nurse practitioner under close senior staff supervision, serves as the primary caretaker in the neighborhood centers. In addition to her role as the provider of a protocol-determined, age-related series of physical psychometric, and laboratory examinations the pediatric nurse practitioner also cares for minor injuries and illnesses of childhood. Any child deviating from a clearly established range of norms for any physical, developmental, or laboratory parameter is immediately referred to the senior staff pediatrician for further evaluation. Finally, any patient requiring subspecialized inpatient care is referred to the Massachusetts General Hospital. The senior pediatric staff of the Cambridge Hospital serves the function of coordinating and supporting the rapid interlevel communication which must occur between community service, primary hospital, and a tertiary care facility. This neighborhood health care system is, we feel, a medically sound, educationally exciting, and fiscally responsible solution to a problem facing many urban areas and their academic medical institutions.