Historically, university training clinics were established as the primary clinical training units of departments that offer graduate degree programs in speech-language pathology and audiology. These clinics serve as a valuable source of clinical exposure for students to clients of a wide variety of ages and disorders. Perhaps more important, they serve as controlled environments that provide students with opportunities to translate academic/theoretical information into authentic clinical contexts with real people. This model has evolved over time from one in which all clinical activities were subsidized by departments to one in which revenue generation is an equally important expectation. This revenue is used to offset the costs associated with the labor and equipment needed to support intensive clinical education. Insurance/reimbursement issues continue to be important and complex topics with regard to revenue generation, and these specific concerns have received substantial attention in several other venues. In this article, we direct our comments in a different way; we address the philosophy underlying the business model for operation of a university clinic. At the University of Maryland, the Hearing and Speech Clinic in the Department of Hearing and Speech Sciences (HESP) has thrived for more than 60 years in its mission to provide comprehensive clinical education to future clinicians while delivering high-quality services to individuals in the community. The clinic enjoys a reputation that generates a steady flow of referrals from regional, national, and international sources. This clinic was established in the tradition of the historical model and continues to be partially subsidized by university funding. However, the rapidly changing financial climate and health care landscape of the past decade have impelled even successful university training clinics to incorporate revenue generation as a major component of their operations.
At times, the challenges involved in balancing the missions of student training and service to the community within a revenue-generating model feels like a zero-sum game; anything added in one area must be subtracted from the other. For example, a caseload that is calibrated to clinical education is not maximally efficient at revenue generation. The real challenge for clinic directors and program chairs these days is to find new strategies that simultaneously fulfill both missions. As the HESP Department approached this new frontier, we first made a strong philosophical commitment to ensuring a balance between educational, service, and business goals. And if that wasn’t complicated enough, we affirmed our continued commitment to meaningful collaborative work between the speech-language pathology and the audiology aspects of our program. An essential element of the clinic’s successful business plan has been the open, ongoing communication between the directors; avoiding “working in silos” takes concerted effort and diligence.
A conscious and concerted effort is brought to bear on cross-germinating clinical education for speech-language pathology and audiology students. Cross referrals for services work both ways. For more than a decade, the department has operated a preschool for 3- to-5- year-old children with speech and language impairments. This initiative has proved to be a reliable source of revenue generation, while simultaneously providing valuable classroom-based clinical experience for our students and research experience for faculty and students alike. All of the children served in the preschool access hearing services in the departmental clinic and, in the cases where a hearing impairment is part of the child’s profile, audiology students work on teams with speech- language pathology students to coordinate individualized treatment/educational services for that child. Additionally, clinical faculty in audiology work closely with the director of the preschool and its student clinicians to ensure effective operation of classroom amplification, a standard feature of daily practice in the school setting.
Initiatives That Combine Student Education and Revenue Generation
Approximately 10 years ago, our department established a joint partnership with a local county school system to increase the pipeline of highly qualified students who will be ready to work in the public school setting. The school system provides tuition scholarships to the students and requires a multi-year work commitment after graduation. This program fulfills the school system’s need for additional qualified personnel,and provides the department resources to hire an additional clinical instructor, while permitting funding opportunities to recruit a greater number of talented graduate students.
A more recent departmental initiative is the establishment of a cochlear implant clinic that serves a wide spectrum of needs. In its pilot phase, cochlear implant (CI) patients are seen in our clinic for mapping by an adjunct clinician from a nearby CI surgical center. Speech-language pathology and audiology students are incorporated into these sessions to learn about mapping and to address the aural rehabilitative aspects of case management. And, these same CI patients are recruited to participate in the research activities of the Cochlear Implant Lab in the department. This type of win-win strategy serves the needs of the patients who can be served locally, while advancing the teaching and research missions of the department. Although CI cases do not generate significant clinical revenue at this time, we anticipate that this initiative will serve as the basis for a future student training grant that will support departmental activities.
From a management perspective, we jointly supervise the administrative personnel that handle the clinic’s scheduling and billing operations. We meet regularly as a team with the departmental chair to review shared goals and initiatives and the status of the clinic’s financial summaries-which includes reports on billing, income, and expenditures, as well as the amount of good-will discounts that have been shared with the university community (faculty and students). This collaborative management approach allows us to make coordinated and data-based projections about future trends and to plan for the future. Budget projections include the provision of a sliding payment scale for individuals and families (off- and on-campus) who need services, but face financial hardship. Our clinic currently maintains a “non-participating provider” status for insurance reimbursement; however, claims are filed on patients’ behalf to facilitate reimbursement. Students participate in completing paperwork that includes decision making about billing and coding. In addition, discussion seminars on these issues are incorporated as part of practicum training. As a community-based facility, we seek to maintain sensitivity to the needs of the local community. Management also involves outreach efforts to educate the public, increase the visibility of our clinic, and attract new patients. We routinely participate in local health fairs, provide adult and preschool hearing screenings, and disseminate hearing health care information to local community centers, including consultation on acoustics for dining rooms, lecture halls, and auditoriums.
The co-authors of this article are clinic directors who have had the luxury of more than 20 years of shared leadership. So, we are living proof that being a clinic director is a survivable condition! We are well aware that university directors/clinicians have to wear many hats in the course of the professional day: the CEO hat for running an organization that operates efficiently and effectively, the marketing executive hat for maintaining a sufficient clinic caseload for training, the accountant hat for making sure money going in and going out keeps the operation solvent (or at least solvent enough to supplement university funding), and the faculty hat for focusing on the quality and content of clinical education for students. Because multi-tasking has become second nature to clinic directors, we often half-jokingly speculate that we should “sequester” some of the clinic’s income to build a separate closet for all the hats we have to don during the course of a single day.
What will university clinics look like in 10 or 20 or even 30 years? Will telemedicine and distance learning be the wave of the future? Change is inevitable, and we must embrace it or get run over by it. University clinics must be forward thinking, keep an eye out for new opportunities, and make room for creativity. Will we open satellite clinics at local senior communities? How about a residential summer camp for young children who stutter? There’s an endless list of possibilities that meet the primary missions of educational excellence, effective revenue generation, and rewarding collaboration. Staying passionate about our profession has been the single most important quality that accounts for our success. It has helped us find innovative solutions to a constantly changing educational and health care landscape and discover ways to pass this positive energy and enthusiasm along to future generations of clinicians.