Clinical Connections

Building relationships with coaches, student-athletes, and parents are the keys to successful clinic-based outreach.

By David Hill

David Hill is an Assistant Editor at Training & Conditioning.

Training & Conditioning, 12.5, July/August 2002,

At Jamesville-DeWitt High School near Syracuse, N.Y., the booster club considered their athletic trainer so valuable that they bought her a golf cart to get around the sprawling campus. The generosity of the booster club is remarkable, but even more interesting is that Heather Santillo, MS, ATC, isn’t even an employee of the school district. Santillo works for Sports Physical Therapy of New York and is assigned to the school on an outreach basis.

Clinic-based outreach to high schools isn’t the easiest way for an athletic trainer to work. When the athletic trainer isn’t a school employee, it often is difficult to feel part of the team. Sometimes, coaches and parents don’t trust a new athletic trainer in such settings.

Outreach arrangements can also spread athletic trainers thin, leaving them working with multiple schools at once and giving minimal service to each. The outreach situation makes it hard for clinic-based athletic trainers to get to know the athletes and coaches, and may limit the time they want to give. And because the service is often provided free or at low cost to the school, it may diminish the profession in other people’s eyes.

Nonetheless, many athletic trainers such as Santillo thrive in the clinical outreach setting. What follows is a look at how some athletic trainers are making it work for them, their employers, their schools, and their student-athletes.

Building Trust
The number-one challenge for a clinic-based athletic trainer is gaining the trust and respect of coaches and student-athletes. And many find that starts by explaining what you do.

Josh Herman, ATC/L, LMBT, of Raleigh Orthopaedic Rehabilitation Specialists in North Carolina, says that when meeting new people at his outreach schools, he explains his certification, experience, duties, and how he works under a physician’s supervision. “And then you basically have to prove yourself by what you do,” he says.

“If you have kids come to you, you can’t look at them and say, ‘I’m not sure what’s going on.’ If you really don’t know what’s going on, you have to refer them, but you’ve got to try to do what your training’s taught you, and then build your credibility from there,” Herman explains.

Trust and respect also develop when athletic trainers don’t just perform their duties, but also share their knowledge. “I would observe a lot of surgeries on athletes,” says Kevin Allran, MS, ATC-L, who worked as outreach director for a Hickory, N.C., sports-medicine practice before becoming Head Athletic Trainer at Charlotte Latin School. “So I could say, ‘You’re sore here because this is what he did.’ I explained it to them a lot better and they felt real comfortable.”

Dave Sciera, PT, ATC, of Sports Physical Therapy of New York, spends one to three days a week at upstate Central Square High School. He extols taking advantage of preseason sports information nights and in-service presentations to coaches to foster confidence in his expertise.

“I talk to the football players each year about concussions and spinal injuries and things like that,” he says. “I explain why they need to make sure they’re checked out if they feel they’ve had a concussion during the game, even if they just have a headache, and why I need to make sure they’re okay before going back in. That kind of thing. Over time, little things like that gain the coaches’ and athletes’ respect—they see that you have a knowledge base and that you’re willing to share that knowledge with them.”

However, cultivating trust at a school is sometimes as much about what you don’t say as what you do. When Allran was a clinic-based athletic trainer, he often sensed a concern among some coaching staffs that he might share inside information about injuries with competing schools. To address that fear, he never shared anything about opposing teams that wasn’t public information already.

“I didn’t talk about anything to anybody except the doctor,” Allran says. “The coaches might know that Joe Smith is hurt over at X high school but I wouldn’t tell them anything about whether he was going to play or not. I just proved to them that it wasn’t a factor at all.”

But athletes and coaches aren’t the only people outreach athletic trainers must win over. Shane Redmond, ATC/L, and fellow outreach athletic trainers at Sports Plus Physical Therapy in Belmont, N.C., believe that forming a rapport with parents of athletes is very important. Because of that, they make a concerted effort to attend parents’ meetings for each sport, where they stress their interest and availability.

“We go and we take all of our information—our business cards and our sheets with our names and all of our phone numbers, and we do our little spiel,” he says. “We tell them about insurance and what we cover. We say, ‘These are our phone numbers. Please call. We want to know every bump and bruise. We want to make sure everything’s taken care of.’”

Sharing the phone numbers with parents is crucial, adds Jerry Whetstone, MEd, ATC, Coordinator of Athletic Training Services at Kettering Sports Medicine Center near Dayton, Ohio. Besides facilitating communication, it sends a clear signal that the athletic trainer is serious about becoming as much a part of the team as possible, says Whetstone, who passes that advice on to all of the 19 certified athletic trainers he oversees. “I tell them to say, ‘Here’s my pager number, here’s my home phone number, here’s my work number, here’s my cell phone, here’s the TV channel that I watch, this is the time I go to bed, when I get up, go out for a run.’”

Outreach ATCs should also emphasize the benefits their unique situation can offer teams and families. Santillo points out that her relationship with a clinic means she can often get a doctor’s appointment for an injured student-athlete faster than the parents could on their own.

Extra Mile
Sometimes, success as an outsider also requires giving extra value and doing more than the minimum. In Redmond’s case, the contract between the company and school district details which sports are to be covered. It focuses on high-risk contact sports, but Redmond says he and fellow athletic trainers for his company make the rounds at every practice field at their schools, whether they are high-risk sports or not.

“In the spring, we’re only required to check on girls’ soccer, but we also check track, boys’ tennis, and softball,” he says. “We usually spend 15 to 20 minutes with each sport. It’s, ‘Hey, coach, what you got for me?’ We’re not paid to go out and check on tennis, but we do it because they have no other medical coverage. If we don’t go out and check on them, then injured athletes are getting no care at all.

“People recognize what we do for the community,” Redmond adds. “It’s very obvious to everyone who we are. We’ll get calls from middle school parents just because they have our numbers and recognize who we are.”

Whetstone, too, sometimes stops in when he’s not scheduled because he has two sons at one of the schools he serves. “I say, ‘Hey, coach, I’m not scheduled for a visit today but is there anybody I need to take a peek at?’”

In the football-focused South, Allran’s company used to hold a Friday-night clinic in the fall where he and colleagues would see injured football players. “If they had a sprained ankle they didn’t have to sit in a hospital waiting room only to have somebody say, ‘You need to see an orthopedist,’” says Allran.

Those who have succeeded at outreach work say that to excel, athletic trainers must implement tactics for extending their prize resource—their knowledge and skill. One method is empowering coaches and athletes to take better care of themselves off the field. The tactic is not meant to replace athletic training, but rather to supplement it to help professionals be more effective. Preseason meetings and coaches’ clinics are ideal settings for these efforts, many say.

Sciera focuses on what’s pertinent for the upcoming season: He’ll cover preventing and recognizing heat-related injuries for coaches of fall sports, for instance. Preseason sessions should also include basic first aid and CPR refreshers.

The same principle applies once the season starts. A good outreach athletic trainer, realizing he or she can’t be on-site all the time, will teach athletes to take better care of themselves. “I try to set kids up on a routine and get them to carry through with it and then come back and follow up with me,” Sciera says.

At a couple of private schools that contract for minimal outreach, Redmond and colleagues schedule a Wednesday night clinic with an orthopedist. They also set up athletes with home-exercise programs.

Whetstone’s company serves a small school where many of the 75 student-athletes play multiple sports. So the athletic trainers talk to the coaches about watching for and preventing overuse injuries, stretching, the use of ice, and basic biomechanics. For example, they point out that cross country runners ought to vary their routes to avoid using the same road every day if it’s crowned in the center.

Whetstone also tries to keep sight of the bottom line: athlete health. That means not only conducting CPR and first aid clinics for coaches, but also trying to teach coaches the basics of injury assessment because the reality is athletic trainers can’t be on-site all the time.

“I don’t have a problem with coaches taping ankles even though that’s my profession,” Whetstone says. “There are a lot of schools that just can’t afford athletic trainers or that will not even consider that route, so the coaches do some of the taping. You can’t get worked up and say, ‘I’m the athletic trainer, and I have to tape the ankles.’ I don’t want to go that route. I want to make sure the kid gets taken care of. “

Juggling Details
Beyond relationship-building, outreach ATCs also face organizational and logistical challenges—from communication and documentation to having space in which to work and equipment to do it with. Each situation is unique, but here are some ideas that will apply to many.

First, set priorities. This is important for all ATCs, but particularly so for outreach athletic trainers who spend only part of their working time at a school and their time in each building is limited. Sciera, for instance, gives priority to game coverage for the highest-risk sports, such as football, ice hockey, and lacrosse, followed by non-contact but collision sports such as soccer, basketball, and gymnastics.

Individual athletic trainers also say they need to sort out what comes first and what can wait. “I will go to the school with a greater number of injuries or the school with the most severe injuries,” says Redmond. “It’s kind of like a triage thing.”

When other athletic trainers and medical professionals will be involved with athletes under your care, record keeping becomes important not just for management and billing, but for getting the job done right. Allran strongly recommends using injury-tracking software, some of which is compatible with personal digital assistants.

“Documentation is important for consistency of care, so that if you’re not the one going out there, someone else can see what’s been done in the past,” says Allran. “Software is being designed so that you can say, ‘I saw them in the clinic on this day, and this is what we did at school X.’”

For outreach athletic trainers working at multiple schools, coming up with a schedule can be a challenge. Redmond, while acknowledging it’s not possible in all cases, has found it beneficial to arrange to see student-athletes during their physical education classes. “We’re kind of lucky with our schools,” he says. “They allow their students to come see us during their PE classes. We are able to do some treatments during the school day so when we get out to our schools we’re not spending an hour treating injuries.”

Be sure to build injury checks around game coverage, Sciera adds. “Try to set up a schedule that will coincide with games that you’ll be covering as well.”

SIDEBAR: Worth The Effort

Clinical outreach has its challenges. But it can be a satisfying setting for many athletic trainers who learn how to smooth out its drawbacks and revel in its rewards. It’s the best of all worlds, says Santillo—a stimulating variety of injuries and rehabilitation, a chance to be part of a team, and professional collegiality.

“For the new athletic trainer, clinic outreach gives them what they don’t have at school, which is a great rehab background. We get to see everything, all different types of injuries, in young and old athletes, at our clinic,” she says. “We have six [athletic] trainers who work at the clinic, and we meet weekly to discuss things we’ve seen during the week as far as injuries or programs. It’s great to have our professional ideas go back and forth to each other. It’s been really great that way.”

Supplying athletic trainers through a clinical outreach arrangement traditionally has offered competitive prices for the high schools and an effective means for physical therapy clinics to gain referrals and recognition in their target communities.

Today, the clinical outreach arrangement is undergoing change due to the ubiquity of managed health care. For example, under many managed care plans, athletic trainers cannot refer a student to a clinic. Such referrals can be made only by a patient’s primary physician, and only to clinics in certain provider networks.

The inability of athletic trainers to directly refer patients to their home clinics is making the outreach arrangement less and less profitable for clinics. “In the past, the clinic would set ATCs up with a referral base and you brought people into the orthopedists,” says Jim Clover, MEd, ATC, PT, Coordinator at The SPORT Clinic in Riverside, Calif. “Now with the HMOs we have out here, unless you have a ton of kids involved, it’s questionable how much it really helps out.”

In response, many clinics are changing the way they do business with high schools. Here are some of the ways that clinics are trying to keep outreach profitable while offering sufficient care for their clients:

In Ohio, Jerry Whetstone, MEd, ATC, Coordinator of Athletic Training Services at Kettering Sports Medicine Center near Dayton, has gone to providing outreach on a paid-contract basis. “We took a firm stand that if we’re going to come to a school, we need to charge for some services,” Whetstone says. “We developed a contract in which we sit down and say, ‘OK, if you want football coverage at 10 varsity games, we know that it’s going to be X amount of hours, and our fee for services is this amount of money.’”

The SPORT Clinic, which is affiliated with a large medical practice, entered into contracts with 13 schools to provide an athletic trainer from 2 p.m. until the work is done, every day. At the same time, it provides a la carte event coverage to 40 high schools for about $25 an hour.

Not only do contracts put an end to outreach’s referral value, but, more importantly in Whetstone’s view, it puts the service on more of a professional footing.

“When you look across the country, there are a lot of clinics that just say, ‘Well, we’re going to give our services to them,’” Whetstone says. “If that’s what they want to do, that’s fine, but I personally feel that our profession will never advance as long as we continue to give services away.”

One of the biggest clinic operators, HealthSouth, is also exploring new arrangements, with both its staff athletic trainers and client schools. With the former, one approach is graduate assistantships: HealthSouth pays for graduate school classes in the morning in return for the student serving as a scholastic athletic trainer later in the day. With schools, another set-up has HealthSouth providing athletic training to a school district by paying a teacher-ATC’s athletic training stipend rather than assigning a clinic-based staff member to the schools.

“I think the model of working in the clinic 40 hours a week and then being at the high school every afternoon is somewhat fading away,” says Steven Brobst, ATC, a HealthSouth Market Coordinator. “It’s going more toward making sure that we can get somebody out there every day, trying to get them involved in the schools and communities, and being an integral part of the entire school process and the entire school community.”