Community hospitals elsewhere have been struggling in the shadow of Boston's big teaching institutions, but hospitals in the region south of Boston are not only surviving, but growing.

They are fighting to keep patients in town, and preparing for aging baby boomers, by building new facilities, adding the latest technologies, offering more complex procedures, and expanding links to doctors, programs, and services at Boston's top-tier hospitals.

''What you're seeing is the execution of some alternative strategies," said Don Thieme, executive director of the Massachusetts Council of Community Hospitals. Even though recent studies have shown that community hospitals provide similar quality of care at a lower cost to the healthcare system, ''there's no incentive not to go to Mass. General, except for maybe the commute," he said, so local hospitals are finding new ways to encourage patients to seek care from within their own communities.

''Everyone has choices, and we want them to choose us," said Alan Knight, president and CEO of Jordan Hospital in Plymouth, which recently completed the largest expansion in the hospital's history, adding 34 patient beds and a surgical suite, and doubling the size of the cancer treatment center. Around the same time, South Shore Hospital added emergency angioplasty 24 hours a day, Milton Hospital announced a new affiliation with Beth Israel Deaconess Medical Center, and Brockton Hospital brought an infectious disease expert from Tufts-New England Medical Center on board.

Not all are so robust. According to a Massachusetts Council of Community Hospitals study released this fall, community hospitals statewide are struggling as the healthcare market has shifted strongly toward Boston's big teaching hospitals. Facilities affiliated with medical schools -- such as Harvard's Massachusetts General and Brigham and Women's hospitals, Boston University's Boston Medical Center, and Tuft's NEMC -- accounted for nearly half of hospital admissions in 2003.

The growth in smaller hospitals south of Boston reflects, in part, their efforts to prepare for an aging population. The senior population is expected to balloon by 62,000 people between 2000 and 2020, according to data from the state Executive Office of Elder Affairs. People over 65 utilize hospitals at six times the rate of younger people, the council report stated.

But Thieme said the flurry of affiliations, expansions, and new services also are examples of different strategies in the attempt to lure residents to seek medical care in their neighborhoods.

It may run counter to conventional wisdom, but recent surveys document reasons for residents to choose a local hospital over a bigger urban institution. Many community hospitals provide secondary care, such as obstetrics and appendectomies, at a lower cost and at about the same quality as teaching hospitals, they found.

A report by the Pioneer Institute for Public Policy Research last year found that patients in community hospitals in six states, including Massachusetts, were less likely to suffer death, wound infection, or postsurgical urinary tract infection than at a teaching hospital, and that on average, the cost of each inpatient case was 19 percent higher at the teaching hospitals.

''Community medicine can be done in the communities," said Joseph Morrissey, CEO of Milton Hospital, which sits just 10 miles from Boston's world-class hospitals and will report a small profit this year for the first time since 1998. Milton Hospital's new affiliation with Beth Israel Deaconess Medical Center -- which will bring hand surgeons, a gynecological surgeon, and a joint prostate cancer treatment program to the neighborhood -- will help reinforce that message, he said, with the imprimatur of a Harvard teaching hospital.

Milton's new affiliation with Beth Israel Deaconess will attract ''those younger, more mobile people who work in town and are 45, 50, 60 years old," Morrissey said. ''It's easier for them to get their care close to where they live."

Farther afield, Jordan Hospital, which sits 40 miles from Boston in Plymouth, has fewer worries about losing patients to Boston hospitals, but is instead expanding to meet the needs of a growing, changing population.

The hospital serves 12 towns in a region with 15 percent population growth in each of the last three decades. On top of its recent expansion, a cardiovascular department will open next year, and the hospital is planning another major addition to expand patient beds, critical care, the emergency room, and clinical laboratories.

''We plan to again double the size of our oncology center, because as people live longer, cancer is primarily a disease of [the elderly]. . . . The older we get, the more body parts we need to have serviced," Knight said.

At South Shore Hospital in Weymouth, the ''strategy is a little different, because they have chosen to move up the 'severity curve,' " treating more complicated diseases and sicker patients, Thieme said.

Like Milton Hospital, South Shore announced an affiliation with Brigham and Women's Hospital earlier this year. But the hospital also has pursued more complicated patients and services to establish itself as a ''regional medical center," said Peg Holda, a hospital vice president.

Early next year, the hospital will participate in a clinical trial to offer voluntary angioplasty to open blood vessels of those at risk for heart attacks, and patients can participate in clinical trials of cancer treatments at the hospital instead of driving into Boston.

''There's no question that there is a perception that world-class care is available in Boston; however in expanding the . . . affiliation with the Brigham and the strong relationship we have with our colleagues at Children's [Hospital Boston], we're not competing with them, we're working collaboratively," said Holda.

Across the board, hospitals have changed services, hoping to meet changing needs of the community and keep them close to home. Brockton Hospital, a community teaching hospital, deals with a diverse patient base where ''people are homeless and we see local dignitaries, local legislators: We have this wide range of patient population, some of whom can choose to go anywhere else they want in the world and others who have no other choices," said hospital president Norman Goodman. Brockton began an affiliation this summer with Tufts-New England Medical Center, ending a 30-year partnership with Boston Medical Center. Quincy Medical Center has been affiliated with Boston Medical Center since 1999.

''This is always going on: Relationships come and go . . . sometimes [in the past] it appeared to community physicians that the interest of the teaching hospital in providing these kinds of services was to take their patients away," said Thieme. ''But now we've reached the point where all the physicians are busy . . . as the elderly population tends to use services more, there's going to be an explosive growth."

Carolyn Y. Johnson can be reached at cjohnson@globe.com.

Big vs. small

A study of hospitals in six states, including Massachusetts, compared the secondary care delivered by major teaching hospitals with that at community hospitals for patients under 65. It found:

Cost for inpatient cases at major teaching hospitals is, on average, 19 percent higher than at community hospitals.

Quality of care was similar among teaching and community hospitals. Community hospitals fared better under some measures; wound infection, death, and postsurgical urinary tract infection were all less likely at a community hospital than at a major teaching hospital.

Length of stay figures for community and teaching hospitals were nearly the same.

SOURCE: Pioneer Institute for Public Policy Research, Nov. 2004