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Mar 30, 2020

Social Distancing for Rehab Therapists

Leveraging Part-B In-Home Care and Telehealth in Your COVID-19 Response


Recorded Thursday, March 26, 2020  |  2:00PM EST


In light of the recent COVID-19 pandemic, the CDC has recommended ‘social distancing’ as a key tactic to help reduce the spread of the virus. In this webinar, our guest speakers will discuss two options to help rehab therapists continue delivering care during COVID-19.

Hilary Forman, PT, Chief Clinical Strategies Officer for HealthPro-Heritage, a leading consulting and therapy management firm, will share best practices for effectively and safely delivering care through Part-B in-home care. Additionally, consultant Rick Gawenda, PT, President of Gawenda Seminars & Consulting, will discuss telehealth legislation now in effect, which supports the practice of ‘social distancing’ while continuing to deliver necessary outpatient rehab care.

Included in the webinar are details related to:

  • COVID-19 pandemic and CDC recommendations
  • Risks associated with traditional therapy ‘clinic’ settings during COVID-19
  • Benefits and best practices associated with delivery of Part-B in-home care
  • Telehealth legislation and application for rehab therapists


The continuation of outpatient rehab care plans during this unprecedented time requires careful thought as to how we adhere to new recommendations while providing the quality of care traditionally delivered in public locations such as outpatient clinics and gyms. This webinar is designed to help you as you seek ways to adapt your care delivery in today's new environment.



Gawenda Seminars Website

Healthpro Heritage Website

Rick Gawenda Twitter

Hilary Foreman LinkedIn


For more information on Hilary:

Hilary is an experienced, sought-after health care reform expert with a dynamic approach to advising providers within the post-acute care industry. As a solutions-oriented leader and consultant, she meets the challenges of a rapidly changing health care environment with innovative clinical and financial strategies. With more than 15 years of experience in rehab management, Hilary has worked with hundreds of clients to optimize marketplace strategy, clinical program development, and compliance integrity.

Hilary has presented at several association meetings to share up-todate information and insights as well as her thought- provoking approach to meeting the challenges of health care reform initiatives.

She has established a reputation for facilitating meaningful partnerships between post-acute care (PAC) providers and upstream and downstream cohorts. Hilary’s philosophy encourages open collaboration, proactive communication, and honest dialogue regarding outcomes, safe care transitions, and financial opportunities/pitfalls.

With a keen sense of humor and a no-nonsense approach to solving problems, Hilary has the ability to assist groups in thinking strategically, challenge the status quo, and ultimately succeed in leveraging positive outcomes.


For more information on Rick:

Mr. Gawenda has presented nationally since 2004 and currently presents approximately 100 dates per year around the United States.

He has provided valuable education and consulting to hospitals, private practices, skilled nursing facilities, and rehabilitation agencies in the areas of CPT coding, ICD-10 coding, billing, documentation compliance, revenue enhancement, practice management, and denial management as they relate to outpatient therapy services.


Read the full transcript below:

Tannus Quatre (00:00:02):

Welcome everyone. My name is Tannus Quatre and today I'll be kicking us off with our webinar on social distancing for rehab therapists. Before getting into our topic I'd like to take a moment to acknowledge and appreciate each of you that are on the call today, as well as the teams that you work with to serve patients in your communities. As a physical therapist myself and as part of an organization that proudly serves rehab therapists, this is a really heart wrenching time as we watched this coronavirus pandemic unfold and impact lives across the world, including the interruption of the care that you provide to your communities. As part of our effort to help rehab professionals continue to deliver care in your communities during a time of putting my hands in quotes here, social distancing and sheltering in place, phrases that are new to us, we've assembled a team to present for you two business models today, part B in home care and e-visits.

Tannus Quatre (00:01:03):

And we hope that these will facilitate the continuation of the care that you provide while helping your patients and your staff adhere to guidelines that require that during this time we limit our physical exposure to one another. We've got an amazing speaker lineup for you today. Starting off with Rick Gawenda, physical therapist, compliance and billing expert and president of Gawenda seminars. Rick's going to help us understand some recently expanded legislation regarding telehealth and e-visits for rehab therapists. We have Hilary Foreman, physical therapist and chief clinical strategies officer with HealthPRO heritage. Hillary is going to walk us through health pros, part B in home rehab model and how this model is uniquely positioned to help protect her patients and her team during a time of social distancing. And we have Sheila Cougras, registered nurse and director of compliance at net health, who together with Sarah Irey, also a physical therapist will be setting the stage for us today by introducing us to COVID 19 and considerations that impact us as rehab professionals.

Tannus Quatre (00:02:12):

Now, today's webinar represents our best efforts to help rehab therapists adapt to a very unique circumstance. We're working right alongside you to adjust and learn as things change and I know for all of us things are changing hour by hour at this point. So in our webinar today we'll be sharing some information that is both fairly broad in nature and then we're going to be zooming in to discuss details that are really pretty technical. So we hope that the information will help you stimulate thoughts and ideas that you can use to continue care for your customers, but please do know that the information is changing rapidly and you're going to need to verify if and how this information applies to your particular business. Now finally for me on a housekeeping note, we're going to be pretty fluid with this webinar today and we're going to take the time needed to cover the information that we have planned as well as time for Q and A at the end.

Tannus Quatre (00:03:06):

If you have questions that come up during the presentation, please use the Q and A function that you'll find on your desktop or your phone and we'll get to as many of your questions as we can. At the end of the webinar, we have about a thousand attendees on the call today, so we probably won't be able to get through all questions. So we'll be providing our contact information following the webinar so you can reach out to us for followup if and where that that is needed for you and for those that cannot attend, that may be within your organization or colleagues that you'd like to have attend this webinar after the live version. We will be sharing a recording following the live presentation today, so expect that in your inbox. So with that, I'm going to hand it over to Sheila Cougrass and Sarah Irie to introduce us to COVI- 19 and clinical considerations that apply to rehab therapists.

Sheila Cougras (00:04:00):

Thank you, Tannus. As Tannus mentioned, I'm a registered nurse and a certified wound care nurse that is certified in healthcare compliance. I have been at net health for the past 12 years and serve as the compliance subject matter expert for our products. But before I even get started, I really sincerely want to thank all of you on the front lines who are caring for our patients and communities. What you're doing is really, really appreciated and very much noticed throughout the world. I'm going to also first state that we recognize that all of you are being inundated with a lot of information for COVID-19 that's coming in through, you know, firehoses a lot of information and it only seems so appropriate though that we open with a high level of information we're receiving every day from the CDC to other regulatory and professional agencies across the country. It's also important to note the information is being updated every minute. Even as we speak. I'm reading and learning that new regulations and legislation is introduced at us at a startling pace. We already have over 500 bills and 250 regulations that have been introduced and proposed across the States and the use of the executive order has skyrocketed.

Sheila Cougras (00:05:17):

So we also recognize that this information varies for all of you. Depending on where you provide services, you may be in a home health, you may be in a SNF, acute hospital, private practices, assisted living facilities and with that said you may have a lot of variations with your facility and local policies and federal guidelines. So we want to keep that in mind. As we know, corona virus has been around for a long time. It is a group of related viruses such as SARS that causes disease in humans, in animals, the world health organization, they recently identify COVID-19 is a new virus group, Corona virus which typically respiratory illnesses and most will recover as we know without special treatment. As we've heard, it mostly impacts our elderly population and those that have specific underlying conditions or immunocompromised. We are also hearing about many of the treatments that are off label that are now being made available being introduced today for treatment. But currently there is no vaccinations and treatments are just now starting to be introduced off-label. It is active in all 50 States and I guess it's also active within our surrounding four jurisdictions of our country. And the last we seen reported I know that this is obviously probably updated since, but the last reported by the CDC is 27 are reporting community spread.

Sheila Cougras (00:06:46):

We are hearing that it is also being noted by the new England journal of medicine that COVID-19 is also stable in aerosols and on surfaces that can last from several hours to several days. So we want to keep that in mind when a person sneezes or coughs without proper coverage into their elbow or their sleeve, it creates a bubble of air that contains the virus. It could be suspended for hours and so with that said, if someone walks through that area an hour later, they could potentially pick up the virus.

Sheila Cougras (00:07:23):

So this slide is not only to share with you common recommendations from CDC and the world health organization, but also think about setting up competencies for your staff and educating your patients. We obviously want to maintain that good hand hygiene as being occurring washing for at least 20 seconds with soap and water and hand sanitizer with at least 60% alcohol reasoning is because those soaps we use contains surfactins which neutralizer removes the germs from the pathogens such as COVID-19 that has a crown like structure and outer membrane made of lipid molecules and protein that is then runs down the drain. Do not touch your face. We hear that a lot with unwashed hands is specifically your eyes, your nose in your mouth where there's much entry into your system. Where if face mask, if indicated by your facility policy protocols, we know there's a lot of uncertainty in this area due to the limitation of supplies.

Sheila Cougras (00:08:21):

So please check how and when you are to utilize face mask and the type of mask you should be wearing Disinfect your common touched surface areas. Often whether it be tables or knobs, countertops, desk, phones, keyboards in any other equipment that has commonly touched you. It's also helpful if you increase ventilation by opening windows or adjusting the air conditioning and we also want you to limit food sharing, stay home if you're feeling ill or have an ill family member and most importantly is you're going to hear threaded throughout this presentation and as Tannus mentioned is social distancing maintaining a safe distance three to six feet between you and others. It's so important given how this virus is transmitted. Sarah will speak to this further but before I hand it off to her, I want to share that a I have been listening to other professional organizations speak about ideas and best practices they're sharing.

Sheila Cougras (00:09:14):

I was on a call a couple of days ago with American hospital association in CMS with Sima Burma where she was encouraging the physicians to share ideas. Some are setting up tents outside of their offices to do the screening conducted prior to allowing the patients or staff to enter the building. Some are calling the patients prior to their appointments and asking a series of questions provided by the CDC to triage those patients. And many of you are hearing utilizing telemedicine and you will hear more from our other panel speakers on that topic. Additionally, I heard that in HPCO, which is a hospice professional organization just yesterday. They're getting so creative that they're providing care through windows and standing outside of the patient's home and looking at the patient through the window and addressing the needs with the caregiver at the door. So as we know, this is the time to really get creative and treat your patients safely as much as you can.

Sarah Irey (00:10:07):

Thanks for that great information Sheila. Before we start, I'll let you know a little bit about me. I'm a clinical liaison for net health, but my background is as a physical therapist with nearly 20 years of experience working in various settings including private practice, hospital outpatient and acute care and skilled nursing facilities. I'm lucky enough to use my clinical experience here at net health, but I do some clinical work still now and then. Let's continue to build on what you learned from Sheila. An important part of social distancing includes being able to identify patients and staff who have COVID-19 or who may be a risk of carrying or contracting the disease. Many facilities are now using screening protocols, as Sheila mentioned, to identify these individuals. If you're part of a larger organization, check your organization protocols to determine the process for screening patients and staff and know how to refer them for additional testing if they're possibly infected.

Sarah Irey (00:11:12):

If you don't have a formal protocol, you might want to consider creating one using sources from the CDC website as well as checking with your state. The CDC outlined some recommendations such as using your clinical judgment. Clinicians should use their judgment to determine if a patient has signs and symptoms of COVID-19 and should be tested so the signs and symptoms that you've heard about include fever, cough, and difficulty breathing. Other risk factors are having contact with someone who has or is suspected to have COVID-19 or pneumonia of an unknown cause within the last 14 days. Someone who's recently traveled outside of the United States or in an effected area and someone who has residents in an area with community spread of COVID-19. Like Sheila mentioned, your screening can actually begin before your patients arrive at your clinic. When you're making appointment reminder calls.

Sarah Irey (00:12:09):

You might want to consider asking screening questions and making recommendations for exposure risks in mildly ill or high risk patients to stay home per social distancing guidelines. We realized that many of you may still need to see patients in a clinical setting. So let's consider some ways to keep you and your patients safe while keeping social distancing in mind no matter where you treat your patients. First, follow the screening guidelines we just discussed to decrease your risk in your clinic. You also may want to ask patients to wash their hands prior to starting the treatment session and after you could even maybe consider having them stand on one foot to practice balance while they wash if it's safe, right? Wash your hands as well. Always follow standard precautions and use PPE per your organizational protocols. Be mindful to follow the six foot social distancing guideline in the waiting area and your treatment space.

Sarah Irey (00:13:09):

So you might need to modify your waiting area seating setup or your schedulings practices to support this model. Maybe use private treatment rooms for patient visits instead of the gym area. Avoid group and concurrent therapy treatment and consider treating patients in their rooms if they reside in a skilled nursing or assisted living facility. Also think about if you can change treatment and treatment plans to decrease physical contact with your patients, but still provide quality care. Examples of this might include instruction and self mobilization techniques instead of manual adjustments or mobilization or instructing the patient in use of tools for soft tissue mobilization such as foam rollers and trigger point release balls rather than direct therapist to patient touch. Also consider keeping your patients with one provider per visit instead of sharing care to decrease contact. So you may need to change your scheduling and staffing practices there. Finally consider educating patients on alternative treatment options such as part B in home rehab and eVisits. So let's learn more about part B in home rehab with Hilary foreman from HealthPRO heritage.

Hilary Foreman (00:14:22):

Thank you so much Sarah. And as Sarah said, my name is Hilary foreman. I am the chief clinical strategy officer at HealthPRO heritage. I am a PT by background and I've been lucky enough to be with HealthPRO for about 18 years now. I'm moving from operations into our clinical role. I have the honor of being in charge of our clinical and consulting business lines over our rehab services that span across the post-acute continuum. So as Sarah said, I wanted to talk to you about our first business model, which is part B in home rehab. Though HealthPRO heritage did not start this model in light of the current COVID-19 situation, it now more than ever in this era of social distancing has become one of our standards as it makes more sense as a consideration. This model can be used by both rehab companies and home health agencies to better meet the needs of some of our seniors.

Hilary Foreman (00:15:19):

So let's start with what is part B in home rehab. Very simply, it's the concept of the traditional outpatient therapy model being provided in a patient's home as opposed to a free standing clinic or the gym of a senior living community. Services still remain covered under Medicare part B. They may also be covered by managed B or some commercial payers as well. By being able to deliver this service in a patient's home, it provides a lot less anxiety for a patient and a much happier person. Patients in this scenario are not home bound, but due to other circumstances prefer to stay in their home, whether it be convenience, safety, or cost. One caveat to this model is that because patients aren't home bound, they can also not be receiving any part a benefits as this is a part B benefits. So those two insurances do have to be separated.

Hilary Foreman (00:16:27):

So why would we do part B in the home first? As I said, it would be convenience of care. According to some recent AARP statistics, over 89% of patients over 50 years old would prefer to receive these type of services in their home for many of their own reasons, but now in the era of social distancing, this can be a more protected setting. This can also be a great solution for protecting some of our most vulnerable patients, but continue to provide those essential rehab services with reducing the risk of illness or injury to those patients.

Hilary Foreman (00:17:14):

As we continue down the path of why we would do this, one of the other has to do with a lot of the regulations going into place. Many of us are looking to expand our referral base, so whether you're a rehab company or a home health agency, chances are you're looking for different partnerships in your community. In light of changes with PDPM on the skilled side and PDGM on the home health side and changes and just the level of competition in many markets, you may be looking at different ways to partner with other people in your community. Whether you're looking to expand with physician services, many outpatients we think of as partnering with orthopedic physicians. We all know that orthopedic physicians tend to use their own clinics or hospital based rehab settings. In this model. Healthpro heritage chose to partner more with primary care physician groups in order to better expand into the community.

Hilary Foreman (00:18:17):

These primary care physician groups, we're community-based or we're already partnering with many of the senior living and assisted living communities in the areas. This paired nicely with their house calls programs, so we just like the physicians would start making house calls. It became a very good word of mouth referral source for us as well as a network between different senior living communities who wanted to partner their therapy across all their levels of care. So having therapists provide services through the home health agency as well as part B in the home. This helped the therapist become a standard part of the community, whether it be on that campus or in the greater community. Another reason you may consider why we would do part B in the home is just to reduce overhead for providers. This model reduces costs associated with brick and mortar clinics and the costs associated with keeping those running or even dedicating space within an assisted living or independent living community for patients.

Hilary Foreman (00:19:27):

This reduces a lot of their anxiety. It may also save time, money and effort for them traveling, worrying about parking and worrying about keeping all their appointments straight by having us go to them. It is a lot of their worry. And lastly, in order to follow any of the trends in healthcare, we all have to change, diversify and grow. Most importantly, meeting people where they are and where they want to be. Chances are that is going to be in their homes. We wanted to be able to offer more alternatives to where they could get the essential rehab they needed. Now again, in the era of social distancing, we were able to meet them in their homes and it was a great new business model for us as well. So killing two birds with one stone, but now as Sheila shared in the era of COVID-19 we did have to take some additional rehab considerations.

Hilary Foreman (00:20:28):

So we at HealthPRO heritage, decided to do a few things before we ever entered someone's home. First, we implemented a very strict policy of staff monitoring where staff self-monitor temperature checks twice a day, attest to whether or not they have any signs or symptoms. We even instituted a smell check. Some of the more recent literature indicated that people ahead of coming down with the symptoms of COVID-19 had actually lost their sense of smell. We also reviewed contact or exposure history, looking at what would be a low or high risk exposure and choosing whether or not therapists would see some of our most immunocompromised patients in their homes or not. We also instituted patient screening calls as Sarah suggested, making sure that we not only asked about the patients themselves, but anyone else that might be in the home at the time of the visit.

Hilary Foreman (00:21:28):

So many of our seniors have their spouses or older children home with them. They may be caregivers for grandchildren, so we did want to make sure that in addition to asking just about the patient, we knew about them as well. We did follow the CDC guidelines on what we could and couldn't ask, but it also helped us explain to our patients what infection control steps we would take prior to coming into their home. We did focus a lot on our staff and making sure that they understood what those infection control steps were. We did add additional steps in light of the current situation, especially when it came to clean bag and equipment technique. We wanted to take extra care of everything we did or did not take into a patient's house and how we were able to take care of that.

Hilary Foreman (00:22:19):

The other issue we have run into, and I'm sure many of you on the call have as well, is the availability of PPE. In cases where we do have low risk or high risk situations, patients still may have required care and we did have to make sure that people had the correct availability of PPE and understood proper use and retirement of that PPE well in the home. We did ask our therapists to continue to maintain social distancing rules from others in the house, in the apartment or in that senior living community. We did see that there was a lot of opportunity there as well. We were able to be another set of eyes for our seniors in the community or in the senior living community. Looking for other needs they may have. Being able to address things such as medication that may need to be delivered, additional signs and symptoms of other issues outside of COVID-19 that may increase a patient's risk of rehospitalization and we were able to work better with our senior living communities in that way.

Hilary Foreman (00:23:29):

So now that you know a little bit about our model and now it's time to look to see if this is the right model for you as you're possibly considering this as part of your growth and diversification strategies. There are a few things both pro and con you should consider if you are a home health agency, there are differences between billing part a and part B. You still do have a homebound requirement. You have to look at what those billing differences as well as what the different therapy documentation rules might be because this is part B and the home. It does follow traditional part B documentation and billing guidelines with all of the modifiers attached. A benefit to this is for the home health agency. Being able to provide additional rehab services after perhaps nursing services have ceased as a need, gives you the ability to divert those critical nursing visits to more high risk patients that may be elsewhere in the community. In this case, rehab would focus mostly on safety in the home and basic ADLs. If you're a rehab company, there's a little bit more to consider here. We were able to, in different parts of the country operate this model either under a group practice or a rehab agency. These both models have specific regulations by state that vary and we did need to look into all of those different rules and regulations and setting up the different practices and different locations.

Hilary Foreman (00:25:05):

The other challenge we had was looking at our therapists and their skill sets. This is a unique model because you do blend the skillsets of a home health therapist by being in the home, being more innovative and looking at what you have available to you in a home to provide therapy while mixing it with true outpatient skills. So looking at our therapists being able to work at the top of their license and looking at things from medication management all the way down to manual therapy. As Sarah shared, we did have to make some alterations in the care we've provided recently in light of some of our infection control procedures. But to our patients still receiving that essential therapy was still most beneficial in some cases in making this decision, you may have to actually look for additional consulting services in your area to help you either set up this program or work through the regulations. I hope this gave you a good overview of this possible new business model. And now to talk about our second alternative business model, I pass to our next speaker, Rick Gwenda.

Rick Gawenda (00:26:16):

Thank you very much. My name is Rick Gawenda. I am a physical therapist. My wife, I and another business partner do own two clinics here in Southern California. And then also for the past 17 years I have been a national speaker and national consultant in outpatient physical occupational speech therapy as relates to documentation, CPT coding, diagnosis, coding, payment reimbursement compliance. And all stuff nobody really likes to talk about. So with that, we're going to talk today about telehealth and e-visits. As we go to the next slide. This information I'm going to share with you is current as of 2:00 PM Eastern time today. Cause obviously I used to say things, you know, change weekly or monthly things are changing hourly. We're seeing many state governors mandate insurance plans in their state cover telehealth. We're seeing insurance companies doing this on their own saying they're adding PT OT SLP as telehealth providers. And we are waiting patiently for updates from these centers for Medicare and Medicaid services. So again, everything is current as I speak today. Most likely things would change either tomorrow or early next week. We are in the Medicare program as well as maybe other insurances in many States.

Rick Gawenda (00:27:47):

So speaking with the Medicare program first, so CMS, the centers for Medicare and Medicaid services issued a document over a week ago and they talk about three types of virtual services that you see here on this slide. And the commom mistake I'm hearing people make is they're using the terms eVisits and Telehealth interchangeably synonymously, the same as, and they're not the same. They're completely different. So again, three types of virtual services per the Medicare program right now. Medicare telehealth visits, which we're going to give you the current status of that coming up, virtual check-ins, which were not apply right now to PTs, OTs and or SLPs. And then we're going to talk about eVisits that will apply to PTs, OTs and SLPs.

Rick Gawenda (00:28:45):

So as I speak to you today, now about, I believe it's around 2:30 East coast time, March 26, the Medicare program still does not pay for tele health services for outpatient, physical, occupational and or speech therapy services. They consider this a non-covered service because the Medicare program does not pay for these services for therapy and they consider it non-covered. You right now today can provide tele health services to your Medicare part B beneficiaries and charge them your cash rate for the telehealth services. And an ABN, an advanced beneficiary notice of non-coverage would not be required to be issued to the Medicare beneficiary. You can issue a voluntary ABN to the Medicare beneficiary if you want to and I do recommend you do that but it's not mandated. You issue an ABN to the Medicare beneficiary and the reason why it's not required is an ABN is only issued when normally the services are covered by the Medicare program, but under the circumstance you think Medicare is not going to pay or since right now today, March 26 telehealth services provided by PT OT SLPs or statuary, non-covered and ABN would not be required.

Rick Gawenda (00:30:24):

Also, if you are familiar with the ABN form in section G there's three boxes and the patient's supposed to select one of those three options in section G since your issue in a voluntary ABN, you are not going to ask the patient to choose an option. The patient does not need to sign and date the ABN because you're not going to be submitting the claim to the Medicare program. So people haven't been asking me, well, Rick, what CPT codes do we bill to Medicare for telehealth? You're not going as I speak today, you will not submit a claim to Medicare if you are providing telehealth services for outpatient PT, OT SLP to a Medicare part B beneficiary because it's statutorily non-covered. And since these services are non-covered, the mandatory claim submission is not required. Now I will say there is a barrel that we expect the house to vote on tomorrow called the creating opportunities now for necessary and effective care technologies.

Rick Gawenda (00:31:32):

The acronym is connect, C O N N E C T act, the connect act and in section three seven zero three of that bill. If it gets passed by the house passed by the Senate, everything stays in president Trump signs it. It's going to broaden the authority of the secretary of health and human services to wave tele-health requirements as they currently are. So we're hoping that once the house is supposed to take a voice vote on that sometime tomorrow followed them by the Senate. My opinion only, it should pass pretty easily. Hopefully the president signs it, then hopefully then the secretary of health and human services would then waive the current restrictions house for Medicare beneficiaries and allow PTs, OTs and SLPs divide those services and build the Medicare program for that. Also, as we speak today in the office of management and budget, there is an interim final rule regarding COVID-19 and some updates in that interim.

Rick Gawenda (00:32:43):

Final rule. Unfortunately we have no clue what's in that interim final rule. It could be some things way too. What I'm still going to talk about here today about E-visits could be about tele-health, could be about easing restrictions and supervision, requirements of assistance, could talk about certifications recertifications it could have nothing about therapy and you know, we don't know again, it's still in the office of management budget to OMB. Hopefully it leaves there either later today or tomorrow and then gets published in the federal register. But that's why I add that disclaimer. We expect things to change with the Medicare program here shortly. We expect clarification to come out from CMS on some things we're talking about right now during today's presentation.

Rick Gawenda (00:33:38):

Let's talk about now e-visits. So again, e-visits and tele-health are not the same. The two are completely different things. So CMS did come out over a week ago and say that they would pay for eVisits provided by physical therapists, occupational therapists and speech language pathologists. I cannot stress enough that top bullet point, they must be initiated by the patient for each E visit, which means the patient needs to reach out to you, the provider, either via a phone call, via an email request. In this E visit. Now CMS did clarify you, the provider of therapy services can educate the beneficiary on the availability of this service. So you can send out an email to your current established patients about the option for ae-visit and all of that. So you can quote I guess like a better word, advertise this service. However the patient must initiate this visit now, but we don't know.

Rick Gawenda (00:34:42):

Here's this third bullet point says patient must be an established patient with the provider who is conducting the visit. And what we're hoping to get soon from CMS is clarification and the definition of an established patient. Because these G codes I'm going to talk about in a moment on the next slide, they actually are brand new this year just came out January 1st of 2020 and to be honest with you, they were not designed for what CMS is allowing us to use them for right now. This is not the purpose of these codes. Now these codes are kind of a, a knockoff, kind of a shoot off of the nine eight, nine seven zero CPT code nine eight nine seven one CPT code nine eight nine seven two CPT codes that are used by physicians for evaluation and management services for these visits done through an online patient portal.

Rick Gawenda (00:35:45):

Now when you look at the physicians and the definition of established patient for a position, this is somebody that has, you know, maybe seen that physician within the last three years. We don't know how CMS is using that definition of established as it pertains to PT, OT, SLP. I'll be honest, it could be established patient as in this is a patient that you were currently seeing for therapy services and now they can't come into your clinic right now you've shut down your clinic, you want to do an visit. Is that what they mean by established patient? Could established patient mean this is the patient you've seen sometime in the past three months, the past six months. Are they going to have to go back, you know, quotes three years like they do physicians. We don't know the answer right now. What we do know though is if you're going to do an evisit any Medicare beneficiary that that patient could not have been seen by you for a physical visit within the previous seven days for the same condition.

Rick Gawenda (00:36:48):

And then once you do this evisit they're not coming in to see you within seven days for that problem. Now, CMS does say that you must use an online patient portal. And I'm giving you the definition of an online patient portal by the office of the national coordinator for health information, which is a secure online website that gives patients can be it 24 hour access to personal health information from anywhere with an internet connection. And there's the URL link for you cause people, you know, if you read the CMS information that's come out, you know, you saw, CMS mentioned that they're the lax scene, they're kind of easing the HIPAA rules and regulations. You know, you saw CMS mentioned Skype and mentioned FaceTime, they mentioned Skype and FaceTimes for tele health services, not for E visits. So right now again we're trying to seek clarification from CMS and boy, can you do a phone call, can you use FaceTime, can you use Skype before we get that clarification.

Rick Gawenda (00:37:57):

I've got to, you know, talk here and say you have to use an online patient portal. And again, you can go on the worldwide web, go to any search and you want to go to, I just use Google and type in a search box, you know, types of online patient portals. You know, what is an online patient portal? You know, I know my physician, and again, I'm not endorsing this product. My physician uses the call it, it's called charm, C, H, A, R, M, all capital letters where she can send me my test results. You know, my lab results. She can give me updates on my medications. You know, I create an account, I log in, I see my test results, I see her email, I can respond to her, she gets notification and with things like that. But again, it must be initiated by the patient for each E visit.

Rick Gawenda (00:38:54):

Next slide. So here are the three G codes, G 2061 G 2062 G 2063 and I cannot stress enough those words that are underlined, assessment and management, and then shooting the tib time during the seven days. So let's talk about what are the seven days. When is day one? When is day seven so here's my example. Let’s say on Monday, March 23rd the patient reaches out to you either via a phone call or an email requests in any visit. You don't respond to them until March 25th. March 25th is going to now be day one, which means six days later that's going to end that seven day period. So, so say you know, March 23rd the patient's sent you an email requesting any visit and they had some questions for you maybe about their home exercise program or should I use ice or should I use heat or how many times do you want me to do my exercises a day?

Rick Gawenda (00:40:03):

Things like that. You respond to them on March 25th and as I say, I'm going to make math easy here today. You spend five minutes typing out the instructions, answering their questions. You send that to them on March 25th on March 27th the patient responds, requested another e-visit with additional questions on Friday, March 27th and you spend another five minutes, you know, answering their questions, whatever that may be, send it back to them on Tuesday. March 31st patient requests another E-visit with additional clarification. They want some information from you. You spent another five minutes on March 31st answering their questions via email or via that secure online patient portal. You send it back to them. That's, and that's it. There's no more other e-visits within that seven day period. So I kept math simple. So you did three separate eVisits spent five minutes each time answering their questions via email, sending it back to them.

Rick Gawenda (00:41:12):

When you add up five plus five plus five that is 15 minutes, that's going to fall between 11 to 20 minutes. So on that last day to service, during that seven day period on March 31st you're going to bill one unit of G two zero six two because the QM to time during that seven day period was 15 minutes. And the question I know you want to ask me is, Rick, can we do more than one seven day period? You know, can I bill G 2060 to say from March 25th to March 31st but that from say April 3rd to April 9th, I spend 27 minutes. Can I do G two zero six three and ms dancer, you hate for me today, we don't know. We're seeking clarification from CMS because again, these codes were not developed for this purpose. We did not know COVID 19 epedemic was coming when these codes became effective January one of 2020. So we're not sure if CMS as well as other insurance companies are going to allow us to build these G codes for more than one seven day period. Now you see it says underlying assessment and management as the go to the next slide.

Rick Gawenda (00:42:33):

People always want to know what is a qualified healthcare professional. And this definition comes straight from the American medical association. So if you have a CPT book, you know, especially or more current one, but if you have like a 2018 2019 2020 CPT books at the beginning of the CPT book, a Roman numeral number of pages explains how the book works, where the AMA provides this definition of a qualified healthcare professional. And in really the key is the words or the sentence who performs a professional service within his, her scope of practice in independently reports that professional service. Well, as a physical therapist, an occupational therapist, a speech language pathologist, you meet this definition because in a private practice you enroll with Medicare, you enroll with other insurance companies, you get an NPI number, you can report the CPT codes independently of anybody else that people was asked for.

Rick Gawenda (00:43:35):

Rick, what about a physical therapist assistant or an occupational therapy assistant? Can they report these G codes you just spoke on was to go to the next slide. You can now see the definition of a clinical staff per the American medical association. And you see in that first bullet point is a person who works under the supervision that'd be physician or other qualified healthcare professional that goes on to say, but who does not individually report that professional service. So that would include a physical therapist assistant and an occupational therapy assistant. So right now it's my interpretation. I know APTA interpretation that PT assistants, OT assistants, you know, can't provide the evisit. And also if you get a definition, if you go back to two sides from replays, you know it says assessment and management and really who's assessing the patient, who's managing and changing what's going on with the patient. And that's really within the scope of practice of the therapist, not the assistant. Now again, we're hoping to be CMS allows assistants do these G codes. We don't know waiting for clarification, but right now I don't feel comfortable saying they can do it based on the definition of a qualified healthcare professional as well as the words assessment and management. Because that is done by the therapist, not the assistant.

Rick Gawenda (00:45:09):

Now how about modifiers? Now, CMS did say if you are submitting a claim on a 1500 claim form and if your Smith claims on a 1500 claim from you are a private practice, the Medicare program did say to attach this CR modifier to the applicable G code. If you are a non private practice, you submit claims you be zero for claim form. You would not only attach the C R modifier to the G code but you also need as a condition code the R. So again that R is not a modifier that R is a condition code. Now we are hearing issues and concerns from households around the country that these G codes can't be submitted, can't be built on the UBS or four claim form. We are still waiting for clarification from CMS on this. You know, can hospitals, can facilities that submit claims any UBS four claim form? Can they bill the G codes? A part of me thinks yes, I'll be honest. Part of me thinks no because again, these G codes, a kind of a knockoff of the nine eight nine seven zero (989) 719-8972 CPT codes which are really the physician codes and typically physicians are only been at any 1500 claim form. But again, we are just waiting for clarification with CMS as well as other insurance companies. Can non private practices bill these G codes and get paid by that insurance company.

Rick Gawenda (00:46:56):

Now, documentation for an evisit extremely important that at minimum each E visit you do must have the following documentation. You must document that the patient initiated and or requested the visit. You must document the patient consented to the visit and then you must document these services, the education, the training that you provided during that e-visit. So an example I gave where you did visits one on March 25th one on March 27th one on March 31st you would have a note for each date of service that will contain at minimum these three bullet points, but the billing would not occur to a date service March 31st

Rick Gawenda (00:47:51):

Now let's talk about telehealth and tri care. You know Tri-Care, believe it or not does cover house services and they've done so since July 26 2017 and that top moral point, that sentence is right out of the tri care manual that they cover telehealth services if these services are otherwise covered. Tri care benefits, well since Tri-Care covers outpatient PT, OT, SLP services, this means that they would cover telehealth services for PT, OT and or SLP services and nicely my Tri-Care is they allow payment for telehealth provided both asynchronous and synchronous. Now non-Medicare, it's the answer you hate. You've got to go check with every insurance company. And when I say every insurance company, we estimate they're over 6,000 insurance companies in the United States. Whether they cover telehealth, it's all over the board. If they do cover tele-health, which CPT code or CPT codes they allow or want to see all over the board, which modifier or modifiers do they want and every CPT code all over the board.

Rick Gawenda (00:49:17):

You know, this is changing hourly because we're seeing many state governors issue declarations, issue orders mandating all insurance plans in their state that are overseen by their insurance commission, you know, cover tele-health. That's great. You know, we've seen some insurance companies like Michigan blue cross California blue shield of blue cross blue shield of North Carolina do this voluntarily where they now expanded telehealth for PT, OT SLP on a temporary basis. And again, the CPT codes, IMC and I'll all over the board which ones they want. Just, you know, when to kind of maybe give you some guidance here. The most common codes I'm seeing be and allowed for tele-health a PT and OT are nine seven one one zero 30 exercise nine seven one one two neuro re ed nine seven five three zero safety activities, nine seven five three five self care, home management and for speech is nine two five zero seven.

Rick Gawenda (00:50:30):

The treatment of speech, language, voice communication, Archway processing disorder. You know, don't try billing ultrasound for through telehealth. A manual therapy would also be a no through tele health cause your hands have to be on the patient. The other thing to ask when you check with these insurance companies is are they covering tele-health for only patients that were already established. You know, you've already seen them for therapy. There's already an active, you know, plan of care going on and now they can't come to your clinic. Or are they also covering tele-health for new patients as well? That's something you're going to want to check. If you're in a private practice setting they usually want to see for the place of service code for telehealth be a zero two. So again, extremely important to check with each insurance company and their coverage of telehealth services.

Rick Gawenda (00:51:34):

You know, how do you keep up to date with all this, you know, number one, stay current with your national associations. APTA. Also check your state associations website. You know, most of them now have a dedicated page for COVID-19 many of them are, you know, doing daily updates and information that they find out. You know, why not go bookmark your top four or five, six insurance companies that you deal with in your practice. You know, and again, go to Google and search box. Just type in for example, Georgia Medicaid provider page, tri West provider page, Nebraska blue cross blue shield provider page. In those last two words, stay the same provider page. That's what you want to get to on insurance company's website to provider page. And most of them now have a dedicated COVID-19 page and they've got dedicated page for, you know, quote, telemedicine, tele rehab, tele-health and those three terms don't all mean the same thing we've got. I think we're using them synonymously right now and I'm okay with that. But they are different. But get on those payers websites. If you're not on social media, get on social media, get on Twitter, get on Facebook. Many of us are putting out tons of information hourly on all of the changes.

Rick Gawenda (00:53:02):

Not to get too excited about these G codes. Just so you know, the Medicare program has about 112 different payment localities across the United States on just using each choice, Michigan. And you see the approximate payment amounts here. And before we go to get questions. And one thing I really want to say about tele-health. You know, normally if you're gonna start tele-health in your practice in your organization, it's usually about a four, five, six, seven, eight weeks start up. Yeah, I know a lot of people are trying to start tele-health in 24 hours and 48 hours. Be careful, you know, even though CMS has eased the HIPAA enforcement doesn't mean you can be careless. Just because CMS has eased HIPAA does not mean other insurance companies may not come after you. You know, you got to make sure you have your policies and procedures in place.

Rick Gawenda (00:53:52):

They're going to do telehealth, you know, have you updated your consent forms to include telehealth services, have you gotten your consent forms to your patients for them to sign, you know, how you document in the medical record and keep a track of, is the patient consenting to telehealth, have they consented to be videoed and have that recorded and saved in case they want to look back at it? You know what happens if you are doing a telehealth visit and you're doing it with Tannus and you see Tannus all of a sudden he grabs his chest, becomes short of breath, he falls off his chair, there's an emergency situation. You know, what's your policy? What's your procedure to address those kinds of things because you could have a liability. So again, you need to check with a healthcare attorney to make sure you got the proper policies and procedures in place. Because my hope is those of you that initiate tele-health, like right now when the COVID-19 pandemic is done, I'm hoping you're not done with telehealth. I hope you continue to do tele-health into 2021 2022 2023 as I think this is an important aspect of your business growth. Keep in mind, tele-health is not appropriate, not applicable for all of your patients.

Tannus Quatre (00:55:16):

Outstanding. Thank you so much Rick. Hilary, Sheila, Sarah wonderful presentation. We're going to get into some Q and a now and I will go ahead and moderate this portion of the webinar. And while we're doing this, we have our contact information up on the screen. So for those that would like to get in touch with us, if you have further questions or would like to learn more about what each of us and our organizations are doing to help rehab professionals adapt to COVID-19. We want to have this up on the screen. So with that we've got a lot of questions coming in and I know that we're right up against the hour. Like I said before, we're going to be kind of fluid with this, so if you're able to stay on, we're gonna answer as many of these as we can and then anything that we're not able to get to, we'll figure out a way to follow up with you independently afterwards. So I'm gonna start with I'm going to start with one here. For Rick, would encrypted organization based email be considered a secure patient portal for delivering he visits?

Rick Gawenda (00:56:23):

Yeah. Great question. And again, my opinion, my interpretation as it stands right now today is yes, because the email is encrypted, which usually requires a patient, you know, to create a username and a password to then access that encrypted email.

Tannus Quatre (00:56:24):

Perfect. Another one for Rick here. Are these codes billable by home health organizations or just outpatient organizations?

Rick Gawenda (00:56:54):

Well you know, when you say home health, if you're doing quote part B in the home which we believe you can bill the G codes. Again, we're just saying for clarification where if you're talking to home health under say part a under a home health agency plan of care, the G codes would not be applicable to that setting.

Tannus Quatre (00:57:19):

Excellent. Thank you. And we're going rapid fire here with Rick. I've got another one here for you. What POS code should be used for hospital-based outpatient clinics with any commercial insurers? Should it still be zero two or does it need to be different?

Rick Gawenda (00:57:33):

Yeah, great question. And again, if you are a private practice, and again some hospitals you've got offsite clinics that are set up as a private practice and you submit any 1500 claim form if you do in telehealth services, the place of service code would be a zero two. If you are a non private practice, which again could be, you know, as a hospital outpatient department, you know, hospitals can I have clinics ops site but they still fall under the hospital umbrella. You submit claims, NAU B zero four claim form in place of service codes are not used, most likely what you're going to have to use, which we didn't really talk about today. When you go to CPT codes you plugging up to put you to modify your GT or a modifier nine five on the CPT codes and that indicates that it was tele-health provided through a synchronous communication.

Rick Gawenda (00:58:32):

Now I know the follow up question is going to be which modifier do I use? It depends on the insurance company. You know, some insurance companies may tell you to use modifier nine five some may say to use GT if you're not a private practice. So again, unfortunately you just have to check with every insurance company you want to do tele-health with. And that's why I'm stressing so much to make sure you've got your policies and procedures in place and you've checked this through risk-management your attorneys to make sure you got your I's dotted, T's crossed and all of that.

Tannus Quatre (00:59:08):

Excellent. Thank you. Okay, so one here about part B in home. So Hilary if you can unmute. How is reimbursement different for part B in home versus in a free standing outpatient clinic? Right.

Hilary Foreman (00:59:21):

Great question. It is not that is why if a home health agency does choose to implement this program, they are going to have to look into a different way to do their billing. So it is still done by CPT code with modifiers just like a traditional outpatient setting.

Tannus Quatre (00:59:41):

Great. Thank you. Hillary. Another one about part B and home, how long does it take to launch part B in the home? If I only have done freestanding outpatient therapy?

Hilary Foreman (00:59:55):

It would depend on two things. One, if you were going to go a group practice or rehab agency route group practice is much quicker to get up and running, but there are some restrictions, especially depending on the state that you're in. A rehab agency is a much longer process and does require some additional filings. Some of them depending on the state you're in, you can do some retro billing in some cases. So you are able to start before everything is completed, but it's very state specific. If you, whoever asked if you want to reach out and let me know the state, I'd be happy to point you in the right direction for those answers.

Tannus Quatre (01:00:36):

Great. Thank you, Hillary. Okay. Another one here for Rick regarding eVisits. So per webinar a previous webinar or attended Medicare calls, e-visit a non face to face consultation, therefore Skype and such may not be required can be done via email or phone call. Is this accurate?

Rick Gawenda (01:00:57):

I'm sorry, what? I'm not understanding the question. Are they asking, is Skype and FaceTime allowed for a e-visit?

Tannus Quatre (01:01:03):

I'm interpreting this as is it required. So this, I'm going to go ahead and restate it. So Medicare calls e-visit and non face to face consultation, therefore Skype and such not required, can be done via email or phone call.

Rick Gawenda (01:01:21):

Well again, as I said during the presentation when CMS discussed Skype and FaceTime in that publication they released, they were using Skype and FaceTime for quote telehealth services not for an E visit. So right now an E visit needs to occur via email or a secure online patient portal. We are waiting for clarification with CMS regarding a phone call. You know what a phone constitute that cause right now as you know, a phone is not considered an online secure patient portal. So right now I can't tell you to use a phone to do an E visit. So right now I would say use encrypted email or use a secure online patient portal such as charm or you know, other online patient portals that are available to you.

Tannus Quatre (01:02:17):

All right, thank you Rick. Okay. Another one on E visits. When asking for an evisit do they have to, so the patient, does the patient have to directly address it as this or can they electronically ask a question? So for example, through a communication portal for us to then address outside of the clinic and we can count this as a patient contact.

Rick Gawenda (01:02:41):

Yeah, it's a great question because you know, again, this is like not what these codes are designed for. So obviously if a patient sends you an email asking a question I guess my recommendation if you want to play it safest, which is what I really have to do right now on this kind of call, is do you respond to the patient and say, you know, would you like me to respond to your question via an encrypted email via a secure patient portal, as an E visit? And if that patient then responds, yes, I would, you know, then I think that that's the request. And then you, I think you then save that email and then you go and address their question or questions that they had. In my opinion only is I think CMS is going to kind of be lenient on this right now.

Rick Gawenda (01:03:34):

I think other payers would be lenient on this right now, but again, you just in case something were to happen, you kind of need to cover your rear end and have that documentation there. I also think that since these codes don't really pay a whole heck of a lot of money you know, when you look at that G 20, 63, you're spending, you know, 21 or more minutes with them during a seven day period, you know, that payment's going to be somewhere between 32 to $36 depending on what state you're in, what locality you're in. So I don't see CMS really doing a bunch of audits on all of this stuff, but it's more just from a legal perspective and to protect yourself in case something happened where it happened with the patient.

Tannus Quatre (01:04:19):

Great. Thank you. So I've got one here. I'm gonna pose this to Hillary and then Sarah, you may want to chime in on this as well. Are you tracking COVID-19 related cancellations? How are you doing this in your EMR?

Hilary Foreman (01:04:36):

We are tracking missed visits in our EMR. We just haven't placed in the notes section. And we're just trying to look at it. We unfortunately are seeing quite a few many more and the home health side then on the senior living side. But I think as we go we are starting to see more and more people I want to say get more comfortable with infection control both on their side and on our side. So we expect to see that pick back up. Our customers are able to, for some of our products create custom questions or custom cancellation reasons so that they can just click that that was the reason and then they can run some cancellation reports on cancellations due to COVID-19.

Tannus Quatre (01:05:30):

Great. Related, do you know or have an estimate of how many PT clinics are still open versus temporarily closing doors due to COVID-19. Anybody want to take a stab at that?

Hilary Foreman (01:05:47):

I can speak for healthpro heritage that's very state specific. We have some States where it was ordered that they all closed, voluntarily closed due to whether or not they were treating a very immunocompromised caseload. They voluntarily chose to close for safety reasons. But I would say maybe half and half at this point for us.

Rick Gawenda (01:06:19):

And this is Rick, I think, is this an educated guess? I agree. I think it is state specific. I would also say it's probably also region specific within a state and the number of cases going on. And as I said already, the types of patients you're seeing in terms of diagnosis and also the age of the patient, their comorbidities, their risk for COVID-19. You know, obviously, did you have a patient that was now diagnosed with COVID-19 and they were already in your clinic yesterday or two days ago, three days ago. Is that going to force you then shut down and quarantine your staff? I think it's going to be a tough number to really figure out until months down the road.

Tannus Quatre (01:07:02):

Yeah. And some of the tracking that I've had some visibility into from a new claim flow perspective, I'm seeing we're seeing about 40 to 60% kind of in that range, regional specific decrease in the flow of new claims. And so you can kind of extrapolate from there in terms of what utilization is looking like in some private outpatient practices. So thank you. Okay, so this one's for Rick. When billing the G codes on a CMS 1500 form, would we bill just the CR modifier or would we bill GP CR or a PT E visit?

Rick Gawenda (01:07:45):

That is a great, great question. And you're going to love my answer. I think everybody knows my answer by now. We're seeking clarification of CMS on this and now if you are familiar with what CMS calls always therapy or sometimes therapies, CPT codes, those are the ones that always have to have the GP, the G O or the G. And modifier attach them when submitted to Medicare if done under a PT OT SLP plan of care, we're in the 2020 version of always in. Sometimes there'd be codes G 2061 G 2062 G 2063 are not listed in that file, which means right now as we talk today, they're not considered always or sometimes therapy codes, which technically means then GP, G O G N would not be required. However, we are hearing rumors from CMS that for some strange reason they're going to actually add G 2061 G 2062 G 2063 as sometimes therapy CPT codes. Then that would require GP, G N G O modifier, which then means they would actually apply to the annual therapy dollars threshold. Now that's what we're hearing rumors that they're going to do again, so we don't know right now, you know, because we're waiting for clarification. You know, obviously people like me, we've submitted all these questions to CMS trying to get clarification, but as you can imagine, they're swamped. They're trying to figure things out and we're just waiting for those answers to come out.

Tannus Quatre (01:09:28):

Thank you. Rick. got one here for Rick or perhaps Sheila. Do some of these probable changes in Medicare also apply to Medicaid?

Rick Gawenda (01:09:39):

Well it's number one. No. so you think Medicare changes is for Medicare and again, as I always say as I use the word Medicare, that is traditional Medicare doesn't include Medicare advantage. Now would that be in said by law, Medicare advantage plans at minimum have to offer and cover the same services that traditional Medicare does while since traditional Medicare is now covering. So they say those threeG codes, 2061 2062 2063. That means the Medicare advantage plan is also supposed to cover those codes as well. But this is not applied to Medicaid because Medicaid is state specific.

Tannus Quatre (01:10:27):

Great. Thank you. Okay. Hillary how many patients per day can a typical therapist see in part B in home care versus traditional settings?

Hilary Foreman (01:10:42):

Oh, it'll be significantly less. It depends on if you are doing the party in the home. On a senior living campus where the residents are much closer together or if it is in the larger community. So it is very different than a traditional clinic. It would be much more aligned to a home health type where you're counting more visits per day. So when doing modeling for that if you have access to what traditional, depending on your geography productivity expectations on the home health side, where they would be much closer to that. So it could be again, depending on your geography could be 50 to 60% of what a traditional outpatient would be. Thank you. Rick. Regarding initiation and consent by patient, does this have to be written or can it be verbal?

Rick Gawenda (01:11:41):

Well, it's going to be verbal. You almost find a recorded. So I would get it written just to cover yourself. So that again, I, you know, any time you're on this, these kinds of calls and as a consultant, you always gotta, you know, give I guess the most stringent advice or whatever. So I would say to have it written. And it could be something too that, you know, do you send them a document out and once they request a visit, do you create a document that you can send to them? Again, I'm not endorsing this product, you know, via DocuSign or some other format where this is all typed out and you had the patient, you know, electronically sign and date, you sign and date and then you say, that document is what I would do because you also gonna need to figure it out if you're going to be doing tele-health because how you get an EMU consent forms and all of that, that they're going to be consented to telehealth if they can be consented to being videoed and it'd be recorded and all of that.

Rick Gawenda (01:12:41):

So I will always say to try to have as much written down that a patient signs or they sent you an email, something like that that you can save to show just in case you got called out on it.

Tannus Quatre (01:12:55):

Great advice. Okay. What is synchronous versus asynchronous?

Rick Gawenda (01:13:03):

You know, asynchronous would be like that online patient portal. So again, I'm not endorsing the product called charm, so it's kind of a one way communication. It's kind of delayed. We're not live together. My doctor sends me an email, she maybe sends it at 11 o'clock in the morning. I comes into my email box. I may not sign into my account to eight o'clock tonight. I go lead, but she says I may or may not respond to her today. I may wait till tomorrow. Send her a question back or say thank you for sending. When should I come see you were synchronous talk communication, which is really what I think I hope you're going to be doing. If you're doing tele-health. It's live simultaneous two way audio, visual communication. So you know, think of face time. Okay. But you know, there's, and again, as I say some of these platforms and not endorsing them, like doxy, zoom. I know Google has something out there. There's a lot of platforms out there, think of FaceTime. So I can see Ben, Ben can see me. I can demonstrate exercise to Ben, I can watch, do the exercises, correct him. So it's live, simultaneous audio, visual communication.

Tannus Quatre (01:14:20):

Great. Thank you.

Rick Gawenda (01:14:21):

And again, I love Google. Just go to Google and type in asynchronous versus synchronous communication and all that will come up and you can also find different platforms you can use as well.

Tannus Quatre (01:14:35):

Okay. Awesome. okay. Hillary. I'm a physical therapist in private practice. Am I allowed to do in-home part B or is it only for a group practice and or rehab agency?

Hilary Foreman (01:14:48):

It would be for a rehab agency or a group practice. So there are ways to convert into those to be able to, there's some filings, again, depending on the state you're in that can easily allow for that. But you do have to go through some of those hoops to get there.

Tannus Quatre (01:15:07):

Okay. Thank you. Rick. Okay. So this one says just clarifying that we cannot do an evisit to qualify as a fifth or 10th visit.

Rick Gawenda (01:15:20):

Correct. So as we understand it an e-visit is not going to count as a visit towards the Medicare 10th visit progress report. So, for example, you know, you had a patient you know, come in and they had already had eight visits and then you shut the clinic down. A patient is apprehensive about coming in for an actual visit and now you do two eVisits, that's the next, you know, on March 26 and March 31st that's not visit nine and visit 10 towards a 10th visit progress report. So as we understand it today, e-visits do not count towards the 10th visit progress report. They don't count as an actual visit where a patient came in to see you.

Tannus Quatre (01:16:12):

Okay. Thank you. Okay. And I'm doing a time check here. We're going to continue for a few more minutes. We got a lot of questions coming in so we will do some followup from here. But, but I am going to kind of roll through a few final questions here. So this one can be, this may be Hillary, Sheila, Sarah. What PPE do you recommend or are you seeing in use for an asymptomatic home therapy patient?

Sheila Cougras (01:16:41):

This is Sheila. Hi. I would definitely recommend that you check with your local carrier or not your local carrier, but your local facility protocols and what supplies are available and what they have set up. It's been strongly recommended that protocols are set up at the local levels and what your state, local health departments are recommending. That would be your first place to check because I'm not sure which state you're in, but there is a website for all the States and you can check your local Health department.

Tannus Quatre (01:17:19):

Yes. absolutely. So we can work that into our followup communications. Here's another one. Can you elaborate? This is for Hillary. Can you elaborate a little more on the differences between home health provided via home health agency versus rehab company or provide a good resource, which explains the difference.

Hilary Foreman (01:17:39):

I'm sure I could actually provide we have a side by side that I could provide that you could share as part of the followups from this. A lot of it has to do with the billing process. Some of it has to do with credentialing of the therapists. For example, in a group practice, there's eight 55 B forms where therapists have their own PTN numbers. Only therapists can provide services under a rehab agency. Different States, different filings. Assistants might be able to provide those services to do the part B in the home. So there are the state specifics and then there's the therapist specifics. And then there's the billing specifics. So those are probably the three big buckets. But like I said, we have a side by side that I'll make sure that you have to send out.

Tannus Quatre (01:18:32):

Thank you. Hillary. Rick, are eVisits covered at the same 80, 20 percentage as a typical outpatient visit where the patient is responsible for a 20% co-insurance or that 20% gets sent along to their supplemental or secondary insurance.

Rick Gawenda (01:18:49):

Yes. CMS did say that the, you know, the G 2061 2062 2063 that they would count towards, you know, any deductibles, any co-insurance would apply. So again, the Medicare program and on my last slide where I gave you the pricing for Detroit, Michigan, the Medicare program with the 80% of that allowed amount and if they have a supplemental plan your that their Medigap plan, hopefully they would pick up the other 20%. They don't have a supplemental plan and then the patient would be responsible for the other 20%.

Tannus Quatre (01:19:26):

Thank you Rick. Are work comp carriers, paying for telemedicine for PT.

Rick Gawenda (01:19:34):

And my favorite answer, yes. No maybe so it depends and again, I noticed the answer people hate. Unfortunately back when I graduated PT school way back in 1991, it was pretty easy for us back then because every state just had one worker’s comp. We've had Michigan worker’s comp, Nebraska work comp California work comp, but now we have all these middlemen like align network, one call, med risk, etc. You have unfortunately have to do due diligence and check with every insurance company. And I'll be honest, you could call an insurance company and we're just going to make it Ben and you talk to Ben Monday, Tuesday, Wednesday, Thursday, Friday. And you asked them the exact same questions. I have days in a row and Ben gives you five different answers on five different days. Now that's not because he has five different personalities, more, no offense to the people on the insurance lines right now.

Rick Gawenda (01:20:27):

They have an impossible job right now there that they're not knowledgeable on COVID-19 and all of these changes that are going on and things like that. Because I'm hearing people all the time say, why called United health care? And they tell me they pay for telehealth with therapy. Where did you get the link? Did you get the citation somewhere on their website? No identity. Because if you go to the UHC website, UHC, that paid for telehealth. So again, what you're being told on the phone may or may not be correct. So again, very important to know how you're asking the question. And maybe kind of go for the answer you want to get, you know, kind of phrase the question. So the answer may be your way, but you have to answer your way. Ask them for the citation, you know, ask them on your website. Where is it, you know, can you walk me to a site? I can see it in writing cause it was not in writing. It may or may not be true what they're telling you on the telephone.

Tannus Quatre (01:21:27):

Thank you. Okay. So we're going to do three more questions and then we'll go ahead and wrap up at that point in time. So I just want to do a time check here. We're mindful of everyone's time. Hilary, how are you documenting new patient screening calls prior to initiating care?

Hilary Foreman (01:21:47):

In a variety of our systems we were able to add an additional note. In some systems we actually added the screening questions. So either we would do the screening questions and then the patient note would be together. So then once we did the visit, they would be together. And in some cases we've done the screening questions followed by a withheld or a refusal. If something in that screening then indicated that we should not be seeing the patient that day or they refuse that day or whatever those challenges might be. But we actually had added those to the system for that exact reason.

Tannus Quatre (01:22:28):

Thank you. Sarah, do you have anything to add on that? I'm not sure if there's anything that you're seeing with customers documenting screening calls.

Sarah Irey (01:22:36):

I would agree definitely with Hillary. The only thing is, you know, check with your organization.

Sheila Cougras (01:22:42):

Depending on, you know, your organization might want you to put it in your registration software if you have a hospital interface versus the actual act up documentation application. But definitely important to document those screens.

Tannus Quatre (01:22:58):

Okay. Thank you. Okay. Rick, are there any differences for critical access hospitals with telehealth? Evisits billing or reimbursement?

Rick Gawenda (01:23:10):

You know, again, with the e-visits we are waiting for clarification and CMS on, you know, can non-private practices, you know, go for the G codes, be paid for the G codes. So once we get that answer, of course that would apply, you know, whether you're a hospital or a regular hospital a while. So, you know, put a class that's health was, you are not paid under the Medicare physician fee schedule. You are paid any cost ratio basis. That's the other code unknown. And again with Keller house, do you want to check your conditions or participation with the Medicare program as a telehealth provider? Again, Medicare does not pay for telehealth, then they have to meet the two contracts with the other insurance companies that you've signed. So again, I think whether you're a critical access hospital, a regular hospital, your home health agency, do you impart, be in the home, you're a private practice. It's kind of doing your due diligence and check in with all those other insurance companies.

Tannus Quatre (01:24:09):

Okay. Thank you. So, Sheila, I'm going to direct this one to you. And this is in, and then more broadly, we're getting a lot of questions have come in about specific guidelines with regard to protecting employees and patients and use of masks and PPE. So, the one question that I think encapsulates it here, do employees have the right to refuse to treat positive COVID-19 patients if PPE is not available? We know that PPE is in short supply and not available in some areas. And so the way that I think that we should frame this up is do you have a recommendation for resources that our audience can use locally that can help guide them in the right direction for some of these broad questions about safety of caregivers and how they're treating patients in this COVID-19 period.

Sheila Cougras (01:25:04):

Yes, that's a really tough question. There are some resources like you said, that they could check with our state practice acts as well as looking at their local professional chapters and seeing if they can provide guidance there as well as their local health departments. And what are their rights? Is employees and receiving that PPE, I am hearing that quite a bit. And it's all over the news. That PPE, is it a high demand and there's shortage everywhere across the country. So that's a really hard one for me to give guidance or advice on, but there definitely are resources where you could check where are your rights in protecting yourself when you're employed. So I would start with your state practice act as well as your professional organizations and your local health departments.

Tannus Quatre (01:26:01):

Great. Thank you. Okay. So we're about to wrap it. There have been some questions coming in about access to these materials including the slide deck. Yes, we will make this all available to you. The recording. I think it's going to come out to you automatically and we will find a way to get you the slide deck as well, whether that's an included in a link in that email or some other means. So yes, we'll make sure that you've got all of the information here. I want to thank our presenters. This is just you know, we spun this up very quickly you know, over the past few days, I really appreciate you taking the time and investing in our ability to help our rehab professionals get this valuable information.

Tannus Quatre (01:26:47):

So special thank you to Rick Gawenda and Hilary Foreman. Also Sarah and Sheila for helping us put this together and to all of you that are out there on the front lines adapting your business models to continue the rehab care that is needed in your communities. We just really appreciate you. Thank you and are thinking about you constantly. We will have additional webinars that are coming out of the net health organization by you registering for this webinar. We will be able to make contact with you and let you know about those if you would like to attend more sessions and once again thank you so much for attending be safe and be well.


Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram  and facebook to stay updated on all of the latest!  Show your support for the show by leaving a rating and review on Apple Podcasts!

Mar 28, 2020

On this episode of the Healthy, Wealthy and Smart Podcast, Jenna Kantor guests hosts and interviews Clay Watson, Tyler Vander Zanden and Kelly Reed on the Private Practice Section’s Key Contacts. PPS is more effective with the support of members who are dedicated to advocating on behalf of the industry. You can get involved in the section's advocacy efforts by becoming a Key Contact, joining the key contact subcommittee, or by taking action online via the APTA Legislative Action Portal.

In this episode, we discuss:

-What are the responsibilities of the PPS’s Key Contacts?

-How a Key Contact bridges the gap between legislators and constituents

-The personal and professional benefits of being a Key Contact

-And so much more!



Tyler Vander Zanden Twitter

Private Practice Section Key Contacts


A big thank you to Net Health for sponsoring this episode! 

Check out Optima’s Top Trends For Outpatient Therapy In 2020!


For more information on Clay:

Clay Watson a Physical Therapist and owner/operator of Western Summit Rehabilitation, a consulting and therapy services staffing agency for home health. He is a  Past President of the Homecare and Hospice Association of Utah, a member of the Utah Falls Prevention Alliance and a recipient for an NIH falls prevention grant. This year I received the Excellence in Home Health Therapy Leadership Award from the Home Health Section of the APTA.

For more information on Kelly:

Kelly received her COMT (Certified Orthopedic Manual Therapist) from the North American Institute of Orthopedic Manual Therapy in 1994 and is an Orthopedic Certified Specialist (OCS). She received her Physical Therapy degree from Pacific University in 1983.

Kelly prides herself as being an excellent general orthopedic physical therapist. She specializes in lower-extremity dysfunctions, biomechanical assessments related to running/sports injuries, and assessments from minimalist training to custom-molded orthotics. She focuses on injury prevention through balancing the full body, not just the area of pain.  Additionally, she has specialized in the area of Temporomandibular dysfunction (TMD) for over 30 years.

Most recently she has been active in starting a BreathWorks program focusing on evaluation and education related to breathing physiology and its effect on overall wellness and healing. Her clinical skills continue to move in a direction that empowers clients to achieve their highest level of function in a balanced fashion.

Kelly was a 3-sport collegiate athlete and continues her love of athletics through her own personal training, running, yoga  and being a supportive presence  at her kids’ sporting events. An outdoor enthusiast, she loves trail running, hiking, gardening, camping, and keeping up with her husband Greg and their 3 active kids.

For more information on Tyler:

Dr. Tyler Vander Zanden is the former Founder and CEO of Movement Health Partners, a private practice company partnering with federal, corporate, and educational agencies to provide physical therapy services.  Tyler currently serves as a member of the Key Contact Subcommittee for the Private Practice Physical Therapy Section (PPS), where he meets with legislators to increase awareness of the key issues facing physical therapist-owned businesses and their patients.

Tyler earned his Doctorate of Physical Therapy from Marquette University along with a BS in Exercise Science.  Upon graduation, he completed a post-doctoral residency in Orthopedics from the University of Wisconsin-Madison.  Tyler is a board-certified by the American Board of Physical Therapy Specialties (ABPTS), as a clinical specialist in Geriatric Physical Therapy.

Tyler has an avid passion for high performance, technology and entrepreneurship and speaks regularly about finance and technology as it relates to the future of physical therapy.  He currently resides in Austin, TX where he serves his church and community and is launching his next start-up venture.

For more information on Jenna:

Jenna Kantor (co-founder) is a bubbly and energetic girl who was born and raised in Petaluma, California. Growing up, she trained and performed ballet throughout the United States. After earning a BA in Dance and Drama at the University of California, Irvine, she worked professionally in musical theatre for 15+ years with tours, regional theatres, & overseas ( until she found herself ready to move onto a new chapter in her life – a career in Physical Therapy. Jenna is currently in her 3rd year at Columbia University’s Physical Therapy Program. She is also a co-founder of the podcast, “Physiotherapy Performance Perspectives,” has an evidence-based monthly youtube series titled “Injury Prevention for Dancers,” is a NY SSIG Co-Founder, NYPTA Student Conclave 2017 Development Team, works with the NYPTA Greater New York Legislative Task Force and is the NYPTA Public Policy Committee Student Liaison. Jenna aspires to be a physical therapist for amateur and professional performers to help ensure long, healthy careers. To learn more, please check out her website:


Read the full transcript below:

Jenna Kantor (00:00):

Hello, this is Jenna Kanter with healthy, wealthy, and smart. I am here with three newer friends this year. We all our key contacts with the private practice section and we're coming on. Well, they're going to do more of the talking here. I'm just going to be doing the questions and if we're coming on to just say, Hey, this is a great opportunity to get involved. If you do not like the CMS cuts, this is what we do. We go and speak with the legislators to talk about that. We're getting more people to come and join us in this huge movement to fight for our profession, especially the private practices for all you people are working for private practices. This is the committee to be a part of, so please, please join the APTA, come join us and be a part of this great movement. I am here with Kelly Reed, Tyler Vander Zanden and Clay Watson. Yes, you guys. First of all, thank you so much for coming on. So I'm going to hand it to you first. Kelly, how did you first learn of being a key contact?

Kelly Reed (01:06):

Yeah, so I've been a member of PPS since I got out of PT school and I've always been involved. I've been on the board of PPS and wanting to get back into it. And so I just put my name out there, who needs help, how can I be helpful, wanted to kind of get on the government affairs committee. And instead I got asked to be on the key contact task force and it's been amazing.

Clay Watson (01:33):

I'm friends with some other physical therapists who've participated in this project and we had some interesting legislative successes in our state that helped reform some payment policy issues. And it kind of led to them asking me to help out with the congressional level.

Tyler Vander Zanden (01:53):

I actually got invited last year at the 2019 Graham sessions in Austin and I live in Austin. And that really kind of propelled me to do something, a call to action and how can I get involved personally. And so I looked at PPS to see where I could be of service and one of the openings was this key contact position.

Jenna Kantor (02:15):

I love it. And just to make sure for any students who might be listening, PPS stands for private practice section. So it is a section of the APTA. Clay, I'm going to move to you just because my eyes just happened to look up at you. So what does a key contact do?

Clay Watson (02:33):

We have been asked to develop relationships with specific legislators and every member of the private practice section and the APTA lives in a congressional district or they have a Senator and it makes sense to pair up people who have vested stake in policy to have a relationship with a representative or a Senator from their state. And this program designed to help us have longterm relationships so that when policy needs are coming up, we'll have a listening ear and there'll be able to hopefully hear the sides of our argument that are most beneficial to our profession.

Jenna Kantor:

Kelly, what is the time commitment with this?

Kelly Reed (03:14):

Yeah, minimal. We are asked, well a couple things, we have a monthly meeting and we are given contacts of which you just email the people and try and hook them up with their legislator and that might take, depending on how long your list is, you know anywhere between 15 to 45 minutes. Then we have an hour meeting and then the bigger thing is that we are provided all the information we need and when an action item comes out they send it to us and then all we have to do is basically cut and paste a letter and send it off to our legislature.


Jenna Kantor:

Yes. Would you Tyler mind differentiating between being a key contact with private practice section and also being a key contact on the committee?

Tyler Vander Zanden (04:09):

Yes. So being a key contact in general, what we're asking of those individuals that they be a private practice member and that they live in the district to what we're trying to assign them to. So we want them to have a relationship with that Congressman or Congresswoman in their specific district. So like as Kelly said and clay said, when there's an issue at hand in the profession or just to private practice in general, that congressional leader has a name and face of a person or a clinic that they can say, Oh, wow, you know, Kelly or Jenna or clay, like, you know, you're dealing with this right now and you're one of my constituents. And so we can have that relationship. And so that's what it looks like more at the key contact level. For us, like Kelly said we're on the committee side.

Tyler Vander Zanden (04:55):

We're the ones who are providing education to that specific key contact in the form of emails. We'll kind of give them block templates. So when they have to make that communication, it's not so hard. We send them and the practice or a chapter here sends us emails that they can be kind of up to speed on these legislation things. And then we recently had shot some videos in DC explaining the roles of the key contact. And so there'll be some videos that we'll have on the PPS website that they'll be able to always link back to if they need more education.

Kelly Reed (05:33):

Yeah. And I just wanted to build on those videos. They're short snippets, they won't take a lot of your time, but it gives you a lot of key information, just the nuts and bolts of what you need and you can look at them at your leisure and really helpful information.


Jenna Kantor:

Yeah. Clay, does it work? Does making a phone call if instructed to do that to sending an email or meeting with the legislator? Does that or is that a waste of people's time?

Clay Watson (05:59):

Well, it wouldn't be a waste of time or we wouldn't do it. Right. I mean one of the most interesting things when we had a legislative fly in this fall, I was with another therapist who had actually written the letter to get the wife of one of our congressmen into physical therapy school and it was her first employer. Now she's a home health physical therapist and that's what I do. I'm private practice owner, but I work in home health and when we are asking him questions specific to our industry, he understands private practice and he understands home health better than almost any Congressman out there. And so that's just a huge listening ear that we wouldn't have if we didn't have those longterm relationships.

Jenna Kantor (06:41):

I really just want to add in person is more effective than on the phone. On the phone is more effective than email. It is like any other relationship. So really the best way to make no change is to not do anything. What we're doing is the best way to make a change. It's where we have this insane power as constituents. Now for you, Kelly, what has been the biggest thing that has moved you and how the private practice section runs and works with the key contacts? Like what do you think is just so incredible that they do to make us so efficient with what we do to put our message out there to the right people?

Kelly Reed (07:27):

Yeah, I've been really impressed with the amount of information that PPS already has put together and the task force and members before us that are currently on the task force. Basically they hand you everything you need to be able to do your job to make and develop a relationship with your Congressman. It's really easy and I want to say for those who may be put off a little bit about not getting politically involved, we have to, this is our profession and when we know what we know, we know what we love and all we have to do is communicate that message. We build relationships every single day and that's exactly what this is just talking about what we love.

Jenna Kantor (08:11):

I think that's excellent. And any last words that any of you would like to say in regards to becoming a key contact for anyone who might be hesitant on jumping in?

Clay Watson (08:23):

One of the most important things I've learned is the value of the mentorship I've received from participating in this. Every time I have a question about how to approach an issue with one of our legislators, I have three or four other therapists who are also doing it that I can ask. They may know context about the legislature themselves and how to approach them on specific issues and they know the nuance of the issues in a way that helps me understand them with a lot more depth. So it's sort of like a pretty high value team to help the whole situation move forward and that's invaluable.

Jenna Kantor (08:56):

I love that. Thank you so much. And if you're wondering, I don't know what this is for me, why am I listening to this? They're just selling me, telling me to get involved. This is where the change you want to happen. I get the most interactions on my personal Facebook page when I write the word happiness because people are happy in the physical therapy world. This is what we are doing to make that huge change. I am saying this statement very strongly. I know everybody can have their own opinion. This is mine, but this is the majority of the profession in which I interact with which are non-members. This is the big culture of unhappiness and this is where we make that change. The private practice section are movers and shakers and are listening and taking such great action. These people who are here, who I'm interviewing are passionate, kind humans. We are all volunteering our time. We are all not getting paid and we're all doing it for you and we would love for you to join us because your voice is valuable.

Clay Watson (09:58):

Well, I think most of the time the people who are unsatisfied with the profession are the least engaged and sometimes they are very engaged in are not happy. But generally speaking, the more you're involved with the APTA, the more voice you have and the more ability you have to affect change. As physical therapists, our whole life is based on helping people affect change. And if you feel disempowered or however you want to describe it, the way to get that power back is to follow your own practice and dig in and take responsibility for it as much as you can. And there are many times when you're going to do it for not, that's just how life works. But the truth is trying to get better is amazingly empowering. And once in a while you get lucky and you actually do make a big change.

Tyler Vander Zanden (10:46):

Yeah. And I just wanted to say one more thing to dovetail is you're not alone. So if you're right now, if you're stuck and you're trying to figure out what to do, you have to start somewhere. And one of the beautiful things about getting on this subcommittee now less than a year is the networking and everything that the PPS and all the people that I've been able to meet not only in private practice, but then as a result of this legislative work that we've done. So something really to consider and if your slot is taken if you want to get on here and we don't have a specific slot open in your district, you can always start these efforts on your own and we would always be able to help you with that education that's still on the website there for your use.

Jenna Kantor (11:28):

I love it. Thank you. Thank you to each of you for coming on, this has meant so much to me. I know it means a lot to you as well. If any of you want to learn more, you can go to the private practice section website. It's under the advocacy tab where you'll find committees and you'll find key contacts. That's how you can get involved. Thank you for tuning in. Take care.


Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram  and facebook to stay updated on all of the latest!  Show your support for the show by leaving a rating and review on iTunes!

Mar 26, 2020

This episode of the Healthy, Wealthy and Smart Podcast features a Private Practice Section Webinar, “Telehealth NOW” to address ongoing concerns for physical therapy practices during the COVID-19 pandemic.

In this webinar, we cover:

-How to navigate telehealth terminology and different vendors

-State and federal telehealth regulations to frequently check

-How to effectively bill for telehealth services

-An example of a telehealth physical therapy visit

-And so much more!



Lynn Steffes Twitter

Mark Milligan Twitter

Ali Schoos Twitter

PPS Covid19 Resources

ZOOM Recording of Telehealth Now Presentation 

Telehealth NOW Presentation slides

PPS Promoting Telehealth to Patients

PPS Tips and Tricks to Starting Telehealth


PPS Telehealth Coverage Policies during COVID19  


For more information on Lynn:

Lynn Steffes, PT, DPT is President/Coach/Consultant of Steffes & Associates, a rehabilitation consulting service based in Wisconsin. Providing consulting services to rehab providers nation-wide working.

She has enabled providers to achieve optimum success in the delivery of high quality, cost-effective care to their patients/clients.


Coaching/consulting in:

  • Marketing, program development
  • Selection, training & support of Practice Marketing Specialists
  • Customer Service initiatives, patient alumni programs
  • Lifestyle Medicine Programs
  • Negotiating managed care contracts, payer relations


Dr. Steffes is a 1981 graduate of Northwestern University and Transitional DPT in December of 2010 Evidence in Motion's Executive Management Program.


For more information on Mark:

Dr. Mark Milligan, PT, DPT, OCS, FAAOMPT earned his DPT at the University of the Colorado. He is a full-time clinician and owner of Revolution Human Physical Therapy and Education, a concierge PT practice and micro-education company. He is adjunct faculty for 3 Doctor of Physical Therapy Programs. Mark has presented at numerous state and national conferences about telehealth, pain science, dry needling and has been published in peer reviewed journals. He is the founder and CEO of Anywhere Healthcare, a telehealth platform for all healthcare disciplines. He is an active member of the TPTA, APTA, and AAOMPT.


For more information on Ali:

Ali Schoos received her degree in physical therapy in 1982 from the University of Puget Sound. She is a co-founder of Peak Sports and Spine Physical Therapy, practicing in Bellevue, WA. 


Ali has been active in numerous roles in the Physical Therapy Association of Washington (PTWA) and APTA.  She  has chaired her state private practice Special Interest Group (SIG) and Orthopedic SIG, and  currently serves on the APTA Private Practice Board of Directors. She is also currently serving on the PPS COVID19 advisory task force. She is a past board member of the Bellevue YMCA and on the King County Regional Advisory Group for the Alzheimer's Association


Read the full transcript below:

Carrie Stankiewicz (00:00:05):

Hello everyone. Welcome and thank you for joining us for this special webinar tele-health NOW. I'm Carrie Stankiewicz with education and program manager for the private practice section. Before we get started, I'd like to review a few procedural items to submit your questions. Please enter them into the Q and a box which you can access from the zoom menu. We'll collect your questions there and the speakers will respond to them. As we go through the presentation, we expect to have a large number of questions so we need to manage them carefully in a moment. Ali Schoos will give you some parameters around entering your questions. If you have a technical question, you can type that into the Q and a box and I will respond to you in text. Please note that with the extremely high volume of companies and individuals that are now using online platforms for conferencing, there is a strain placed upon the technology and the infrastructure. Our vendors have done their best to provide a high quality experience, but neither we nor they can control internet slow downs resulting from unusually high volume. In the chat box, we posted a number of resources for you to refer to. Please feel free to copy these links and save them for future reference. This webinar is being recorded and will be posted on the PPS website for everyone to view. And with that I'll turn this over to PPS board member Ali Schoos to get us started.

Ali Schoos (00:01:26):

Thanks Carrie. Hi everybody. I’m Ali. I am a private practice physical therapist from Bellevue, Washington. And thank you for that musical introduction. I am the cofounder of Peak Sport and spine physical therapy in the Pacific Northwest. And I do have the honor to serve you on the board of PPS. I'm also on the advisory task force around all things COVID-19 and this webinar is a result of that task force. Our goal is to bring you business owners relevant information right now to help you manage your practice through this crisis and come out whole on the other end. But the end a couple things about our question process. There are 500 of you on this webinar. So we do expect to have probably more questions that we can answer. So we would ask that when you post a question look and see if anyone else has posted a similar question so that we don't get bombarded with the same saying.

Ali Schoos (00:02:28):

Don't ask state specific questions that's relevant to the laws in your state and mandates in your state. So we're not going to be able to answer a state specific questions, although we will keep a copy of all the questions that come in and try to deal with them later. We will stop intermittently to answer as many questions as we can and I'm going to apologize in advance. I don't think we're going to be able to answer every single thing that you asked, but we'll do our best. I would like to introduce our main presenters. Dr. Lynn Steffes is a graduate of Northwestern university and earned her transitional DPT in 2010 from evidence in motion's executive management program. Lynn is the president, coach and consultant with Steffes and associates. It's a rehabilitation consulting service based in Wisconsin. Lynn provides consulting services to rehab providers among a wide range of services including marketing and program development selection and training and support of practice management specialists lifestyle medicine programs, negotiating contracts.

Ali Schoos (00:03:34):

And Lynn's also been a frequent provider of content, the educational webinars that KPS puts out. Our second presenter is Dr Mark Milligan who earned his DPT from the university of Colorado. Mark is a full time clinician and owner of revolution human physical therapy and education, a concierge, PT practice and micro education company. That was a new term for me, Mark as an adjunct faculty for three PT programs. He has presented at numerous state and national conferences on tele-health, pain science and dry needling. And he's also been published by peer review journals. Mark is the founder and CEO of anywhere healthcare, a TeleForm platform for all health care disciplines. And with that, I would like to let Lynn take it away.

Lynn Steffes (00:04:32):

Okay. So welcome to this webinar. And before I get started, the first thing I wanted to say to all of you is really we're here honoring you for the good work that you're trying to do in serving consumers in your marketplaces. So we know that all of you are incredibly dedicated, compassionate, amazing clinicians and business owners that are looking at this COVID crisis today. And then also looking forward and seeing how can we best serve our patients. And, many of you may be continuing to serve some people in your clinics or you may not be, but we certainly wanted to talk about this really important option. And to give you a little bit of background on some details with it. So with that, I'll jump into more of the content information. So the objectives that I'm in a primarily deal with are just looking at the position, talking a little bit about the statutes and rules that will govern your ability to deliver and access these services. And also some information about payment policy, whether it's federal, state, commercial, work comp. And then I'm going to turn it over to the real expert who is Mark Milligan. And so I kind of get stuck with the fun stuff, the payment and policy things. So next slide.

Lynn Steffes (00:05:58):

So APTA has long had a position that tele-health is an appropriate model of service delivery and as long as it's delivered with the same essence really that we deliver care. And so this isn't new to APTA to be looking at telehealth as a way of delivering care. At a state level. Different States have different rules or excuse me, statutes and rules that govern your ability to deliver telehealth care. So rather than us focusing on any one state today, what I'm recommending to you is that you reach out to your state level associations. APTA has a site that looks at state statutes and rules and determine what your current level of coverage is regarding tele-health. So there are two different aspects of telehealth that you would need to look at that are legal at a state level, which is obviously governs what you can do within your scope of practice. And the one is your statutes and rules that govern your scope. And the second one really is, are there specific tele-health laws in your state that would in any way limit you from delivering those services?

Lynn Steffes (00:07:17):

Keep in mind that if you've looked before or downloaded those policies before they may have been updated or there may be some emergency provisions in place. So I encourage you to begin there. So that’s an important first step. Certainly anytime you deliver outside your scope of services, your malpractice insurance is no longer required to cover you. So it's important to do. So one of the things that we want you to think about is as your considering telehealth we want you to first check your state practice act to verify just as I had mentioned, and then also find out if there are emergency provisions. It's possible that your state practice act is silent on tele-health and as long as there isn't a prohibition that I would turn to your chapter for guidance and they're examining boards need look further, you certainly are going to document legal and ethical reasons.

Lynn Steffes (00:08:14):

You're converting patients to telehealth visit, so if you've never done tele-health before or eVisits and you're going to start doing so, I think it would be important for your practice setting to document that transition and the decisions that were involved. You're going to also have to make sure that you are securing consent for each of your patients along with the right to refuse. I've been most of you know that your individual States have consent laws that govern what type of consent you have to get and it'll be important for you to get consent for telehealth or evisits and the format from your patients. Most of the time it will be fine to secure that consent verbally and to document when you received it carefully in the medical record. It's also a good idea to look at what types of emergency policy procedures you might need to put in place.

Lynn Steffes (00:09:10):

For example, if you were to be teaching a patient exercises and they're working on them in their home through a telehealth visit and they fell, what would you do to address the emergency? Are there other folks that their family members, caregivers there and then how that might be handled. And that's something you may even want to look at with your legal team. Keep in mind also if you're going to start using telehealth, that a secured portal is ideal and if you have a secure portal or something that is designed to share information over the internet or phone, you're going to need a business associate agreement in place that ensures HIPAA compliance. I think Mark's gonna deal a little bit later with some of the other HIPAA things that give us a little bit of wiggle room right now and then finally make sure and review your malpractice insurance policy to make sure you're covered.

Lynn Steffes (00:10:03):

I know HPSO provided guidance that we have a link on. And I also know PT1 PGM provided guidance on that saying you're covered. So, real quickly, I want to just start off by saying there are different types of visits. I think when this was first announced that Hey, Medicare is gonna cover a PT as a tele-health service. Everyone got very excited and what they didn't realize is that Medicare actually is not covering telehealth. Instead, we're going to talk about the distinction between the eVisits and then telehealth. We also have third party payers, commercial payers that are covering assessment and management visits and not tele-health, and then the actual telehealth visits. So we're going to kind of explore those three areas, but we want you to really listen for which area might fit your practice in your regulatory environment.

Lynn Steffes (00:11:03):

So true tele-health. Let's start with the good news. If we could do true telehealth and we can often, we're going to bill our 9700 codes. We're going to continue to apply the GPP PT modifier, but we're going to also use the OTU place of service code, which is going to communicate that we're doing tele-health. Now, some payers may actually be looking for either a different modifier or an additional modifier. So we're going to talk a little bit later about how you get that information from your payers, but it certainly is important.

Lynn Steffes (00:11:47):

I wanted to start off by saying that a lot of codes are out which are often used in telemedicine, which is physician covered telehealth 99421, 22 and 23. These are actually evaluation and management or ENM codes and those codes are really reserved for physicians or other qualified non physician providers such as PAs or NPs in general. These codes exclude therapist's ability to bill. However, we have been hearing occasionally that there are third party payers that want us to use that code. So I'm just going to say if someone suggests that you use those codes to bill those services, make sure that they provide a URL or a link for you so that you can see the policy that ensures that you will be covered for those codes. Because those are traditionally not therapy codes. Payment from Medicare. So we were super excited and we heard tele-health is covered. And really that was a misconception at the beginning. Medicare doesn't consider physical therapists as an approved telehealth provider. The list is in the bullet below. But Medicare advantage plans can actually make their own decisions and may choose to cover tele-health itself. A lot of times policies are carrier specific.

Lynn Steffes (00:13:20):

This slide is really pretty important and it's just to give you the sense that take a look at the date of this press release, CMS finalizes policies to bring innovative tele-health benefit to Medicare advantage. That was April of 2019, which seems like a hundred years ago right now. A very different time. And so Medicare advantage plans definitely had plans to expand telehealth services, but those plans also did not include PT, OT and speech. So this is not a new idea or a new fight that we're trying to leverage. However we may be in a unique position and I'm kind of a silver lining person and I'm hoping that this opportunity might actually give us a window to get in next. Your Medicaid programs. As you know, Medicare is more federal and Medicaid is state driven. So some Medicaid programs have tele-health policies.

Lynn Steffes (00:14:24):

The telehealth reimbursement policies vary state to state. Those are very fluid. We just have had multiple updates being published in the last three days in Wisconsin. So I know for a fact that you're going to have to kind of stay on top of that to determine if you're trying to serve the Medicaid beneficiaries in your state. How that policy might change in response to the COVID crisis. So keep looking and you're going to have to, this is a moving target. So keep in touch, keep going. So what type of virtual visit again and we talked about there's an evisit, there's assessment and management or tele-health. Let's look at what the actual definition for an evisit is in the 2020 physician fee schedule. Final rule, CMS described eVisits as non face to face, patient initiated. So I want you to really pay attention.

Lynn Steffes (00:15:21):

This has to be initiated. So the contact has to be initiated by the patient. Digital communications that require a clinical decision. So again, clinical decision, that's really important. So you are going to have to document that clinical decision making was made during the contact of a visit that might otherwise typically been provided in your office. So this is the definition of an e-visit and the code descriptors that Medicare is using. Our hick picks codes are related to the eVisits and they're really designed as a short term, kind of like a, I always think of it as like a bridge loan when you're building. They're designed to cover short term up to seven days of assessments and management activities that are conducted online or through a digital platform. And then again include clinical decision making. So what's an online patient portal? HHS has described a patient portal as a secure online website that gives patients convenient 24 hour access to personal health information.

Lynn Steffes (00:16:29):

Patient portal requires a secure username and a password in the absence of broadband access online accounts or smart phones or other means. CMS has indicated they want the service to the furnace, so they're giving us more flexibility. Mark's going to talk more about the technology a little later, but I just wanted you to know the Evisit has, you know, variety of opportunities including something like doing FaceTime with your patients. Go ahead. The billing and coding is what I think you're all waiting for. So physical therapists are eligible to use the Hicks picks codes and these codes require a CR modifier and the CR modifier really indicates that they're related to the COVID crisis. So we have G two Oh six one six two and six, three again, the definitions qualified, non physician healthcare, professional online assessment management. It has to be for an established patient.

Lynn Steffes (00:17:27):

And lots of questions come up. What is an established patient? It is a patient who you're currently seeing under a plan of care. And so what would happen is if you were seeing the patient, you'd have the next seven days to provide some type of E interaction with that patient that provided clinical decision making in input with them. That would be much like what you do in the office. And so the different code levels are really time-related. So imagine that you saw someone today's Wednesday. So imagine that you saw them in person on Monday. There would be a seven day consecutive day window at which time you could have one contact with them or you could have a couple contacts. Each time you had a contact you would have to document the contact information. But really when you actually go to bill the code, it would be a summary of the seven days and the documentation at that point in time would summarize what type of clinical decision making assessment and management occurred over those contacts. As you can see nobody's retiring with this funding. We've got the five to 10 minutes at 1227, 11 to 20 2165 and 21 or more minutes at 33 92 so pretty limited. The place of service is the location of the billing practitioner, which Medicare is suggesting that we would do places service 11 and you can deliver these services via the phone.

Lynn Steffes (00:19:10):

Assessment and management are comparable codes. Non hick picks but they're CPT. So nine, eight, nine, six, six, six, seven and six, eight and those are actually used for telephone assessment and management services, again by a non qualified physician health care professional to once again an established client. But this one further expands and says a parent or guardian. So these are again established patients and they have to be initiated by the patient. That doesn't mean that you can't contact the patient and offer them this service. It doesn't mean that you can't help them set up et cetera. It just means that the call itself that you're doing, the assessment and management code has to be initiated by the patient. The assessment and management codes have a little bit more parameters put around them. And one is that the call can't or it can't originate from the provider and it can't be within the previous seven days.

Lynn Steffes (00:20:13):

So the case I gave earlier for the visits, it would have to be seven days prior. And then it would be the assessment and management calls and then you couldn't see them again within the next 24 hours. So there are these windows of time, seven days prior you couldn't have had a physical one-on-one visit with them and 24 hours after. So as of right now, if you're going to be doing these assessment and management codes they would have those limitations. These are codes by the way that I'm starting to see emerging from some of the commercial pairs as covered in lieu of the hick picks codes.

Lynn Steffes (00:20:59):

These again are telephone discussion times thereby to 10 minutes, 11 to 20 and 21 to 30. And of course, because these are other payer codes, you'd have to look to the payer for coverage of the codes and payment. So true tele-health, we're back to that. There really isn't a specific CPT code for true tele-health. You would be using the therapy codes, the 9700 series paired with the OTU place of service code, which would indicate that it was provided remotely. Because if you're going to be providing these CPT codes, face these what are called face to face codes, which I would argue if you're doing telemedicine or telehealth, excuse me, they're face to face, you're going to have to verify that the payer allows you to use these codes when they're tele-health. So you can't just build these codes leading the pair to believe that they were provided in our office X. I wanted to say payer policy is fluid and that is followed by multiple exclamation points.

Lynn Steffes (00:22:07):

This is changing so fast. I literally just got off the phone before I stepped on this call saying we've got legislation coming in our state that's going to do some mandates. So you may have to check regularly. For example, in the state of Wisconsin, our governor just issued a stay at home order. So peers are going to have to reevaluate their policies if they want to continue to have their enrollees get services. So when you are, whether you hear from one another provider or whoever that someone covers telehealth or someone covers assessment and management or EAD visits, I would suggest that each time you call, you verify benefits and you're going to ask several questions, are you or the physical therapist eligible for telehealth payment? If so, which CPT codes would be completed via telehealth, so which CPT codes will be approved and then what modifiers are required.

Lynn Steffes (00:23:07):

So the modifier GT or 95 is often used in facility billing and the place of service OTU in independent practice billing. And then you're going to want to also find out what their payment rate is. So if they allow you to build nine seven one one zero will there be parity in what they pay you or equivalency and what they pay you based on telehealth versus in office. Are there any restrictions on the location of the PT or the patient? Because of course, right now if your PTs are practicing from home, that would have to be okay or your patient may actually live in a CBRF or other facility. Then what devices or applications do they have any restrictions on that and what if any consents are required and then any special documentation requirements. So those are some of the good questions to ask.

Lynn Steffes (00:24:00):

The other thing I will say is regardless of what they tell you, if you can get a link to their peer policy or anything in writing from them, I would highly recommend that you do that. And then don't assume that what is not covered today will not be covered tomorrow. And what someone tells you is covered may not be covered. I've already had providers that said, they called and asked about telehealth. They said it was covered and when they called back in a second patient, they said, well that's not what we meant. So be careful. And finally both Mark and I have been using this a lot. The center for connected health policy has a ton of great resources, but one of the best that I think you're going to want to download that will give you far more details than I'm able to give you in this brief discussion is their billing fact sheet. So the link to the billing fact sheet is here and I wish you the best. I think we can provide amazing services in person and also via these wonderful technologies. So thank you.

Ali Schoos (00:25:10):

Thanks Lynn. So a number of questions, they've come in and I answered a few of them. So if those of you who received the answer, if that wasn't enough clarity, ask it again. But then I'm just going to let you know what some of the questions are more clever. We can answer them. One, yes, you'll have access to the presentation after it's over. This is being recorded and it will be posted on the website, the next question, will we have access? Why need an option to refuse consent? Wouldn't the person just declined to sign consent? It said in the consent form that we have to give them the option to refuse.

Lynn Steffes (00:25:49):

Well, part of the option to review is, and that's a really good question, is if someone gives consent once, they still have an opportunity to withdraw consent or refuse it in the future. So someone tells you, you know, I'm happy to do telehealth or I'm happy to do evisits and they give you consent and the next time that you're in contact with them, they call and they say, I don't want this anymore. They always have that opportunity to review. So that's typically what that's for. I will say that each state practice act and sometimes an overriding practice act over healthcare professionals tell you what's required for consent.

Ali Schoos (00:26:28):

And then another person asked about the secure patient portal being ideal, but it didn't CMS make a, the HIPAA compliance issue more lax and the pre-cancers yes.

Ali Schoos (00:26:43):

Mark, he's got that later in the presentation. Can you build the e-visit code every seven days or just once and done?

Lynn Steffes (00:27:01):

As far as we don't, I don't know. We've been asking that question if it can be billed repeatedly. We've heard yes. And we've heard no. So I'm not sure. I don't know Ali or Mark, if you know anything more.

Ali Schoos (00:27:14):

It's the same thing. And I apologize, we cannot get a straight answer on that. I think some people are saying, I'm just going to do it more than once and see what happens. Again, it's not a big charge. You're not going to get rich or go broke. So if you want to try it, the worst that'll happen is that a bit tonight.

Lynn Steffes (00:27:30):

Right. And we haven't had to seven day periods to try it yet. They've been released. So it hasn't even been an opportunity.

Ali Schoos (00:27:36):

Right, right. And then does the evisit have to occur within seven days of the last in-person visit or could it be 10 days or 14 days after the last in-person visit?

Lynn Steffes (00:27:53):

I don't think there's a restriction that says it has to be within seven days. I just think it can't be sooner than seven days.

Ali Schoos (00:28:00):

Yeah, I understand. Okay. and then someone wanted an example on it, an example regarding the verbage to justify the clinical decision making to use an evisit

Lynn Steffes (00:28:16):

For an individual patient or the practice.

Ali Schoos (00:28:18):

So when you're documenting, you know, political decision making. Yeah.

Lynn Steffes (00:28:23):

Okay. So you could document that either the facility or the patient or the clinician made a decision that it was safer to do an evisit versus the in person visit. And that there was a good, a good reason to do that in your clinical decision making would reflect that you advise the patient or gave the patient it's specific instruction. The patient asks you questions, you update an exercise program, you perhaps revisited how they're doing on something and gave them feedback. So again, it's kind of like you're documenting a regular visit but the clinical, so I would decide that you did the visit you know, virtually for a fairly simple, straightforward reason that that was what was appropriate at the time due to the crisis or for the patient. Now, Mark, you may address this later when you're talking about tele-health on an ongoing basis because there's lots of good reasons to do it. But right now I think we're talking COVID.

Ali Schoos (00:29:29):

Right? And then Mark you want to address now or later what you might be documenting when COVID is over.

Lynn Steffes (00:29:38):


Mark Milligan (00:29:42):

So this is a new space to navigate. And so when this crisis is over, I think that this will be a normal part of a plan of care. Right? So it will be an expected plan of care that you will put forth in a patient that they will have a combination of both digital and in person visits. If you line it out from the beginning and set it up that way, then there no deviation or there a deviation from your initial plan of care. That's how I would handle it.

Ali Schoos (00:30:10):

And then one person did ask if you have, if the patient, if you do a second seven day visit, yes. The patient would have to initiate that phone call the second time as well or that contact the second time as well. Yeah. Can you see a Medicare patient per tele-health per cache? Some many visits are covered and I did answer earlier. Yes. You can see Medicare patients for past, since telehealth is not actually covered.

Lynn Steffes (00:30:39):

Absolutely. Any patient where it's not a covered service unless you have, for example, say you had a contract with a certain commercial payer that had a prohibition to doing any services, which rarely do they for a non-covered service. You would inform the patient that this is not a covered service and you could go ahead and bill cash for it. For your Medicare patients. And ABN is not required, it's optional, but some folks will use the optional ABN kind of as a backup to ensure that they feel that their Medicare patients were well informed that this was not a covered service.

Ali Schoos (00:31:17):

That's a great question. Wanting to know if your PTA can provide the telehealth service if the supervising PT is not online with them because it's virtual

Lynn Steffes (00:31:30):

Currently for Medicare. The answer I believe is no, but I don't know with other payers. And that would be a question. If you were anticipating a PTA providing the services telehealth services that you would ask. I would think that the visits because they involve clinical decision making and the assessment and management would likely not be covered. But I can't, I think telehealth would be flexible. What do you think Mark?

Mark Milligan (00:31:59):

Right, so Texas just, I think we also have to default to the rules and regs of the state level as well. Texas just eliminated the verbiage that eliminate, that took PTs away from delivering tele-health. So state rags may have a prohibition written that physical therapist assistants can't provide that care. I need, I'll pull up the Texas specific language that I believe there's a caveat that says that it cannot be used for supervision, but no one has defined whether or not a PTA can perform it being unsupervised. Does that make sense? PTs are not physically being supervised in all scopes practice, right? Like in home health settings. PTs are not digitally covered or supervised by or physically supervised by PT immediately. It's by phone contact. Right.

Ali Schoos (00:32:48):

Well I get in state law. Yeah. And obviously in a private practice for Medicare there has to be onsite supervision.

Mark Milligan (00:32:58):

Right. So state law and then I'll, yes, I can check with the Texas regs too, but it's a state regulated issue.

Ali Schoos (00:33:06):

Yeah. Very good question. And there they are pouring in now guys. So lots and lots of questions here. I'm trying to go through them. Should we keep going and let Mark deliver and then we'll go back and ask more answers. And some of these make an answer with Mark's presentations. We'll come back to these. Yup.

Mark Milligan (00:33:23):

All right. So thank you for allowing me to be here and being with you guys in this presentation. Lynn, I know that you said earlier that that's not the exciting stuff, but that's what everybody wants to hear. So regardless if it's exciting, it's definitely information that is necessary for all of us to continue to keep our doors open and see patients. Right? So again, I'm Mark Milligan, I'm out of Austin, Texas and we're going to cover, basically we're going to cover just what tele-health is. We're going to get some baseline terminology, technology who players in the game evidence and then kind of how to implement it in a practice. Then is going to actually talk to us how to implement it into practice, right. Ali is has implemented this into her clinic. She's delivered care.

Mark Milligan (00:34:09):

She's also as a clinic owner has implemented as a clinic owner. So she's going to give us the nitty gritty on how this actually looks for a private practice owner. So we're going to start with basic terminology because again, terms, words have meaning and terminology can be misleading. And there's been a lot of misleading terminology that's been spread around the physical therapy world since tele-health and eVisits have all been introduced. So tele-health really is just a very large, broad term that describes any type of health, education or delivery of care using telecommunications technologies. And as you'll see that it applies to almost every profession other than medicine. Telemedicine is specifically owned and basically utilized only and exclusively with physician deliver care and their extended providers. Right. So I think one of the bigger issues that came across our country earlier or late last week was when tell them when I think the president said that telemedicine is going to be available for everybody and that you know, that there's these broad sweeping terms where it doesn't really change if you hear the term telemedicine, it doesn't shift anything for physical therapists necessarily.

Mark Milligan (00:35:21):

So you have to do your due diligence when it comes to looking at the information about telemedicine and who that applies to. Right? And so also when you look at your insurance policies and, and other types of documents, make sure that you're referring to telehealth or telerehab for physical therapy services. If you ask about telemedicine benefits, you will not be considered a provider for telemedicine. So make sure that you make those two distinctions. So tele-health again is we help manage our patients through their own their own illnesses to improve self care and access to education support systems and treatment. Telerehab is more of our specific a tele term, if you will. So really it's about delivery of rehabilitation service over a communication that works and the internet. So you can do assessment and functional abilities in their environment and clinical therapy.

Mark Milligan (00:36:12):

So when you're looking at benefits, you can also check to see if they have tele rehab benefits. Telerehab benefits also shows up more in clinical research, right? If you do research and look into the efficacy and effectiveness of digitally delivered care, tele rehab will be a much more used, utilized term than tele-health for physical therapy specific. Tele-Health again really accomplishes and encompasses all types of providers, dentists, counseling disaster management, consumer and professional education. So really tele-health is one of those terms that is not a very good descriptor of exactly what we do. But during these times, it's the most accepted term of what we do. So out of the all those things, just make sure that telemedicine, you understand that does not apply to us as physical therapists. And to make sure that if you hear something about telemedicine that you clarify that or that you clarify that those rules apply or may or may not apply to us.

Mark Milligan (00:37:13):

Some other terms that are coming up across the country are models of telehealth, right? So some terms of delivery so right now currently, what you're watching and how we're interacting would be a live video or synchronous technology. So this is a live two way interaction between the person and the patient and the caregiver or the patient, a caregiver or provider using the auto visual [inaudible] communications technology. So this can be used for both diagnostic and treatment services. And it's just like anything you've done on a video call with your family. So as long as you're live face to face talking to the patient, you're good. Second term is asynchronous. You'll hear this term floated around a circle. The asynchronous modes of communication are basically or otherwise known as store and forward. This is non live communication, right? So this could be emails of HEPs.

Mark Milligan (00:38:05):

This could be a recorded video of exercises that you send the patient. This could be a recorded exercise where the patient demonstrates their exercises and sends it to you. It could be lab results, it could be any type of electronic communication that happens on non-life, a synchronous video. So that's the important differentiator in those two modes of delivering telehealth. So those in some States, these get specific, I in Texas, I'll just give Texas, I'm here in Austin and Texas, you can't initiate tele-health via asynchronous mode of delivery. You have to have a live synchronous session before you can actually utilize asynchronous care. So depending on the state that you're in, that may impact the mode and model of how you deliver telehealth. So please be mindful of these types of definitions.

Mark Milligan (00:38:59):

Also there's remote patient monitoring is another term that's used. This is really about data health data that's collected from an individual at one location and delivered electronically to another. So when this comes to a lot of patients that have chronic diseases that they need to be monitored or something needs to be checked on them regularly, like wait for patients that have CHF they have a digital scale, they can weigh themselves daily and then that data is uploaded into the physicians portal or cloud and then they're monitored on a daily basis remotely for any progression of weight gain. That could be a contraindication or a need to necessitate a medicine change due to CHF. Typically right now, not a lot of physical therapists are in this space. They may be monitoring some of those patients, but they're not too many PTs are actually delivering this model of care.

Mark Milligan (00:39:50):

Typically this is a physician or hospital base. And then mobile health really depends on or is determined by apps and different mobile devices and things that appear that can be very portable, including tele-health. So I would, I would umbrella tele rehab and M health together because you can deliver it via a PDA, cell phone or tablet. Right. So this is more just to the, the more mobile you are as a provider, you can do telehealth with someone on the beach. And depending on your place of service code, you could deliver telehealth while you're on the beach. So just think about that as, as we talk about more app based functions of some platforms that could be applicable to that. So some of the technology that's really out there that we'll pretend I'll briefly brushed these just so you're aware of them, but know that right now in this time of the COVID 19 crisis, some of these may not be the best thing to implement into your practice right now, but know that the virtual reality and tele rehab is an extremely that's a very quickly developing technology where patients put on goggles and they can meet and go into augmented reality and meet their therapist in different spaces to perform exercises or to see exercises demonstrated.

Mark Milligan (00:41:03):

So it's a really cool technology. There's motion technology where patients can see themselves on the computer. And so they were they were able to look through and see themselves moving or get the movement collected from their body and pushed into a system. So sensors and body body monitoring have been they're an interesting technology where you can actually wear a piece of clothing or have a different sensor that will sense your body positioning and space and alert you and change your posture. Haptic technology as really interesting to me. It's cloth and clothing that you can actually generate sensations through distantly. So I could, a patient could have on a haptic cloth and then I can manipulate something a hundred miles away and they could feel the sensation on their skin. So I know if anybody has a new car and they're, and they've, you know, kind of diverted out of their lane and their seat has vibrated on there.

Mark Milligan (00:42:00):

But think about that as haptic technology and how that can be utilized in physical therapy for tactile queuing and for input AI, artificial intelligence that will come into play when we look at a larger type of systems and startup companies that are leveraging AI in order to deliver a digital physical therapy PDAs, electronical medical records, wireless technology, mobile apps are all just different ways that people can connect and also get data and information that can be a really important for medical monitoring. Right? So I think we all notice the explosion with the Apple watch that started to take a heart rate and other sensors and other vitals. And so that would be an idea of wireless technology and then that would also tap into the Apple medical records. So it all kind of is encompassed and in those, in that realm as well.

Mark Milligan (00:42:55):

So just terms that you should be aware of, not necessarily in the immediacy for the deployment of telehealth into your practice, but just to be aware of. So for your business really to get down and dirty and tele-health, typically it takes some time to implement telehealth into a practice. So do due diligence. You need to come up with your business plan, your patient demographics, right? Some people will not want to tele-health or they wouldn't choose telehealth at a given rate. But now with the current situation, many people are seeing this as a really viable option to dilute, to get care delivered to them. But you also have to make sure and take into consideration general cultural and generational issues. And also there's a tremendous bias amongst the long low income patients because they don't have access to high broadband wifi or they may not have a tablet to get care or they may not have access to a safe space to exercise.

Mark Milligan (00:43:46):

So please take into consideration patient demographics and the ability to deliver care because that may be impacted greatly depending on the patient population that you serve. So you also need to have relevant current healthcare delivery systems to how you deliver care. If you you need to make sure it blends with your current type of care and the delivery method that you deliver to your patients, you need to have skills and responsibilities as a PT providing tele-health. I'll touch on this briefly. Ali's going to cover some of this is that you've got to have good video, adequate etiquette. You have to make sure that you have, you know, appropriate lighting room to move and you need to be able to communicate nicely over video. And so that's a different wait, I know some of you have always had been on a tele on some type of teleconference when there's 48 people talking.

Mark Milligan (00:44:35):

Understanding the rules and kind of engagement by a telehealth is important to know as well. You also need HIPAA compliance scripts for patient communication and the protection of PI, right? If you're delivering care in a busy area where other people can hear you, you're transmitting their PI. So making sure that you take precautions and steps in order to and to protect your patients who you're treating digitally and on the other end, patient needs to be protected as well. And you also need to make sure you have appropriate policies and procedures in place for consent for medical emergencies. What Lynn covered earlier to protect PI, I know there's talk about people recording visits, right? Some payers I know in Texas are requiring recording visits to get paid for a telehealth. And so that video becomes a part of the patient's PI.

Mark Milligan (00:45:21):

So how are you going to store that? Who, where are you going to store it? How long? I mean, you store it from the normal five years. Right? So making sure that you have all of your business practices and policies in place for procedures is really important. And then your IT development and installation. Every system is different. Right now across the board you could have a list of a hundred different ways to deploy tele-health in your business. Just depends on how that model fits into your business and your patient flow. And to your workflow. So right now because of this rapid adoption, there's a lot of trying to navigate in plug and play systems, which is pretty normal. But it's even become more apparent that the need for some centralized systems for delivering this digital care.

Mark Milligan (00:46:08):

So you need it. That's my second question. You need a strong IT department to make sure you have secure system set up in place with your policies and procedures and protocol, right? So your equipment, I really want to make sure you're HIPAA compliant because as lens that earlier there has been a lowering of the shield of HIPAA during this COVID crisis. I'm going to sit here and tell you that you should always choose a HIPAA compliant, secure platform to deliver care if it's available. If it is not, then you may in that circumstance use a non HIPPA compliant platform, which we'll talk about later. But you need to do your due diligence in documenting why you chose that. And you need to document the time, the approximate length of time that that patient's PI was could have been compromised and the patient needs to be able to consent to this non HIPPA delivered care.

Mark Milligan (00:47:00):

Right? So I think that's an important part that a patient, like Lynn said about denial of their consent. You need to inform the patient, Hey, you know what? This isn't a secure platform. This is not a HIPAA compliant encrypted platform. Are you okay with continuing to go through with this? And they may or may not say yes, right? So you need to make sure that your connectivity reliable, you need to have bandwidth, audio and video interface quality. You need to make sure that the staff can use and learn the equipment both easily and onsite and remotely when needed. So can this function when you can't get to the clinic? Right. That's a great question. And is the system compatible with your current hardware software? Most tele-health systems right now can integrate. It just takes time. There's a process, typically integration of a telehealth system, depending on how you deploy, it can take a couple of weeks and maybe two to three weeks depending on branding and depending on how you want it to look.

Mark Milligan (00:47:55):

And so the scope of how you can deploy it into your clinical practice, the timeframes can vary anywhere from 12 hours, six hours to two, two to four weeks to six weeks, depending on the level of integration and the level of branding and the level of system that you want to deploy in your practice. All right, so some simple, the beautiful thing about this is most systems operate with very simple hardware, right? So you have some wifi up and download speeds that need to be a minimum. The minimum requirements, they need a laptop microphone or a headset. I prefer a good old wired headphones, right? I know this seems antiquated, but most people are switching to battery power to rechargeable headphones and they're lasting for an hour or two and then they're dying. So if you're in the middle of a healthcare day, if you're treating and training and triaging patients, I highly recommend either having a couple of sets of rechargeable earbuds or headphones or just go old school with cables and you don't have to worry about that at all, right?

Mark Milligan (00:48:56):

The mobility may be a little bit limited, but it depends on how you function in that telehealth visit that this may be restraining or not. It just depends on how you're set up. But again, it's hard. It's very challenging. Once your headphones die to do a visit through just the speakers on your computer, the qualities, it goes down pretty quickly. And then you need to think about what you're surrounding yourself with. You need to create a neutral background. We need to have a quiet room. You need a room to move as Ali will show you soon. That movement and room for both the therapist and the patient are super important because this isn't a normal, this isn't a normal treatment in a clinic where you have a table and you have a confined space and you do everything within that space, right?

Mark Milligan (00:49:44):

This is an opportunity where you have to help the patient move and show them. So Ali was going to be an amazing demonstrator of how you need to have the space both for the provider and the patient and similar on the other side, the patient needs that wifi service or cell service in order to get those uploads and download speeds. And there's simple tools that you can send to your patient but they can check it's just you can, there's probably 20 free links that they could just click a speed test and it can check the speed of their wifi. So that's an easy way to make sure patients have the capability. So there are other technology out there like VR and all these fancy systems. But look, when the rubber meets the road right now we're trying to get everybody on and adopting telehealth as quickly as possible.

Ali Schoos (00:50:28):

And these are the bare requirements, the essentials that you need. So practice models of telehealth. Actually, I was just a good time to stop or is it for questions? Yeah. All right. Well let's pause. Well, you're muted though. There we go. That's smart. Thank you. I've been madly typing away, so I'm really trying to answer the questions that I can just to simplify things and if there are questions that I think the whole group has to hear, I'm trying to save them. So we've been doing a little bit of both Mark. You've got some really good questions and land these yeah. Either one of you. If a patient has authorized visits, do the telehealth visits count towards those authorized visits? So if they'd been given six authorized visits, would Pella and I have a telehealth visit? Would that be one of them?

Lynn Steffes (00:51:21):

I guess if you're authorizing the visits and you're authorizing tele-health and that is one of the visits. Telehealth itself. Yes. if you're doing E visits or the assessment and management calls, those are not counted. And so I think it depends. It's pay are going to be peer specific. Mark, I don't know if you have any, anything else, but to me a telehealth visit is a visit. It's truly therapy. It just doesn't have to be, it doesn't happen to be physically present. So I would say it would count. But in the case of the eVisits, we've been told they do not count either toward the therapy threshold or toward the visit count.

Ali Schoos (00:52:04):

Yeah. And if insurance isn't paying for the visit at all. So let's say you had two in clinic visits in one telehealth visit, if the patient, it's cash for the telehealth visit and that would not count towards their authorized business because insurance company isn't counting it. Oh, that's a good point. Yeah, absolutely. Yeah. And if you needed authorization for an in an in clinic visit, you would need authorization for a telehealth visit. If it's going to be paid for, unless your insurance company waives that. So you really have to ask every single one of your payers what their policies are around this. All right. Amazing. Just the language that you said just there is confusing enough for a million people to navigate that. I want to say that better Mark to explain it was part, no, I'm just saying it was perfectly explained yet. It's still so confusing. No. Yeah. somebody want clarification. The seven, they felt like the seven days after the last in clinic visit it helped the 70s started after the patient reaches out requesting the phone call. No, it's actually the plane. Right?

Lynn Steffes (00:53:13):

There's be a separation of seven days from the last at least seven days than the last time you saw the patient to build the assessment and management code and then you can't physically see the patient for another 24 hours. And so I think what they're trying to do is say, Hey, you know, this clinical decision making probably isn't need right away. I don't know if I agree with that, but if you're going to see them any way, they probably didn't need this call. I'm not saying I agree, but I'm just saying that's my interpretation. Mark. Do you know anything else?

Ali Schoos (00:53:46):

And, and I think just to clarify one more time when I think it's a misunderstanding when it's an assessment management versus,

Lynn Steffes (00:53:53):

Okay. So the Eve visit did not have that same restriction. It's assessment and management that has that restriction.

Mark Milligan (00:53:59):

Okay. So could you clarify when the visits can be seen?

Ali Schoos (00:54:07):

It has to be more than seven days after the patient was last seen and it has to be an on Epic open.

Lynn Steffes (00:54:14):

Yeah. To be an established patient on the product.

Ali Schoos (00:54:17):

Right, right. But it can be 10 days later, 14 newsletters throughout the COVID process actually.

Lynn Steffes (00:54:23):

And I've not seen anything that says you can't see them within 24 hours after that. I've not seen that. So do you guys have speak up? Yeah.

Ali Schoos (00:54:36):

Does the patient have to be in the same state of the time of the event as if there's a super important Mark?

Mark Milligan (00:54:41):

Yeah. So licenser compact rules and state licensure co licensures rule here, you must have a license in the state that the patient resides in to deliver care for that patient or have practice reciprocity through the licensure compact to provide care to that patient. There has been floating rumors around this country that are licensed. We now have national scope of practice and that w our limits of state have been dissolved by some magical powers, but that I can tell you that that has not occurred. And that we still have to maintain state boundaries for our licensure on a state level. So the location of where the patient is, you have to have a license in that or practice reciprocity in that state.

Ali Schoos (00:55:29):

Thanks. And then Mark, we are only, this person wants to know if they can only see current patients for telehealth purchase. Can they see new ones? And again, the answer is different if it's Medicare or commercial payers can explain that.

Mark Milligan (00:55:43):

Yeah, of course. So for Medicare, they've established that it has to be an established patient for an evisit. So for initiation of an evaluation, it's going to be state level. If you have any regs and rules for your state that that doesn't allow you to do that. I've not heard of that yet. In fact, some policies in this country are just paying for the evaluation only by a telehealth, which makes no sense. But you can, for cash based patients, you can do it at a treatment and about and evaluations and treatment based on your state rules and regs. And so same thing for commercial based on your state rules and regs, you can perform an evaluation and treatments. So we have to default to your practice act in order to make sure you can do those. But are you guys aware of any States that don't allow? Well, there are a couple of States that have been questionable, right? Arizona just came through this morning saying that they have tele-health abilities to practice that. But I'm trying to think off the top of my head. If any state doesn't allow telehealth for physical therapists, my brain is a little mush. Right.

Ali Schoos (00:56:50):

Wow. That Arizona. But they just changed it. That's when you said that just changed today. That's allowed it. But I couldn't tell you which ones still maybe don't.

Mark Milligan (00:56:59):

So defer to your state rules and regs. If you can participate as a provider and provide telehealth services, then that shouldn't limit you as to whether or not you can eval or treat. But it may, it may.

Ali Schoos (00:57:13):

Okay. I'm typing one more answer here. Someone asked if they could take care of patient, just skip over the whole evisit process and do a telehealth visit. And the easy answer is yes. You don't have to do EVAs. That's just because they have Medicare in favor of a telehealth visit.

Mark Milligan (00:57:29):

They have to pay cash for that telehealth visit though. Right?

Ali Schoos (00:57:40):

Sorry. I'll chance to seven days at the end, I think. Why don't you go ahead and keep going back.

Mark Milligan (00:57:45):

Yeah. Awesome. Sure. Thank you. Those are all great questions. And those questions, again, the beautiful thing about the ambiguity of this presentation is that all answers will not be valid within the time that they've left my mouth. So you can't, or Ali’s mouth or Lynn’s mouth. So things are changing on an extremely rapid pace. And so please be mindful and please be considerate or consider that these answers may not be applicable tomorrow depending on the circumstance. So current practices in telehealth, really I like to break these down in just three kind of buckets, right? Companies that provide a service for you as a business owner to connect with their patients and provide care. There's companies that have licensed providers that actually deliver care. And then there's companies that use technology and sometimes a human combination to deliver care, right? So this bar, so the bar, the top one is what I want to focus on with all the PPS owners, because that is who you want to connect with in order to provide your patients with care.

Mark Milligan (00:58:47):

Okay. The other two, I would consider these to be in competition, right? So video platforms are platforms out there that allow you to sign up either a monthly or subscription. Some are free, and you can use their services in order to deliver care through your staff to your patients. That's the important key here. Again, I'm the founder of anywhere.Healthcare. We are HIPPA compliant platform that allows schedule and messaging with the connection of video. We're a relatively inexpensive for now we have it as $10 a month for three months to get everybody on board. And as fast as possible, our normal prices, $25 per provider per month zoom, there's a free version, there's a free version that's not HIPAA compliant. But HIPAA compliant for zoom for providers is $200. Five providers is $200 a month, so $40 per provider per month.

Mark Milligan (00:59:36):

Coveo has a free system. Doximity has a free system. But these are just basic. You're, you typically pay for bells and whistles in these systems, right? So we'll offer you a room based system where you just send a link to the patient, the patient meets in the room and that's what you do. There's no messaging and there's no other type of communication or ability to for the patient to sign on. I think that, you know, it's unique that I said platforms in here, but not all of these are actual platforms by definition of the secure platform from Medicare. So back to Lynn's point earlier, I think there's needs to be distinction that some of these like zoom and doxy and Skype they do not have portals, secure portals that patients have to sign into to qualify as a visit communication anywhere healthcare does.

Mark Milligan (01:00:25):

And I believe clock tree has a patient sign in as well. And so you need to be, when you look at these platforms, take into consideration the patient population that you're treating. So when it comes to, we'll get to the HIPAA compliance and just a little bit we know right now due to the lax of HIPAA rules and regs that you can use things like FaceTime or Google chat or Skype or Apple. What else? Facetime. There's Google. There's WhatsApp, there's lots of different communication platforms on your phone right now. They're advising that at this time that you can use those as long as you document well. But choose a platform that's secure if possible. All right, so tele-health platforms and systems and EHR is also anywhere healthcare Cario Bluejay in handheld med bridge now has a telehealth option practice.

Mark Milligan (01:01:17):

Perfect. EMR has a tele-health option. PT everywhere is an EMR with a telehealth option. So these are going to be a little bit more in depth and how they engage you and your system and your clients. So some of these, I know Indian health in handheld has a complete patient management or CRM, a customer relationship management system. You know, PT everywhere is an entire EHR. So some of these systems may not be right for your practice right now because of the integration needed at this point, not very many people want to go through an EHR integration or transfer during the middle of a healthcare crisis. So these are all opportunities as you look into the future. First kind of systems wide platform setups that you can take into consideration for your company. Companies like you, health, wellness, health, physio, physio, reflection, health there.

Mark Milligan (01:02:08):

Now these companies are companies where a patient can click on this website and be connected with a therapist by their company. So this would be in my consideration, the competition to private practitioners across the country, right? So these are companies that are providing tele-health for, for PT specifically and others in the game such as hinge health, simple therapy, Chi health and Kyo are all app based that solicit direct to patients. So you can search simple therapy or Chi health and they are an app base where a patient will pay a small monthly fee in order to get web delivered. An avatar directed exercises or exercise videos. And I bring this to mind because these four companies, this is a huge exploding space and musculoskeletal care because these are contracting with major employers to be their provider of musculoskeletal care or their first line in musculoskeletal prevention.

Mark Milligan (01:03:02):

So as private practice owners, we need to be really aware of this, of these companies in the space. Because just last year alone, those four companies had $165 million in capital investment, right? They had massive amounts of funding that were pushing at these because they're scalable and because they have infinite amount of users because they're AI driven and you can deploy them rapidly to, to huge audiences. So really be mindful in how you communicate about the services that we offer and the importance of what we do. Because there's people out there and there's companies out there, there are trying to eliminate the physical presence of physical therapy across this country. So knowing the rules is really important, right? The biggest important thing that you can know as a PT providing telehealth is that you can treat, you have to treat the patient person the same way as if in the clinic.

Mark Milligan (01:03:54):

This is paramount. So you have to have consent form signed. You have to have consent to treat, you have to have all your your dots. Dot eyes I's dotted and T's crossed. When you're treating patients to make sure that you treat them just like they're in person. This, just because you do a digital cash based visit doesn't mean you don't have to document. And I say that only because people have asked me that, right? This is a real patient. You have to treat it as a real patient, as a real visit. So please be constantly professional and how you manage patient care. Knowing the licensure compact is also super important. The patient, what I defer to earlier, the patient, you must have a license or practice reciprocity in the state that the patient resides in. There have been talk about, well, what if somebody goes on vacation?

Mark Milligan (01:04:38):

What if somebody goes on or their summer home? That that is a very gray area that hasn't been well defined to my knowledge. Have either of you heard of anyone defining them being out of their compact state for a defined period of time? I have not. So you're talking about the patient or the therapists, right. Let's say my patient in, I have compact reciprocity in Missouri. Let's say my patient in Missouri goes to Indiana for four weeks. Can I now treat them while they're in Indiana because they're not in a state that I have a license or compact or reciprocity?

Lynn Steffes (01:05:17):

Well, it really is, it's my understanding that it's the location of the patient at the time of the encounter. We've had lots of questions on this behind the scenes as well. Like what if my patient is, their residence is in one state and I'm doing tele-health and another if they were to come to me, I'd be covered, but then they would be in your state. So in the case of telehealth, it's my understanding that if you are licensed in the state, whether through your primary license or compact license that the patient is in at the time of the encounter, then it's covered. If not, it's not covered any different.

Mark Milligan (01:06:01):

I've just, there's been people argue like, what if my patient goes skiing in a state that doesn't cover in Nevada and they hurt their knee, right? And they're gone for a week and I still consult them while they're gone for a week. Technically, since they're not, you know, they're not a resident, they're not living there. So those questions are extremely gray right now. So I would default back to the current rules and regs that say that the patient has to be in the state that you have license to practice them.

Ali Schoos (01:06:24):

Yeah. I think people want them to be great because it sounds like they're only gone for a week, but that doesn't only gone for me as a Trump law. So unless we're specifically pulled, that is true. I would not do that.

Mark Milligan (01:06:37):

Right. And why should you care? One, you could, it could be damaging to your license too. You can pro, you can really do a lot of targeted marketing across those areas, right? So you can now reach people across the country. HIPAA, a fun topic. That's the old definition of HIPAA that we need to maintain or the telehealth provision we need to maintain it. But really current language means that we, they're going to, they're not going to impose penalties for noncompliance. And so under this notice, Apple FaceTime, messenger, video chat, Google Hangouts, Skype, Mmm. Can it be used to provide without risk that they will be imposed penalty on. However you need to notify those patients that these third party applications or predict potentially introduce risk and that you need to get an okay to use them. Again, this is temporary.

Mark Milligan (01:07:26):

Most of the information that we're talking about with insurances and compliance and everything are all temporary orders. So make sure that you're understanding that it's out of the essence that you maintain as much as you can. Cause separate costs a lot of money. All right, so why should we care? It works. Customers want it. I'll go through these pretty rapidly because right now customer driven decision making is not as, I don't think is as relevant, but after the fact that we need to come back to this when this is over, this is relevant. Customers want this. Customers by age group want to try a telehealth across all demographics. And so just make sure that you understand that before we had this crisis, many people would love for their care to be delivered digitally. And so across. There's different reasons that they have time savings, faster service, cost savings, better access to professionals.

Mark Milligan (01:08:21):

However, there were some perceived barriers as a person in person care was a preference. There's privacy concerns, uncertainly about reimbursement tech and then how to use it. All of these things can be alleviated during these current times with communication and helping your patient understand the technology that you're using. Right? But why should we really care as a profession because it works, right? There's been a lot of studies that look at the efficacy of our effectiveness of telehealth in tele rehab specifically. There's been over 50 studies that and more coming out that tele rehab is a benefit or as is no less than effective as in-person care. All right. There's one major study with Veritas from Duke that they looked at a 300 ortho patients that had total knee replacements. Half of them went to inpatient or half of them went to outpatient orthopedic and clinics.

Mark Milligan (01:09:12):

The other half went to home with an app to get exercises and there was no difference in longterm outcome or total cost in three months after discharge and they saved almost $2,800 per patient. So there are studies that are coming out and post-stroke MSK, pulmonary rehab, cardiac rehab, joint replacements, low back pain that have all demonstrated that digital delivered care, whether that be in person or some apps can be just as effective as in person care. So knowing that those are the cases that we actually can make an impact digitally. It's an incredible opportunity for us as a profession, right? But I think we also need to step into the space and own our profession because others recognize the viability and the validity of how we use technology to treat musculoskeletal conditions. And they're stepping into the space too in a hurry. So it's just the beginning and now I'm gonna turn it over to Ali who's going to you know, my back hurts. Ali, can you help me?

Ali Schoos (01:10:08):

So, yes, I can, I'm going to screen you via telehealth before I let you come into my office. So Carrie, I think you're gonna try to give me the full screen Mark when those are off. MarK Fullscreen.

Ali Schoos (01:10:28):

There we go. All right, so you guys, I asked him to put me on full screen. I don't have slides because I really want to talk to you in a way that you are going to be talking to your patient when you do a telehealth visit. So I had been thinking about doing telehealth for a couple of years and that's a whole nother story why I didn't get off the dime and do it. But when the COVID pandemic struck and it hit really in the Seattle area first, in fact, the nursing home facility that was the epicenter of the outbreak is just up the road from my office. I knew that we needed to get going and get telehealth in place. And although it feels like that was a year ago, it was really about 10 days ago and we've done it, we've gone from zero to providing telehealth in 10 days or less.

Ali Schoos (01:11:13):

Actually, actually we did it in six days. So the thought process that I went through was shoot first aim later and looked at, gosh, let's just go with a free platform. Let's just get going and do this. And the very first platform that I signed up for, I looked at I realized that tele-health was something that we want to be offering as a long game, not just a short game. And I wanted it to be more robust and then I would be paying for a platform regardless. So I looked a little deeper and decided that I the two things were most important to me was HIPAA compliance because I didn't want to change platforms because I'm not compliant now and I'm going to be compliant. And the second issue was really having access to someone who could walk me through the process.

Ali Schoos (01:11:58):

I didn't want a platform where I had to figure all of it out. I wanted someone who could tell me, I'm not a techie person, so tell me what that meant. Do I need, how do I, how do I set it up? What does the patient need? And so this is not a PPS endorsement. I did use I am using anywhere healthcare with Mark and he has walked us through the process. So you know right away when you were able to get I got all my therapists signed up before I even knew what I was doing. Got all a therapist signed up and asked them to go in industry and start using the platform. Have visits with coworkers, have visits with friends and family and just practice and get comfortable and make sure that they were able to do it at the office.

Ali Schoos (01:12:42):

Where did we want to do it? We ended up choosing my office as the best place. This is my home, not my in-clinic office. And then I asked everyone to look into their homes and make sure that they have the appropriate technology and appropriate space to do it at home as well. While they were doing all of that, we were working on the other side to make sure that we had the patient invitation letter or patient welcome letter that we had a letter that describes the patients what they needed to do on their end and have available. And then the consent form, which was all within the platform, which is all online and portal. And then I had my, you know, diving in like I do, I had my front desk start calling the patients who had been canceling their appointments to see if they wanted to take a tele-health option.

Ali Schoos (01:13:27):

And lo and behold, not very many of them did. So realized I think we need a transcript for how we talk to patients about telehealth. And I don't need to let the patient understand the value of tele-health, but to make sure my staff understood that about your health. And it made it pretty clear that people don't really understand how can you do physical therapy through a computer. You have to be able to touch me. Right. I mean, you touched me all the time when I'm in the clinic and it's very true. We do touch our patients and that's a very important part of what we do. But I think the majority of what we do is education and exercise. And that can be done very effectively across this platform. You have to make sure that your therapist and your patients understand that.

Ali Schoos (01:14:11):

So the next thing we did after a script that everyone would use is I created a video and put it on our Facebook page that is too long, but go ahead and go to my Facebook page and look at it so you can get ideas on what you want to do and don't want to do. How we did it for two reasons. One was to explain what we're doing during the COVID crisis, how are altering how we see our patients, and then explaining the telehealth option to them. And then I walked through with them what an actual visit looks like. And so they're looking at their computer while I'm talking to them and said, you know, if we're going to ask you the same questions that we're gonna ask you when you come in for a visit, I want to know what your history is.

Ali Schoos (01:14:55):

I want to know any special tests you've had done. I want to know what makes you worse and better. And then really critically, I want to ask you about red flags, meaning things that are important for me to know to make sure that you are appropriate for me to treat, to safely treat across the health platform, so that if there is something amiss, I can handle that by referring you on to another healthcare provider asking more questions. And again, in this crisis maybe doing a phone consult with another provider to make sure that we get you the appropriate care if telehealth is not. So you do need to make sure that your providers are asking the same red flag questions that they should be asking when the patient is in the clinic. So it's not really different, it's just enhanced importance for me.

Ali Schoos (01:15:42):

So the next thing we did then is have the physical therapists, Oh, let me back up a little bit. I do want to explain to you the other important thing about when you're on this call and what I did on my video was demonstrated for patients. What that visit after those questions would physically look like. So if I'm seeing the shoulders always easy to explain here, if I'm seeing a patient has shoulder pathology, I want to make sure that I have enough room and they have enough room for me to move around and show them what I want them to do. I can't just say, well, you know, flex your arms to 90 degrees or do XYZ because I can't touch them or cue them as easily. I need to be able to show them. So I'm going to ask them to raise their arms above their head.

Ali Schoos (01:16:25):

I just said, I can't really see what you're doing. I want you to push your chair away. Okay, stand up for me now. Go ahead and do this for me. So move your arms. Great. Now can you reach behind your back? Show me what that looks like. Let's go sideways and Oh, that's sucking kind of funny right there. I think Ellie has a rotator cuff problem and you know, go through all their emotions and I might say, well, can you resist yourself? So push down against your arm while you're trying to raise it. Does that hurt? Can you do that? Don't use right or left because that's backwards in a screen now it's even worse than are in the clinic. So say raise your involved arm or injured arm or however you want to do that and your resist that. Make it bend your elbow and push down against your arm.

Ali Schoos (01:17:05):

When you tried to touch your shoulder, just the same kind of cues, but show them what it is that you want them to do. If it's on their back, their knee, you're going to, I can only see part of you. Guess what? My screen moves and you are allowed to move during your tele-health. It's going to tell your patient, I want you to move your screen now so I can see your feet. I'm going to be able to see you. You know, do a little squat for me. Go ahead and hang onto the wall if you need to use the desk. So you're going to use the things that are around you. Turn sideways and then forwards. I can see what your back looks like. You have the ability to have your patients do quite a few things. You don't even, you know, you're looking at their shoulder.

Ali Schoos (01:17:47):

Let's just screen your neck out a little bit. So backwards, any pain going into either are so you can do quite a bit. And your history should have cleared out a lot of your red flags and, but you know, if you're concerned about something more serious that you can't evaluate across the screen. So once you've done all that therapist and a patient, well, much better idea that, Oh, I guess you can do this with me. And then you might want to ask your patient to have some things handy for you to be able to show them what you think they're going to be able to doing, whether it's stretching bands or foam rollers or some lightweights, or even teach them how to make some lightweights at home so they have something to left when you get to that point. Mmm. And then the final thing, two final things.

Ali Schoos (01:18:33):

I had our patient, our therapists call all of our current patients or who were current prior to the COVID crisis. Call all of them. Check in on, I'm asking how they're doing, is there anything that you need from us? And then explain our telehealth and e-visit options to them. Let them know that they can go to the Facebook page to look at the video to understand it a little bit better. And then just that personal touch. And then we are next emailing all of our patients through our patient engagement platform to let them how again that we have altered our in office visits due to the COVID crisis so that are stay in place, mandate by the governor. We will still be seeing extremely essential critical patients in the office. But our largest mechanism for reaching out to them and monitoring them and help them rehab during this time is through telehealth.

Ali Schoos (01:19:24):

So, and I think that's really critical so that when they think they don't need you today, maybe in a week or two, they realize, wow, I really do need to talk to my physical therapist. What did she say about how I could get ahold of her? And they'll go back to that email and find that information and reach out to you, especially if your office is closed, make sure that they know how to contact you so they can do that telehealth visit. And on many of these platforms, there's a mechanism for the patient. They can use the platform to reach out to physical therapists. And that's how we did it. So like I said, six days, we did our first visit from when we said go. So there you go. Mark, back to you and Lynn and let's answer some more questions. Yeah, that's great.

Mark Milligan (01:20:08):

That was awesome. Yeah, it was, I think the important thing that all providers need to understand is there's a learning curve here, right? There's a steep learning curve and you really have to, you have to practice it. Like Ali said, yet everybody practiced before this. And also you need to be, I like to term it humble and open with your patients and understanding that, look, this is new for everybody. This isn't how we've done things for years and now it's time to do something differently. So if you are, if you are if you're with your patient when I started doing this, I'd be like, you know what, John, this is the first time I've seen somebody with knee pain on a virtual visit. Let's figure it out together. Right? And, and work through it. And, and it also gives you opportunity to see where your patients live and the equipment they have.

Mark Milligan (01:20:50):

I know Ali said that you can, they can have equipment, but you know what a can of beans, some cans weigh 16 ounces, that's a pound, right? And they, most people have a belt. And so a belt becomes a great nerve glide or a stretch strap to do nerve glides with. And you know, you just have to get really creative and be a Ninja when it comes to a telehealth visit. IFor me it's really exciting for problem solving because you, you really just a giant problem solver. So thank you Ali. That was amazing.

Lynn Steffes (01:21:19):

Ali, we had a lot of questions. I wonder if I could take a minute and ask some questions that were specific. So one of them was can you talk a little bit about your patient demographics?

Ali Schoos (01:21:33):

Yeah, I think my patient demographics are pretty typical outpatient or so. We have about 20% Medicare 22 maybe it's going to range a little bit, but we see everything from junior high age athletes, kids through that Medicare population. I would say we have a fairly, our geriatric population is fairly active, but about 5% of them are pretty geriatric.

Lynn Steffes (01:22:01):

What about socioeconomic wise?

Ali Schoos (01:22:04):

Socioeconomic imagine value values on you guys? I'm like tech plans. So socioeconomically, I live in a high wealth area, but we also have one of the biggest immigrant populations in the United States. So there's a mix. You have a mix of lower socioeconomic status, but I'd say probably obviously higher than in much.

Lynn Steffes (01:22:27):

Yeah. There are also some questions just about the name of your practice and your Facebook and websites and maybe after you can take a minute to type it in.

Ali Schoos (01:22:36):

Yeah, I mean, I think Carrie, that's on the reason I was like, if not, I'll make sure it's on the resource link.

Lynn Steffes (01:22:42):

Okay. And then there was a question, a specific question. I don't know if you or Mark could take it about the vestibular patients. Give an example of how you might treat a vestibular patient.

Ali Schoos (01:22:56):

So that's a great question, by the way. That is one of the people that I think is essential. And so we have seven treating therapists. We will probably have one therapist in the office or going to the office as needed. I would say a really acute vestibular patient probably needs an in office visits. You could make sure that they're not having a stroke or that, you know, what's the problem? However, let's say, say someone you've seen before that has a recurrent problem or those of you who are vestibular therapists. I'm not, but we do have him in my office, so I don't want to misspeak here, but let's say you can do it on telehealth. I know therapists can demo an epley maneuver. She can actually have a plant and have her computer screens set up. Just got it for me and demo how to do an epley maneuver for the patient. So it is possible if that was your only choice, you don't have to think about what's best for the patient. And if the patient can't access anybody and they're scared to go to the emergency room and your office isn't open, you showing them how to do an Epley maneuver is better than what they're getting otherwise. So there's my answer.

Lynn Steffes (01:24:04):

That sounds good. Mark. There is a question that came in that I think would be perfect or two questions for you and one is that they indicated one obstacle I've been running into is getting the medical history and the body chart filled out on line. Do you have any advice on resources for getting people were converted to digital or interactive version?

Mark Milligan (01:24:24):

Oh yeah, so that's a great question. Great question. So there's actually a couple of companies that do intake digital intakes once, I think it's called intake queue. Is it actually a company that you sign up for their services and they do digital forms? But there's also, I have, when I first started my practice, I just, I'm not that, even though I'm in tech, I don't do a lot of tech, so I don't know how to convert PDF. So I just had, I went to and had somebody do fillable forms for all of my forms. So a fillable PDF form. You just email that to the patient and they can fill it out on their computer and sign it and then just save it and email it back to you. So that's been the easiest way that I've found to do a digital intake is just have your forms be PDF and fillable.

Mark Milligan (01:25:13):

You know, and, and in these times, like I've also emailed patients and had them fill it out at home and then hold it up to their camera and then I've taken pictures of that and then reviewed it. That's another way to do it. And then knowing that I'm going to see a patient in person, I'll often, or you could have them fill out some of the forms and have them take pictures and send it to you over a secure method or email it through you for their phones so pictures can work. So you have to get creative in that space for sure. But fillable PDF forms have been by far the easiest. I have my entire intake paperwork as a fillable PDF form.

Lynn Steffes (01:25:51):

Okay. That sounds good. There's a question about documentation of the sessions and I guess the biggest thing I would say is document. Like you're doing an in person, just go ahead and document that they gave consent, your location, location in the platform. I guess the other thing is the other question I thought would be good to answer live is how long are the sessions? Usually it's tele-health.

Mark Milligan (01:26:16):

Yeah, so that's a great question. Ali can also respond to this with our clinicians. So an initial eval can be anywhere from 30 to 70 minutes. It really depends on the patient. It depends on their condition. It depends on their comfort, the technology they're set up. But followups are typically in the 20 minute range, 20 to 25 minutes. They're not very long. Because you just get it done. You're not entertaining and asking about cats and seeing how their life is, you're really just getting in there and getting it done. For those cash based practitioners out there who want to charge patients cash, I would take your hourly rate and divide it by four and I would just bill in 15 minute increments. Right. Just give the patients manageable, manageable chunks of time that they can pay for and not have to think they have to see you for an hour for a PT visit. And so it makes it, I think, affordable and approachable for some patients. And you can still charge the same hourly rate. It's just broken down in chunks because some people don't need a lot of time. They may just need to review the hip hike and clamshell and, and S sideline abduction exercises that you gave them. That'll take 10 to 15 minutes. But so do it that way. From my experience. Evals anywhere from 30 to 70 and then followups are pretty much 15 to 25, some of them.

Ali Schoos (01:27:29):

Yeah, Mark. So that's what we're doing. We're doing initial evals for an hour because we want to make sure that if you get into this across again at via platform that you really haven't had time to ask all the important questions and all that. That's great. But that return visits have so far, 30 minutes have been adequate for us. Again, I think you can be a little bit more efficient. Some that chitchat doesn't happen. So I think you might even be a little bit more efficient. I'm a chit chatter myself. I'm with my patients and yeah, so I think that 30 and 60 is good. And there was a question about how we're getting reimbursed for these visits. We've been doing them for less than a week, well a week. So I have no idea in terms of if insurance is going to pay us, we have done our due diligence to the best of our ability as to who might pay us and we will bill those insurers. We're doing a cash rate when we know it's not covered and we reduced, we made the choice. Everyone has to do this for themselves. I think there's pros and cons. We reduced our rate mainly because so many people are going to be out of work right now and we don't tell her that's new to my clinic. So we reduced our rates, we didn't make them free, but we reduced our rates to encourage people to utilize the service.

Lynn Steffes (01:28:41):

Mark, there was one other question. I know we have to tie things up, but do you find that your telehealth clients over time, not just for this COVID crisis, but that they offer, may offer a brief first free visit or a sample visit as a way of helping people understand what to expect?

Mark Milligan (01:28:58):

Right. So I think the business owners on this call need to think about how they're going to integrate digital care into their practice when this is over. Right? And so one of the ways that I've seen to be very effective is to offer a button on your screen that just says contact for, would you like a free video consult, right? Just do a free consult just like you would in a free screen in your clinic. And that helps them both get comfortable with it, expect it. And also there's been some good, some good data that we've gathered that people that do that telehealth video visit and then show up into your clinic, have more, I have a higher rate of completed plans of care than if as if they do just a walk in free visit. So just because of the dynamics of the end of it where you, they have to sign up for care and it's awkward.

Mark Milligan (01:29:42):

So if a patient does a video visit and they show up, you know, they're invested, right? They get to meet you face to face before and so they're more likely to stay. So I think that when this is all said and done, finding ways to integrate telehealth into your clinical practice and how it makes the most sense will be necessary. But yes, there's, I mean, you can give away care to any body on this planet. It's legal to give care to Medicare beneficiaries. You can donate care. So you can you would a free screen or a free tele-health touch or free visit is perfectly appropriate way to help introduce people to digital care. I know we're at a time, how do you guys have it to tie this up?

Ali Schoos (01:30:26):

So if I can intervene and I guess I think, thank you Mark and Lynn, you guys just did a great job and everyone, they really have worked very hard. I had no idea how fast these guys are turning around this information for you. So thank you very much. I'm going to put a plug in for your keeping us an ABT boards. They are working their tails off to get people as current information as they can around rules and regulations and billing and tele-health and managing your practices. So when we're going to keep doing it, ups website is open to the public. We've taken a firewall down for all information about COVID, so please use it even if you're not a member. Lynn and Mark and I, and then we'll meet after this to decide if based on what happened today, we should do a follow up webinar. So if that's an interest to you, type something in real quick. And then just use the website. If you have more information or you know, reach out to one of us. Anything else that Mark you or Lynn would like to add? Dive in. Just dive in and do it.

Mark Milligan (01:31:28):

Yup. Just dive in. Just do it. Be kind to one another and understand that this is a working together. We can become a better profession because of it. So that's my final word. Bless you all for doing what you do. Thanks so much for serving as a sounding board.

Ali Schoos (01:31:45):

Thank you. All right, thanks everybody.

Carrie Stankiewicz (01:31:50):

All right, thank you all for attending today. As we've noted, this will be recorded and posted on our website along with a copy of the slide presentations and all of the links that we've referred to are in the slide presentation. And most of those links are to resources that are directly on the PPS website. On our COVID 19 page. So if you haven't already, please take the time to explore that page. Ali and Mark and Lynn, thank you so much for your time today and I'll wish everyone a great evening.


Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram  and facebook to stay updated on all of the latest!  Show your support for the show by leaving a rating and review on Apple Podcasts!

Mar 23, 2020

Live from my personal Facebook page, I welcome Dr. Mark Milligan, PT, DPT from Anytime.Healthcare as he discussing how we can implement telehealth services into our physical therapy practice. 

In this episode we discuss: 

* How to set up a telehealth platform
* How to perform an initial eval and follow sessions
* How to bill (at least what we know right now)
* The paperwork you need to start seeing patients today
* And so much more! 


Connected Health Policy/Telehealth Coverage Policies

State Survey of telehealth Commercial Payers

Telehealth Paperwork


For more information on Mark: 

Dr. Mark Milligan, PT, DPT, is a board certified, fellowship-trained orthopedic physical therapist. He specializes in the intelligent prevention and treatment of all human movement conditions.

He is a full-time clinician with multiple patient populations and is the Founder of Revolution Human Health, a non-profit physical therapy network. Helping others create the best patient experience and outcomes through his continuing education company specializing in micro-education is also a passion.

His latest venture is creating the easiest pathway to access healthcare for providers and patients with Anywhere Healthcare, a tele-health platform. He is an active member of the TPTA, APTA, and AAOMPT and has a great interest in the pain epidemic, public health, population health, and governmental affairs.

Read the full transcript below: 

Karen: (00:07):

Welcome to the healthy, wealthy and smart podcast. Each week we interview the best and brightest in physical therapy, wellness, and entrepreneurship. We give you cutting edge information you need to live your best life, healthy, wealthy, and smart. The information in this podcast is for entertainment purposes only and should not be used as personalized medical advice. And now here's your host, dr Karen. Let's see. Hey everybody. Welcome back to the podcast. I am your host, Karen Litzy and in

Karen  (00:40):

Day's episode. I am sort of re airing a Facebook and Instagram live that I did last Wednesday with dr Mark Milligan all about telehealth. So a little bit more about Mark. He is a board certified fellowship trained orthopedic physical therapist. He specializes in the intelligent prevention and treatment of all human movement conditions. He's fulltime clinician with multiple patient populations and is the founder of revolution human health, a nonprofit physical therapy network, helping others create the best patient experience and outcomes through his continuing education company specializes specializing in micro education is also a passion. His latest venture is creating an easy pathway to access healthcare for providers and patients with anywhere. Dot. Healthcare. This is a telehealth platform. He is an active member of the Texas PTA, P T a and a amped and has great interest in pain epidemic, public health, population health and government, governmental affairs.

Karen  (01:41):

I should also mention that he is also on the PPS coven task force. So if you want to get the most up to date information on how the coven pandemic is affecting physical therapists in private practice, you can find that at the private practice sections website. It's all free even for non-members. All right, now onto today's podcast. Like I said, this is a recording from the Facebook live that we did last week. And in it we talk about what is telehealth. We talk about how to set up telehealth, how to implement telehealth, how to conduct a telehealth session for an initial eval or for a followup. We talk about how to get paid for telehealth and this is the information that we knew at the time. That was last Wednesday. Like I said, things are moving really, really quickly here. So the best thing to do in Mark says this is to check with your individual insurance providers, check with your state things are moving really, really fast.

Karen  (02:45):

And of course finally we talk about answer a lot of viewer questions. So a big thanks to Mark and I think this is really timely and I hope that all physical therapists that if you're listening to this, that you can set up an implement your telehealth practice ASAP. Thanks for listening. So today we're talking about how to implement telehealth into your physical therapy practice. As we all know, the COBIT 19 virus is causing a lot of disruption in healthcare and we're hoping that telehealth can help at least mitigate some of that interruption for the sake of our patients, for the sake of our own practices and for our businesses and for our profession. So Mark, what I would love for you to do is can you just talk a little bit more about yourself, where you're coming from and why we're doing this interview.

Mark  (03:34):

So Mark Milligan, Austin, Texas physical therapists board certified fellowship trained, but also for the last few years have stepped into a telehealth space and have anywhere healthcare, which is a digital platform for delivering healthcare. It's agnostic to provide her, so PTs, mental health providers, anybody that needs a HIPAA compliant platform to connect with patients. So the current situation is it's pretty mind blowing, right? We're seeing a, a world changing epidemic that will change the landscape of healthcare as we know it today. For several reasons. One is that people will be now exposed to a delivery of care method that they weren't otherwise are supposed to before. So telehealth and tele PT and tele medicine had been out there for a long time. Teladoc started in, in 1987, somewhere in there. So it's been around for a long time, but a rapid adoption of telehealth has really occurring right now for physical therapists.

Mark  (04:30):

What we need to know and what are the most important things right now are how it applies to us in this landscape. How can we be the best providers to meet our patients? Demand to help quell fear, doubt and an anxiety for our patients as well as, as providers and our businesses. And so stepping into this space is, it's been a little bit overwhelming. It's been a nonstop 70, 96 hours really. And so everything that I say today may or may not be true and four hours or smart [inaudible] because of how fast things are changing. So yeah, I think that tees it up. You want to kick it off? Yeah,

Karen  (05:10):

No, I think that's, that's great. That's perfect. So let's start out with, we got a number of questions from people from different therapists from around the country. And I think let's start with the number one question is how do you actually set it up? Totally basic one Oh one. So let's start with that,

Mark  (05:33):

Right? So the first thing you have to make sure is that you have patients that want this. And right now everybody wants that, right? So patient adoption of technology can be challenging, especially especially generational. So the issue with in, yeah. Pre COBIT has been adoption by, by therapists and by patients just because of ease of use. Now it's a, it's a forced adoption. So now we're in a set up where we, where are going to want this regardless of whether or not they want it. So first thing is patient population. Second thing is you need to look at your business, right? You need to look at your patient workflow and your business flow. So you need to have the appropriate from a business standpoint, you need to have a liability to make sure that you're covered in the telehealth space. So in my experience over the past few years, almost every liability insurance cover, it doesn't see telehealth as a, is a different delivery mode for physical therapy.

Mark  (06:26):

But with everything changing rapidly, it would be real. It would be highly advised that you contact your liability insurance provider and make sure that tele-health is approved as, as in your cupboard. All right? So that's logistics. Secondly, you need paperwork, you need onboarding paperwork for digital visits. You'll need a telehealth consent form and you'll need the digital release form. And if you're recording visits, you need to have a very specific form that that allows you to record patient visits. Some States don't allow recording some. And so you have to be very mindful of that. So onboarding paperwork, it's, it's good to have in fillable PDFs so that a patient can fill it out and then send it back to you digitally. Making sure that that transmission is is secure. You can also have E faxes, right? So they can electronically fax to you over a secure portal as well. So just basic things that we haven't really thought about as providers we need to adopt as mobile providers. Right. So, Oh, go ahead.

Karen  (07:24):

I know, I was going to say, so when we're talking about who is the best, what is the easiest way for us as a clinician to get that paperwork

Mark  (07:32):

Right? So they can email me. I've gotten a tele-health consent. I've got I've got that. So they can just email me at market anywhere. Dot. Healthcare. And I can send 'em I'm been sending that out over Facebook. I'm happy to share that with people. And of course you need to make sure and adapt it for your state in your practice. It's a word doc so you can switch out the logos and everything, but I'm happy to provide that for people. They can pass that that step.

Karen  (07:57):

And then one more question on paperwork and things like that. So when we are calling our insurance, our liability insurance carriers, aren't there specific questions we need to ask them or like what is the best way to have that conversation with our liability insurance providers?

Mark (08:16):

Right. Just say in this facing time that we're starting to provide care digitally. Am I covered for providing telehealth as a physical therapist? Simple. Straightforward.

Karen (08:25):

Okay. And so you may already be covered in your current policy, it might be part of your current policy, you just don't know it and then you're not, is that then added as a rider to your yes.

Mark (08:38):

Typically it's a very inexpensive writer. Okay.

 Karen (08:41):

All right. So before we set everything up, we get our liability coverage covered and we get consent forms, which can email to you or you can share them on under this post. It's whatever you feel more, most comfortable with or what might be easiest. And then we do what we got the paperwork covered. Now what?

Mark (09:06):

So you're sending that out to the patient. So they need to agree to be treated digitally. Right now it's really an interesting space. The CMS has waived temporarily a HIPAA privacy with when it comes to digital communication. I'm can't stress this enough that this is a temporary wave in, in the absence of mass abilities to communicate or HIPAA compliant platforms that patient that people are able to communicate via other means of non HIPPA compliant video software. So right now Skype and FaceTime are considered and what's the other one? Zoom and zoom and those well-known platforms are, are open, enable all those zooms just increased their prices yesterday. Yeah, so I would argue that you could use the, what's free and what's available right now in preparation as you prepare after this is over, you'll need to go back to HIPAA compliance. So in the immediacy video platforms are readily available across all. You cannot use public facing video platforms like tick talk or other things that mass put out your video. Okay.

Karen (10:22):

Instagram live or Facebook live. You can have your patient video, you can have your patient treatment sessions over live video,

Mark (10:30):

Right. That it means sounds, it sounds obvious, but you never know where people will do right by a group session. You can just do a giant group session. I'm going to train everybody on the East coast of America on a Facebook live.

Karen (10:42):

Yeah. Okay. All right, so good to know. So no one social media lives like we're doing right now, but for the time being during this outbreak, we can use face time, we can use zoom, we can use Facebook, zoom, Skype,

Mark (10:59):

Right. Totally. And you need to make sure that in your notes and documentation for your intake software or your intake paperwork, that you are waiting, that the patient is waiving their HIPAA rights during this time due to the COBIT outbreak and you are using this unsecured software and you will return to it as soon as possible. Right. Okay. This is a window. This isn't something that will last. And you need to note for your own CYA that you are, you acknowledged the existing coven scenario and that you will prepare for post that with, with my platform. Yeah. Yep. So technology on the technology side, it's really easy because you can plug and play as long as you get someone's if they have an iPhone or if they have Skype, easy set up, you can connect technology there. So once you get the form signed, you have the informed consent, the HIPAA, the HIPAA included waiver as well to sure that they understand that they are on an, they have to understand and agree to an unsecured network.

Mark (11:58):

Even though you can provide it, some people may not want it because FaceTime, that's all easily hackable. Right? So so they may not, or may, they may, they may not want to agree to that. So just have to be transparent with them in the, in your services. Right. So once you get that, I mean, it's really a matter of getting the patients, depending on your system, everybody's so different. So if you're, if you are a concierge PT and you're practicing out there for a fee for service cash base, you handle all your own scheduling when it comes for their time, you just flip them and you just call them on FaceTime, right? You collect their face, their number and you connect that way and you do your treatment, which we'll talk about in a bit, some other scheduling systems. You may have to, you know, type in a telehealth visit and your scheduling system or have some type of a demarkation for a telehealth visit versus an in person visit.

Mark (12:47):

And so work with your scheduling software, work with who you work with in order to make sure that that's appropriate so you can have the right amount of, or the right type of scheduling so you know where to go and what to do and how to bounce it. A billing, again, for the concierge practices out there, this is fee for service. Tele-Health doesn't take as long as normal to as normal PT. So I have my hourly rate broken down into 15 minute increments because it's roughly about 15 to 30 minutes. Is it an average tele-health followup evaluations in the last 40 to 50 minutes? But it just completely depends. So fee for service, it's really straight forward. You just charge per time, per minute, dollar, dollar, dollar, $52 a minute to 15 minute depending on your price point.

Karen (13:29):

Okay. All right. So now let's get into, so knowing how to actually set it up. So we've got a lot of these different things. What are some other platforms? I know anywhere. Dot. Health care. Doxy.Me.

Mark  (13:46):

Yup. Doxy.Me co view. So anywhere. Dot. Healthcare is the platform that I created. It's straight forward. Right now I'm offering you a $10 a month, unlimited use for anybody for three months while onboarding everybody. So to, to help people get to see patients doxy dot. Me actually has a free version where that's a, a room where people meet. So you can actually sign up. The patient is sent a link, they click on a link and it drops them right in a meeting room. Super convenient, super easy. There's no bells and whistles and it's free right now. So you can do that. I think a couple of other platforms I've seen throughout the Facebook live of Facebook groups that I'm in a few platforms are pushing out a free entry level software right now. So it's everywhere. So I think

Karen  (14:31):

We'll use G suite

Mark  (14:32):

D suite, right? So G suite, if you have a BA with, with Google, you can use Google meet. Right now actually with the, with the HIPAA waiver that's happening right now, you can actually use Google hangout. That would be another appropriate thing to use as long as the other person has the G suite or Google doc, a Google suite downloaded on their computer. So there are lots of, there's literally lots of options now there, there are other companies that offer other features, right? As you get into anywhere that healthcare, not only as a platform, but also as a billing feature and a scheduling feature. Doxy dot. Me if you upgrade to the higher levels, has a scheduling feature, a messaging feature, all types of stuff. So it really looking for different platforms. You need to be, do your due diligence and test them out to see what fits your practice best. I mean, some, some have exercises that are completely a part of the package that you can just have an HTP that sends right out from the program. Some have an actual, a range of motion measuring system so people can move their arm or their body in front of them. The then they can actually measure range of motion live on camera, which is pretty cool. So it just really depends on the need for your, your practice and also the practice size.

Karen  (15:44):

Got it. Yeah. Okay. So that's a lot of options for people going from free to low priced too.

Mark  (15:52):

$200 a month for co for HIPAA compliance zoom.

Karen  (15:55):

Right, right. Yeah. Yeah. Okay. So lots of options there for people. So we know we need some onboarding paperwork and we need to call our liability insurance carriers to see if they cover telehealth. Presently. And if they don't, then we need to ask them to put an addendum on and you can, they can do that immediately. It doesn't take like 30 days for that to happen. Right. Should be immediate. Okay. And so once we have all of the right paperwork and everything we decide what platform we're going to use and you just gave a whole bunch of different platforms that people can use. So all of those platforms are pretty easy to set up. And like you said, you send a link to the patient, they'd drop in and boom, there you go. And at this time we can use Facebook and Skype and, and not Facebook, sorry, Facebook. We can use Skype, regular zoom face time, all that. Okay. All right. Now

Mark  (16:58):

You may need other equipment though. You may, depending on the situation you may need. So some people, a desktop versus a computer are versus a tablet versus a phone all matter, right? So a desktop computer tends to be really well for you to have good communication and see the patient really well. But it's also very challenging for me to move my desktop to show somebody how to get on the floor and exercise, right? So the part of being a a digital physical therapist is that you have to be able to move and your equipment has to move with you. So some people use, I, you know, some people use a selfie stick to demonstrate exercises, right? Some people have one of those little iPhone holders that can be multiple or wrap around something so they can have different angles or show people at different places.

Mark  (17:41):

So understand that desktop can be good for this face to face interaction and the, and the immediate subjective interview. But maybe moving towards the objective exam or, or showing the exercise parts you may want to find or have a different device that's more mobile. So just thoughts for that. And you also need to think about your area or your headphones, your microphone and your lighting that can all add or take away from the experience of the digital experience. So making sure that you have those things. I use, I'm old school. I just use the old wired ear buds. They, when you're on the computer a long time, the wireless can die, right? And then all of a sudden you don't have new headphones. So I'm always a fan of just good old fashioned things that won't die on you after a long day of work.

Mark  (18:26):

So something to think about. You also may want to get a tripod to hold up your computer or you can get a standing desk. So there's lots of options in that space. But also you have to be considered for your backdrop. I love your backdrop that you have there in New York here and with the, with the cherry tree, that's all. It's very Boston's. That's awesome. I just have a plain white wall. Just be mindful of the environment that you're delivering this care in, right? You don't want you to be distracted. You don't want the patient to be distracted. You need to connect with the patient. Some of the key things that you need to think about are the connection that you're going to have with a patient. Something you can do easier face to face. It's challenging to get the connection and to have the emotional connection with the patient by a digital care. So setting up the environment for not only you to feel safe and, and that you feel comfortable that you're, no one's going to bust in, but also your patient needs to feel safe in that space too, so they can communicate to you in a free way that their patient information isn't being broadcasted to other people as well. So backdrops, microphones, computers, tablets, all have to be taken into consideration while you're doing this, while you're doing this intervention.

Karen  (19:32):

Okay, thank you. Those are great tips. How about cats that could, that could help or hurt you. Right? People love a cat. Great. If not, it can be a problem

Mark  (19:44):

Or at least they're not allergic to it. They're alerted to it. It doesn't matter. Right? So

Karen  (19:47):

Right. So pets can help or hinder, just kind of depends. Okay. So we've got, let's say now everyone has a better idea of how to set it up. And then the next question I got was how, Oh, they said this is great. Sound isn't great. I don't know why this sounds not great on, on Instagram, but, well, I mean it's going to be out on it as a podcast as well. So we'll, you'll be able to hear full sound tomorrow. At any rate, I dunno what to do. I could get my earbuds, but as we just said, what if they time out on me? Yeah. Okay. So let's talk about let's talk about how do you, what was it? How did, Oh, how do you actually execute a session?

Mark  (20:40):

Yeah. So once you've got somebody on the line, once you've got a patient in front of you, right? We know from our PT and our PT exam that about 80 to 90% of your differential diagnosis occurs in the subjective. So you go back to your old way of being, you shut up and you listen to the patient. Right? So, you know, so this is also assuming that you're doing an evaluation via telehealth, right? So most people at this space have patients that they'll flip from brick and mortar or in person into telehealth. So that's a different beast, right? So that's followup. That's exercise progression. Those are obvious things, right? That you're going to show them. You're going to talk them through their progression and talk to them about what they need to do next. Maybe show them a few new exercises when you're, we're, we're going to get, what we're talking about right now is the new patient that you'd never met before and what, how do you gain information to get them treated?

Mark  (21:33):

So subjective is key, right? You need to have your differential diagnosis hat on. You need to ask the next best questions, their intake form. You should have looked over, created your hypothesis list and make sure that you have a good idea of what you're trying to discover. It's your responsibility as a provider. I know it's written in the Texas legislation that if you, if the patient is not appropriate for digital care, you have to get them to an in-person provider, right? So doing your, you still have to do your red flag screens, you still have to do your due diligence and your differential diagnosis and make sure the patient's appropriate. Right? This is, you have to consider a digital visit to be no different than an in person visit. You have to take every precaution that you would take. I'm minus taking vitals unless the patient has their own, you know, portable, vital kit. You're gonna have them do that. But you have to take every precaution you would from an initial evaluation perspective as you would in a digital space. So going back to forms, you also have to have your intake form and consent to treat in there as well. That needs to be signed off as well.

Karen  (22:31):

So the, the same sort of forms that someone would have if they were coming to you or if you're like a mobile practice like me, you have them sign that initial paperwork regardless of whether you're seeing them in their home, in your clinic or, or via telehealth completely.

Mark  (22:48):

This is, you cannot be this any differently. Right? So take it, having all the consent to treat forms, signed all your intake paperwork done, differential diagnosis, red flags, you know, your three tiers. Are they appropriate for physical therapy or are they a treat and refer or they refer. You have to have that, you have to have that hat on. And so if they're presenting with sub with symptoms that aren't musculoskeletal and presentation, you need to be mindful of that and get them to the approved provider, right? So you have to be a triage at this point. So once you get through and determine their appropriate for intervention, you have to get your thinking hat on, right? This is where, this is where things change. And as a mobile PTM, I know that you have walked into somebody's house and been like, huh, how are we going to do PT in here today?

Mark  (23:32):

Or you have to completely be a problem solver. Think about being a problem solver on steroids when it comes to digital health. Right? Because you didn't have, at least in someone's physical environment, you can see what they have available. Right? If you treating me right now, all you would know is I'd have a white wall behind me. You don't know what chairs I have. You don't know what equipment I have. You don't know anything that I have. So asking them about what equipment's available is important. I take all my patients, depending on what they have, if they have, my most common thing I treat is, is back pain. So most commonly about 20 to 40% of patients, that's 20 to 30% of patients will fit into some type of directional preference when it comes to low back pain. So I take them through an active range of motion our digital active range of motion to see what exacerbates or relieves their symptoms. And if, and if repeated extensions and standing it relieves their symptoms, I go why? Clear out other things, but I go right into treatment. Right. So you can use progressive movements, repeated motions right in your treatment from the get go the same way you would do in the clinic.

Mark  (24:35):

Some of them prior,

Karen  (24:36):

It's New York. I don't even literally grown even here at anymore. It's just did with something there. Is there the engine going up, I don't even hear it. Anyway.

Mark  (24:46):

White noise. White noise. Yeah. So you have to go through your objective range of motion in your objective measurements just like you would in home or in the clinic at home. So knowing your physical exam and having a musculoskeletal screen is super important. So if I have somebody with radiating arm pain that I'm treating, where's my arm on my camera? If I have somebody with radiating right arm pain, I'm going to take them through cervical active range of motion. I've actually even had people do over pressure to themselves. Right. To see, I've had somebody to do their own spurlings to see if it's ridic. So you have to get really creative teaching someone how to do a UNL TT a on camera is because you have to back up. Right? That's another thing. You have to have visibility and you have to have the ability to see what the patient's doing and also correct them while they're doing their motion. So I take my patients, do as many physical exams that they can do on their own without, without me being present to do it.

Karen  (25:45):

Yeah. So I think it's important to note cause my good friend Amy Samala said, can you do this for brand new patients in your practice or is this just to be used for existing patients? So I think Amy, I think we're covering that right now, that yes, Mark is sort of taking us through how he might do an initial evaluation with someone via telehealth.

Mark  (26:05):

Totally. Totally. Now I think we should probably circle back to billing again and payment. I think we, we've,

Karen  (26:12):

Yeah, yeah, yeah, yeah. Let's definitely talk about that. And one other thing that I, I want to make people aware of, Mark, is how using you want to have space. So not only you want to make sure that not only your patient has space or depth, but that you do as well as a therapist because you may need to step back to show them something and then come closer.

Mark  (26:33):

Right. And I've I often, so I have a flat couch in the back, so I have this couch that's right behind me so I actually use that. I pushed my chair of the way and I show repeated extensions and prone. It's a six or seven foot long couch and I show double needs to test and I sh if I mirror exercises for patients. So you cannot do everything verbally, you can't. Could you imagine telling somebody, okay, I'm going to walk you through a double a single knee to chest with words only. It becomes extremely challenging. So you get up and you move. I just hop on the couch. I'm like, all right, so you're going to lay on your back. You'll grab both knees. You see my hands on the outside of my knees. Knees are slightly apart. We're going to pull that all the way up until you feel a big stretch in your back and I show them.

Mark  (27:13):

I walked through the exercises with them. Same thing with, same thing with nerve glides, right? If I'm doing a U L T T a I'm going to say, I'll bring your a shoulder all the way up. Like you're going to put those little, or you CC that you're going to put the little ion right and then you're gonna lift your elbow up and see if that changes it. Right. And so you have to walk them through. It's easier for them to mirror you than it is to say, okay, you need maximum shoulder flection with external rotation. NOLA deviate. Like you can't do that.

Karen  (27:39):

Yeah, we know jargon doesn't work. Yes. You can never say that in an NPR. If you are face to face them, you would never just sit there with your arms folded and be like, okay, flex your arm to hear externally. Like if you just want to do that, you wouldn't do it. I think it's important to know that we can still certainly in well versed in strong verbal communication in this space. Oh, that's nice. From work. Yes. Or there was a delay. Oh, okay. So I think we're good. So Amy said, yes, sorry, there's a delay. She's all the way in New Jersey, so forgive the Jersey part. Yeah, New Jersey. Okay. all right. So I think people get an idea that yes, this is how you can set this up. You just want to make sure that each of you have enough physical space to do everything that you want to do. That yes, you can do your initial evaluation. It's all about the subjective, in my opinion, in that initial evaluation anyway. Definitely. and then once you see them for the initial evaluation, as you start progressing them, like you said, it would be like any other exercise progression you're just not putting hands on, but it can be done.

Mark  (28:51):

Definitely. Definitely. If you think about the interventions that we do in the clinic that you can apply to home. So I work with people that you know, that don't, they may not have good balance. So safety is a, is a concern in that space. Right? So I talk people in a corner, I show them what it looks like to get into a corner with a chair in front of me or in front of my couch or the chair in front of me and teach them how to do single leg stance while having my fingertips on the chair. Right eye. You have to physically show people what to do so they understand that better. And so like you said, it's about being able to show and speak at the same time, right? Because a lot of the field like nerve tension testing, a lot of times it's, you can feel the tension before the symptoms ever get there.

Mark (29:34):

So you have to educate somebody that has a really angry nerve that's a, it's a hot nerve and say, look, we're just going to take this up until you barely feel it. Right. We're just going to touch it. And then if you feel it there, just bring it back down. Right. You, you can't rely on your hands to feel that tension anymore. Not that we can reliably feel it anyway, but we want to make sure that we prime the patient for success. Right? Communicate expectations. Like we're going to do some discovery today. We're going to walk through a lot of different movements to see what's happening with your body. See if we can figure out ways that we can help you feel better through movement. Cause that's what ideally what we're going to do, right? We need to make sure that we enable patients and make them feel safe and comfortable that we're going to help them. We're going to take them through this. We just need to, we need to communicate to that. This is going to be something that I should be completely comfortable with. Yeah.

Karen  (30:24):

Perfect. All right. Now let's get to the part that everybody really wants to know about billing. Someone. let's see. Oh, Mark Rubenstein also New Jersey. He had kinda some of the same questions. No, I have nothing against New Jersey, New Jersey. So he kind of had the same question I had before we went live. He said but Medicare will only pay now for existing patients as per info yesterday. So this is the info, I guess on that evisit versus tele-health. So can you kind of give us, cause I know just for background, Mark is a part of a PPS task force and he is really being updated a lot. And I'll let you kind of talk a little bit more about that and, and how you are helping to work the billing aspect of things and the difference between an evisit and tele-health.

Mark  (31:20):

Right. I'd like to first shout out to the PPS members, Allie shoes and the I and alpha are our lobbyist for the APA. We are meeting for hours daily and we are, so everyday we have scheduled calls on this task who have a task force. We're pushing out content on the APA plus the PPS site. So there are 18 to 20 people that are hard at work to get, to gather information, to interpret it and then to question it and then make sure that it's legal. Right. Because there's information that comes out that it's great information, but it may not be legal for us to do based on practice act. So there's, there's a federal level, then there's the, then there's the PTA level, then there's the state level, then there's your individual insurance levels. So there's a, there's so many different paradigms. It's not just a cut and dry situation.

Mark  (32:06):

So right now, some of the biggest things that we're working on behind the scenes with this PPS task force are really are defining out what it means from Medicare as it relates to the visit ruling. So E visits technically are not telehealth. Medicare is not calling these eVisits tele-health. They're calling them eVisits because they derive them from the medical, from the MD coding as, as a bra, a brief and abrupt follow up to a situation where the patient is in an engaged patient. So imagine somebody who may not be feeling well after seeing, having a doctor's appointment just to follow up to touch. So the visit codes right now can only be billed based on time, so their cumulative time and there are three levels. The max level is 21 minutes to be billed one time over a week. And so you add all the time for one week and over 21 minutes is the third code.

Mark  (32:59):

And that can only be a build a once every, well in seven one time in seven days. There is a question right now about whether or not that code can be repeated the next seven days. That information has not been gotten yet. We have not had a clear answer on that. So please be patient while we investigate whether or not that code can be repeated the next week. So right now, currently we are still working on whether or not now that these eVisits have come out, the question is now whether or not CMS sees us as telehealth providers, which upfront does it look like they do. But we still haven't gotten for Bay. We still haven't gotten the, the appropriate word from CMS whether or not we are. We are providing tele-health, which they said we're not. So we can assume we can assume anything.

Mark  (33:49):

But so they said we're not providing tele-health, but we think they will. They won't include us in the, as a telehealth provider, which is extremely important because if they don't consider us Medicare providers, then we can, well, I'll wait about Medicare billing Medicare patients, we'll, we'll wait to hear what happens. I'll have to have an update on that. And so right now we are not approved providers for telehealth, for Medicare. And we can build he visits with an established patient that has to make contact through a patient portal to the provider to request their evisit. Now it's been clarified that you can notify a patient that they have the option of that type of care. You can tell the patient, Hey, you know, we're not treating people in person, but you do have the option for an evisit. Here's how you do it. If you choose, if you were to choose to have an E visit, you would go to this part of our website to our port, your patient portal and request a visit so you can prime patients to go utilize that service. Whether or not you can only do that for one week or multiple weeks, that's in question.

Karen  (34:52):

Okay. And a patient portal is not Skype zoom face time or any of the telehealth platforms that is not a patient yet.

Mark  (35:04):

Well, some platforms have a portal, some, so it has to be a patient portal. So it has to be a place where a patient can log in and request a visit. And so we're still also waiting for a clear definition of a patient portal. But for our understanding the patient, it's a place where the patient goes to get their information or connect or message their provider. Right. So right now that's still being clarified through CMS on the other private payer front and medicate well, so Medicaid is being rapidly adopted by payers all across the country. Right. So we've seen, I know Louisiana is about to release a wording today at some point. I know that I think Minnesota, I think that a few others have already, Medicaid has already blasted that inflammation and that are, that are, that there are approving and paying for telehealth or physical therapists, payers on a national level are all over the place.

Mark  (36:00):

So if you are a, in the work provider, you need to call your payers and ask very specific questions and we have people working on this across the country. You have to ask them if your patient has tele-health benefits, you need to ask them if those benefits are payable to a physical therapist. So if a therapist is a PT, a paid as a payable provider of telehealth services, if they need any modification codes, right? So like an Oh two location code modifier, right? That needs to be asked and then what CPT codes they reimburse for. Okay. Right. So manual therapy is not going to be one, but neuro, our neuro they're ex their acts home care, self care, all of those codes should be available. And it just depends on the, on the payer and the carrier. Okay. I have a Google doc that we can link that I'm trying to collect that data from across the country.

Mark  (36:58):

So people can have open access to it that I can send you that link here and it's on a couple of Facebook pages. But we're trying to collect that data so people can see because, and you don't put any reimbursable fees, don't breach your contracts, don't talk about a fee per schedule, but where you're scheduling fees or your fee schedule. But I'm just put whether or not they pay if it's parody, right? Some States out parody. So here's the kicker. Parody States doesn't miss it necessarily mean payment, right? And this is a, this is a very confusing, a very confusing thing. So somebody says, Oh, we have parody in the state so that, and then we are going to get paid equal in person as we do digitally. Just because you have parody doesn't mean to pay your pace for telehealth, right? They may pay for physical therapy, but they may not pay for tele rehab, right? Yes. Check.

Karen  (37:47):

Why can they just not make this easy?

Mark  (37:50):

Right? So you can have parody in a state and you could have a parody law and then the payer not even pay for telehealth. Right? So there's nuances upon nuance, on nuance. And in some States, some carriers have contracts with larger telemedicine providers and their members can only have telehealth through that tele provider and they may not have tele, they might not have tele PT. So then they had no tele-health, physical therapy option for that payer. Does that make sense?

Karen  (38:28):

Okay, so I'm going to just do this. So for example, I'm just going to take a for example, and tell me if I heard you correctly. Oh one more thing. So Rina said, we're talking about the visits, that's all specifically for Medicare patients only the egoist. Yes, yes.

Mark  (38:46):

As of now we have, we are unaware. I am unaware. I'll say that of any payer that's adopted the evisit policy and that's as of our Medicare Copa. Our coven call ended at noon today. So I don't know. That may change.

Karen  (39:02):

Okay. So let's talk about your individual. Let's talk. Oh, somebody said, Oh Mark, can you bring your microphone closer to your mouth? But you've got the ear buds in,

Mark  (39:13):

Right? So I have my phone a lot. Loose ear buds are going to the computer, but now you see if you can bring the microphone closer to your mouth, then they see my giant fivehead here and I'm like, I mean, how about if I go, that's fine. We'll do that.

Karen  (39:32):

We'll do that. It's fine. It's fine. Okay. Oh, so here, let me just ask some, get some of the questions. So Kim wants to know, she's in New Jersey also. He lives in New Jersey, but her practice is in Brooklyn. How do we find out if our state has parody?

Mark  (39:51):

So again, I, the, I will link you guys to the center for connected health policy and I also have a link to the parody in the different States. So I have links to both of those that I can give you, that we can add to this.

Karen  (40:07):

Yeah, we can put that in the comments under this Facebook under the live here.

Mark  (40:12):

So where, and so the, the commercial parody book is only 150 pages of nice, easy light reading. Where should I go for Facebook live?

Karen  (40:23):

Just go, if you go to my page, just go to me and then you can put it in. You'll see, you'll see us. You can put it in the comment section or we could put it in the comments section. When we're done with the live, we can add it in as well.

Mark  (40:35):

Oh, there we are. All right. So I'm dropping it in the, yeah,

Karen  (40:37):

You can drop it in right now too.

Mark  (40:38):

There's the parody laws. Here is the fact sheet on the UpToDate. This is a live document on what's happening in the world right now. As far as tele-health policies and procedures across the country. So those two documents should have a lot of information. But here's the kicker. Just because the state has a parody law doesn't mean that, that, that the payers have a policy that reimburses tele PT,

Karen  (41:08):

Right? So parody and, and just to be very clear parody means because you, you can do tele-health because you see them in person. So it's like

Mark  (41:20):

No. So parody only means parody only means payment. So parody means if they have a parody law and they both reimburse for inpatient physical therapy and for telehealth benefits, they paid equal.

Karen  (41:32):

Say again

Mark (41:33):

If the, if the, if a payer say let's let's say blue cross blue shield, if that, if that patient has a blue cross blue shield policy and they have a physical therapy benefits and they have tele-health benefits that a physical therapist can provide, they pay equal. Right. Okay. So it's the same face to face as the say. So because a lot of insurances will the 75% or 50% of impersonal versus digital. So it's literally a payment equality clause.

Karen (42:02):

I see. Okay. Okay. But you have to call blue cross blue shield because they may not actually, that patient's policy might not include tele-health.

Mark (42:13):

Right. And then even if they have a parity law, you're not getting paid for it.

Karen (42:17):

Got it. Right. I got it right. It's okay. Kim. I hope that my inability to understand help you. Dah, dah, dah, dah, dah. Can hear Mark fine. I'm physic. Oh, Deborah joy Sheldon. She said, is there a particular language that needs to be included in the documentation? So when we document the visit, how, so? Let's say we know how to set it up. We have the visit, how do we document it?

Mark (42:47):

Right? So you typically documented as a telehealth visit. So there's no you, your billing will coat it with an OTU location modifier, but you need to denote specifically that it was a digital visit. Okay. Yeah, that's the,

Karen  (43:02):

Because we just got a question on what's the location coding for telehealth and you just answered it. So Abby, I hope that that helps you. And [inaudible] can we skip insurance and just bill cash or has this new E health stuff messed that up?

Mark  (43:26):

So that's unsure right now. So the visit has, it's not considered telehealth by early information. That's not considered to be telehealth. We are still not telehealth providers by Medicare. So that should not impact that. That's my, that's my personal uninformed or relatively informed opinion. Please don't take that to anybody else. We're still discovering that. And private payers still do not, are not adopting that yet. That we've heard of. And so you should,

Mark  (44:01):

If you are currently billing or having people pay cash in there and they do not have coverage, then you should be able to continue doing that. Does that make sense? Okay. Right. I mean, you need to check your contract language. Where we get sticky is, is this considered a non-covered service by a policy? Right. So this is where the sticky sticky comes in. Okay. Is tele-health considered physical therapy just delivered in a different manner, not a non-covered service, right? Yeah. Yeah. Well that V that opinion varies. And so if it's a non-covered service for Medicare, you can, they can, you can charge cash for that service. Right? And so, and that also applies to other payers. Correct. So if, if your payer has a policy that considers telehealth to be reimbursable by PTs, you wouldn't be able to pay, have them pay cash. But if

Karen  (45:03):

Your individual patient's insurance does not cover telehealth right, then can you charge the patient cash?

Mark (45:12):

I'm not a healthcare attorney. But we're doing that.

Karen  (45:16):

Where the heck, I know she's on here somewhere here in Jackson. I know she's watching, I saw her log on,

Karen  (45:23):

Come on or Jackson answer that question for me

Karen  (45:25):

Or an answer that question please in the comment section if you're still watching if not, maybe we can ask her or care Gaynor through the APA might be able to answer that question. So again, that question is if Aaron's still watching is if your patient's specific policy does not cover telehealth, again we'll use blue cross blue shield. So they have blue cross blue shield, they do not cover telehealth. Can you charge cash to that patient if they don't have it covered on their policy?

Mark (46:02):

That is a good question. Yeah, that's a great question. And I think, I mean I, I think I know what my answer would be but I cannot speak as

Karen (46:12):

Brought any information to anyone or misleading information. So maybe that's something we can ask Cara Gaynor on Twitter. Maybe she can answer that or if Aaron is still listening, maybe she can pop that into the comment section at some point. So

Mark (46:28):

And having amazing people that are listening that can help. Yeah, exactly. Taking, cause this is a, this is a mad house right now when it comes to legislation and information. So it's all over the place and apparently so yeah, it's just all over the place. We can't information that was [inaudible] I did hear that. Some of the bigger things for Rhode Island and for Pennsylvania this morning, that the governor, the governor assigned legislation that would massively require all payers to pay all providers for telehealth. All right. Yeah. Yeah, yeah. Okay. One other big question that comes up is location for these for, for billing. Right. And so the word from CMS is the, the, the POS code is the location of the billing practitioner. So in the case where remote services are rendered it does not matter where the corporate address of the billing provider is either, nor does it matter what the beneficiary's address, it matters where the services was rendered. That is where the biller is located. Okay. All right. So when that happened,

Karen (47:43):

Put that into like example.

Mark  (47:45):

So when that happens, let's say yes. So if you are, New York has parody, right? Or you got to know you guys have compact revolution, right? Correct. I thought you did. So let's say you're a large provider and you have multiple States that you are in charge over that or multiple States. You treat patients and you're billing Medicare that the, the, the service in the, in the billing, in the service location code is the place where the provider is located.

Karen  (48:18):

I see. So like for example, if we use something like Athletico like a big gigantic company or maybe someone like, I think Michelle Kali has some places in Rhode Island. I think she just went to Massachusetts, but the headquarters is in Rhode Island. So if you're a therapist in their Massachusetts office, you're using Massachusetts.

Mark  (48:40):

No, you're using wherever you are and delivering the code. Deliver.

Karen (48:43):

Where do you get where you are? Okay.

Mark  (48:45):

Okay. Yup.

Karen  (48:46):

Okay. and then Michelle Townshend said, how does this work with EHR? Ours?

Mark (48:55):

Yeah. So eeh

Karen  (48:57):

So she is looking at a separate telehealth provider from our EHR who also does our billing.

Mark  (49:04):

Right. So EHR is, there's only a handful of the HRS in the physical therapy space that offer tele-health as a part of the platform. I think PT everywhere is a platform that has that has it built in. And self doc is another ER EHR that'll be live and in the next couple of weeks they'll have a platform within six weeks. But most of them are stand alone freestanding. So you just have to find the best system that are set up that can work simultaneously with your other systems. There's really no way to unless the company has an integration with your EHR, which the HRS don't like to integrate with people because that's patient data and it's a, it's a whole hot mess. So most of these are just freestanding side by side. So you'll have your EHR on one side and you're in your camera on the other. So you just do, and that's what I did with anywhere healthcare, it's just basic connection so you can document everything ever somewhere else. Okay.

Karen  (50:03):

All right. And then Debra says, Mark, my state has parody related to my hospital being F, Q, H C I do not know what that means. Any insight on that? So what does FQHC mean? Any thoughts if not, maybe

Mark  (50:25):

It's a federally qualified health center federally. Okay. So they have parody. I don't think I understand the question.

Karen  (50:33):

Yeah. In my S my state has parody related to my hospital being FQHC. Any insight on that?

Mark  (50:40):

Oh good. So she Oh, she said they have parody.

Karen  (50:43):

Yeah, they have PR has parody. Yeah.

Mark  (50:46):

I'm unsure on that. That has to parody is I've, I linked that doc into the live on Facebook. I can look up parody by state and by organization. Okay. Yeah.

Karen  (50:59):

Okay. Let's see. Let me we already touched, so I'm just kind of, what paperwork do we need? We talked about that. Oh, what if you're not a Medicare provider? Gosh, all right. Dah, dah, dah. Oh, we are usingG suite and This is from,uKelly Dougan, I think. Yeah. But haven't started officially yet. We have an ABN and I wanted to have liability form as well. So those liability forms, that's something that we can, that you can maybe share also on this link here and people can make it their own. Is that by liability? Like the patient has to sign off on saying yes, I'm okay with having telehealth.

Mark  (51:51):

Is that of course for me. Yeah, I would assume that what she's saying. Yeah. So I'll, I'll create a, I'll create a Google drive folder and drop a link in to the chat

Karen  (52:05):

And then one other, we've got two other questions. So to clarify for service location code, so that you said that, is that like the OTU code? Right. Okay. If I or any of my PTs are in their own home while tele-health with patient, is she using her home address?

Mark  (52:28):

Oh, that I can't answer that I haven't gotten, yeah, that would be a billing question. That hasn't been brought up, but I, we have a meeting tomorrow morning and I'll ask that question.

Karen  (52:39):

All right, Kimmy, we will get to that.

Mark  (52:43):

We're saying the PTs can just stay home and bill from there. But Medicare has specific guidelines on origination sites. And I know if origination sites apply to eVisits versus telehealth. That very question. Do origination, do originations, I'm writing it down so we can ask this to origination sites. Apply to eVisits. Yeah, cause that's, that's a game changer too.

Karen  (53:11):

Yeah, yeah. Oh, sorry. She said, sorry, I meant to say service location. Did you clarify for service location address? If I or any of my PTs are in their home while doing telehealth, do they use their home address or does she use her address? So Kim, like lives in New Jersey, her practice in Brooklyn. So that's a really good question. So, Kim, maybe we can get back to you with that answer.

Mark  (53:33):

And is she a Medicare provider?

Karen  (53:35):

Kim, are you a Medicare provider? I think so. We'll see. We're on like a 22nd delay.

Mark  (53:43):

Yeah. So I'll ask, I'll ask service location for employees versus brick and mortar versus mobile provider.

Karen  (53:52):

Perfect. And then Sarah Catman says, if you are licensed in more than one state, but only practice, may single state, can you only do telehealth in the state you practice in or can you do, hello, hello, hello. Telehealth and States you are licensed in.

Mark  (54:12):

Yeah. So that's where it comes to state rules and regs and yeah. So everywhere that you have a practice reciprocity or you have a licensed in other States, as long as they, you are allowed legally to practice tele-health in that state. Yes, you can practice telehealth in that state. I mean it's, but you have to sit, you have to make sure to abide by the rules and regs when it comes to our the licensure compact of the rules and regs of the state that the patient abides in or they live in. Right. Cause that's just compact language. So like I can do tele-health and Missouri, but they don't have direct access. So I would still have to have direct access or I'd have to have a referral for that patient if I want to open Missouri. Right. So like example. Yeah. so I think, yeah, so we have to make sure that you abide by the laws of the state that the patient resides in. But yes, you can do tele-health across the country. That's the beautiful thing about the compact, right. Compact allows for us to practice across this country with with little, with, without a lot of that a lot of restraint or not restraint, but a lot of challenge.

Karen  (55:20):

Okay, perfect. All right, so we're at about an hour, which is as long as I think people's attention spans are, and I think we have an apparently as long as Instagram will go live. So if anyone has any other questions, please you can keep adding them into this feed here and we'll try and get to them as, as best we can. Thank you Mark for dropping that stuff into dropping those links in here. And again, we'll get some of the, the onboarding paperwork from you and maybe can drop it in here as well, or you can point us to maybe where it's been put in other Facebook Facebook links. But yeah, everybody, you're welcome. You're welcome. And Mark, thank you so much. This was above and beyond. I think what you had to do but I think we all appreciate you so much because we're in a time where there's a lot of uncertainty and tele-health is at least a way to one, keep our patients healthy and moving and to kind of keep our practices going as best we can in these times because we don't know.

Mark (56:38):

Yeah. We don't know.

Karen  (56:41):


Mark  (56:43):

Yeah, I think, I think, I think as a profession we need to remain calm and PT on, right? Like there's a lot of things happening right now. There's to be the, the future is unknown for us as a healthcare profession. All I do know is that it's going to be changed on the other end. This will no longer be an exception to the rule. This will be an expected method of care. People will, will now grow to understand that digital health is a real opportunity in every aspect, not just in, in telemedicine. So I think if I can say one final thing is just be prepared to adopt this and, and, and set up your systems for the long game. Not for this short, immediate, even though the immediate needs to happen. We have things in place like the waiver for using different platforms just to make it happen while it is, but set your practice up, set your systems up for a long game to provide digital care to your patients. Because that's where we're going to go. Part of it is so yeah, but be patient with each other, love each other be kind and wash your hands,

Karen  (57:49):

Wash your hands and don't touch your face. Yeah. And be mindful of the people if you are still, if your offices are still open, be mindful of the people coming into your office. If you are a home health therapist, be mindful of the people that you're that you're going to be treating because they may be in that vulnerable population. And because we, there's so much that we don't know, just be very mindful of how you're doing that and utilizing telehealth is a great way to have that extension of care for our patients, so.

Mark  (58:27):

Right. And feel free to reach out to me market anywhere. Dot. Health care. I'm here as a resource. I'm trying to be as available as I can. I have to go to the bathroom occasionally or drink some water, eat some food, but I'm trying to be as available as I can in order to help help us transition and get through this, navigate this time.

Karen  (58:45):

All right, well Mark, thank you so much. Got it. You've got everything there. Check out. Also, check out Mark's platform anywhere. Dot healthcare. I'll be happy to give a plug for that of course. And thank you so much. I really appreciate it. This is everyone else on this, on this call, so thank you.

Mark  (59:01):

Beautiful. Thank you.

Karen  (59:04):

Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitterinstagram  and facebook to stay updated on all of the latest!  Show your support for the show by leaving a rating and review on Apple Podcasts!

Mar 16, 2020

LIVE from the APTA Combined Sections Meeting in Denver, Colorado, I welcome Tannus Quatre on the show to discuss marketing. Tannus Quatre is Vice President of Sales for Net Health, a leading software company serving therapists across the care spectrum. Tannus speaks nationally on the topics of entrepreneurship, marketing, and finance, and has been published in numerous publications including PT in Motion, Impact Magazine, and Advance for Directors in Rehabilitation.

In this episode, we discuss:

-What do new clients look for when they choose their physical therapy provider

-How to ask your practice ambassadors for a five-star review

-What branding strategies hold the best investment for your practice

-How to convert marketing touchpoints to new client leads

-And so much more!



Tannus Quatre Twitter

Tannus Quatre Facebook

Tannus Quatre Instagram

Tannus Quatre LinkedIn   



A big thank you to Net Health for sponsoring this episode!  Learn more about Four Ways That Outpatient Therapy Providers Can Increase Patient Engagement in 2020!


For more information on Tannus:

Tannus Quatre is Vice President of Sales for Net Health, a leading software company serving therapists across the care spectrum.  Tannus studied physical therapy at the University of California at San Francisco, and has practiced as a PT in outpatient, inpatient and home health settings.  In 2007, he founded Vantage Clinical Solutions, a business services firm specializing in marketing and revenue cycle management for rehab therapists in private practice.  Tannus speaks nationally on the topics of entrepreneurship, marketing, and finance, and has been published in numerous publications including PT in Motion, Impact Magazine, and Advance for Directors in Rehabilitation.


Read the full transcript below:

Karen Litzy (00:01):

Hey everybody, welcome back to the podcast. I'm your host, Karen Litzy. Today, as you can probably hear in the background, it's a little bit louder than it normally is and that's because I am recording this live at the American physical therapy associations combined sections meeting in Denver, Colorado, which has about 15,000 plus people and I am currently in the exhibit hall getting ready for a great interview about why patients come to see us. What is the why behind when the patient coming to see us, what can we do as physical therapists to reach those patients? As we know, there's a lot of people that need physical therapy and a lot of them do not come to see us. To help me through all this, I'm really happy to have Tannus Quatre here to talk about what we as physical therapists can do to help get patients in to see us and to be happy with their courses of care. So Tannus, welcome. All right, so let's just jump right in. Why don't you give the listeners just a little bit more about you and how you went from a practicing physical therapist into more kind of the marketing side of physical therapy.

Tannus Quatre (01:12):

Perfect. Yeah. I started as a physical therapist about 20 years ago. And in my clinical career, I had found that I was much more driven towards being curious about how patients find physical therapists, how physical therapists can run efficient practices so that at the end of the day they can grow their practices and be in business for a long time and care for lots of folks in their community. So I was just really programmed to be interested in those types of things. And so I went off and started my own company that focused in areas like that specifically in the areas of marketing, which a lot of what we're going to be talking about today.

Karen Litzy (01:56):

So then tell us now, why are first time patient s coming to your practice? So in your experience and what you've seen with people you've helped, why are they coming?

Tannus Quatre (02:08):

Yeah. So I mean there's a couple layers to this. So the obvious one is they're coming because they've got something that they need to be fixed or something they need to have addressed, right? They're in pain or, or some sort of, some level of function that they're not currently able to achieve. At a deeper level. And I think this really ties into where we need to be thinking with regard to our marketing strategy is a customer or a patient comes to us because they're looking for hope. They're looking for some better path towards a better life that they are not currently experiencing due to some type of functional limitation or pain or other illness or injury that they're undergoing.

Karen Litzy (02:46):

So oftentimes when people are seeking out a physical therapist, do you think the average person is saying, well, I'm going to look up this physical therapist. I'm going to look up their education. I'm going to see if they did a residency. I'm going to see if they're board certified. Did they do a fellowship or are they saying, how far is this from my home? Do they have parking? Can I get there easily? Do they have appointment times at work for me. So there's a lot of variables there. So what do you think weights as more?

Tannus Quatre (03:21):

Yeah, so really, really great question. I will answer that with kind of a story that pertains to me. I don't know the first thing about cars, but I know that I have to have a car that functions in order to have a productive life, get from a to B, take the kids where they need to go and so forth. So when I need to get care for my vehicle, I go to see a mechanic and I choose that mechanic based on interestingly what, what I think is, is a really good parallel to how customers choose us as physical therapists. I assume going in as I choose a mechanic that most auto mechanics are going to hit a certain threshold for quality. I assume that I go in, I pay my money, my car is going to come out and it's going to work.

Tannus Quatre (04:05):

Sometimes that's not the case, but the most times, and I've used different mechanics over the years, most of the time they hit that threshold. So then the question becomes what are all of the other things that, that not only brings me to find a mechanic in the first place, the one that I choose, but why do I keep going back time and time again? For me, that answer comes down to mostly trust. I in that trust had, there's a lot of tentacles to that rapport, likability, timeliness reliability and so on. But really I keep going back to someone or to a mechanic for reasons other than the fact that they've got the best pedigree and the latest state of the art equipment when it comes to fixing my car because my assumption is my car is going to be fixed when I leave.

Tannus Quatre (04:57):

And I think that that's a mindset that helps me calibrate around what are really truly the drivers of a consumer that comes in and chooses Karen Litzy as their provider and then stays with you over time. I think that assumption that we should be thinking from is that frame of mind shouldn't be that the assumption is the customer's going to get good care and they expect that, but that's the basic bar. It's all of the other things. How much do they like you? How quickly do you respond? How deep is that bond and that relationship you've created that makes them say, I'm going to come back and see you time and time again and not even bother Googling for somebody else that may be out there in their market.

Karen Litzy (05:37):

And I think, I love kind of taking an example outside of physical therapy and as you are saying that in my head I'm thinking like I get my hair colored and I love my colorist. She moved out of New York city. I tried someone else, like the color was good, but I didn't have that bond or that relationship. Like the color is just wasn't, we didn't click, we didn't vibe. So now I'm willing to take an hour and a half train ride to New Jersey to get my hair colored because of the relationship that I have with this stylist, with this colorist. And so I think if we can think about it in those terms, choosing a physical therapist should kind of be the same. So I think you are going for the culture, for the person, for the relationship. And like you said, the baseline should be you get better, right?

Tannus Quatre (06:33):

Absolutely. your hair looks beautiful by the way. But yeah, I think that's a great example. So, you know, another way to maybe say it is how I think about it is we're looking for peace of mind. We're going to have different challenges throughout our life, whether it's our car or our body and we need a doctor as a physical therapist or a medical doctor. We need folks that help us complete our life and our ability to have peace of mind that we have put together that network that is going to help us feel comfortable with the choices that we've made and be able to efficiently realize that the outcomes that we're looking for, even though technically speaking, maybe you could find somebody who is a better colorist for your hair that might even be closer to you, but you've got peace and you've got everything you need and you've got that relationship you need and your meeting that bar for quality. So you go back to time and time again. And I think that's really the threshold we should be thinking about with our customers.

Karen Litzy (07:35):

That kind of segways beautifully into what I wanted to ask next and what is success? So when we think about a successful plan of care or a successful business, is it good outcomes or great outcomes or is it good relationships or maybe it's a combination of both. I don't know.

Tannus Quatre (07:56):

Yeah, great question. So obviously outcomes are extremely important. So I look at that as a baseline. That's the proof that we've set out to achieve with our customers. So outcomes undoubtedly. But when you do look deeper beyond that and you're looking for metrics that help you understand, am I doing a good job of yes adhering to or you know, treating through a plan of care and making sure that I'm doing good in the moment with this one customer. Outcomes is definitely something you should be looking at. But looking deeper than that are we creating a lifestyle that is going to be sustainable beyond us? I start to think about things like, okay, how compliant is a customer or is a patient with the plan of care that I'm putting into place?

Tannus Quatre (08:50):

How good of a job am I doing at influencing that customer to believe they need to be compliant with what I'm asking or prescribing them to do? And then loyalty. Are they coming back? Are they completing their entire episode of care or not if they, you know, do I see them through one episode and then I never hear from them again for the rest of their life when I know for a fact that they're going to need myself or a substitute for myself at some point in time. To me those are really, really important indicators of success when it comes to how good of a job are we doing, not just being technicians as rehab therapists but as educators and ambassadors for the profession. That really the better job that we do there to set our clientele up to be able to know when to use us effectively and how to adhere to what we prescribed to them. To me, that's really where success comes in because by us planting those seeds correctly and motivating an influence in our customers to participate, that's ultimately how they're going to keep themselves healthy for a lifetime.

Karen Litzy (09:57):

I love that you use the word ambassador. I use that all the time cause someone asked me a couple of weeks ago, well I don't want to say, I don't want to say you're a referral source, I don't want to say Oh my patients are referral sources and there's something else I can use cause it just feels icky to this person. It feels icky to me too. And I said, well I, instead of saying referral sources, I say that my former patients or clients are all ambassadors for my practice. And that's what I say to them. Like, thank you for being such a great ambassador. So I don't have a referral fee or anything like that. I just have like a lot of thank you cards. They say thank you for being such a great ambassador. So I'm really glad that you use that because I think that's a mindset that brass people have to get out.

Tannus Quatre (10:48):

Yeah, absolutely. And I appreciate that point. I would say also that I love the word ambassador and I think that by that ambassador, being an ambassador is very empowering and empowering somebody is a gift. And we have the ability to provide that gift to our clientele by helping them feel like they're now part of the profession by going out and encouraging others to experience the same benefits that they have. And if we get that mindset right and we're really have a culture of ambassadorship both within our profession as our professionals and with those that we serve, sky's the limit for what we can create.

Karen Litzy (11:28):

And I think it goes beyond your individual practice, but it helps to elevate the profession of physical therapy.

Tannus Quatre (11:35):

Absolutely. Yeah. And it makes things like when we're talking about marketing, marketing is kind of like a logistical, tactical, strategic thing, right? It's like how do we attract people to us? It makes it very authentic and simplifies it quite a bit when we really think about it from the standpoint of building ambassadors through quality, passionate care that people want to go out and rave about.

Karen Litzy (11:58):

Absolutely. And now I know we've been kind of interchanging these words throughout the interview, but we've got patients, customers, clients. In your experience, what kind of clicks for that potential person coming to see you? What do they want to be called or what should we be calling them or does it matter?

Tannus Quatre (12:21):

Yeah, I think they probably want to be called by their first name. I think that what we want to I think that the mindset that we want to be in though is that, and this is my personal preference, but I'm an ambassador of this idea, so I'm going to be passionate about this is customers have a choice and choice is the key. If we look at that variable there, a customer can choose to come see us for the first time and they can come, they can choose to come see us time and time again. They can choose to be compliant with their prescribed therapies which sometimes are painful or not very enjoyable at all. Right? The choice is really that key term. And for me, choice equates to being a customer. Customers have a choice. So if when we use the word patient, although it's you know, in our vernacular and along the health paradigm in healthcare patient to me is being instructed or being prescribed as to what to do. It's the opposite of having a choice. And so for me, when I'm having this conversation with my customers who are private practice owners like yourself, I really I really advocate for the use of customer because I think it really represents what we're trying to do, which is have customers choose us. Time and time again.

Karen Litzy (13:46):

Be sort of more active, play a more active role. Patient can sometimes have more of a passive connotation that I'm just here waiting to hear what the PT needs to tell me what to do instead of having a shared decision making about their plan of care.

Tannus Quatre (14:00):

Yes, yes. And, as we know and more proof of the phrase customer. Our customers are researching us out before coming in. They're looking us up on Google. They're doing all the things that we do if we're buying a product on Amazon, right? So that those are customer behaviors. And I think by us really embracing that, it allows us to be more agile and strategic about our marketing efforts.

Karen Litzy (14:24):

So now let's talk about, you just mentioned Google. So people are going to Google us, they're going to look at Google reviews, Yelp reviews. So, what drives these positive reviews that people are reading hopefully reading about us.


And on that note, we're going to take a quick break to hear from our sponsor net health and we'll be right back. This episode is brought to you by net health, net health outpatient EMR and billing software. Redox powered by X fit provides an all in one software solution with guided documentation workflows to make it easy for therapists to use and streamline billing processes to help speed billing and improve reimbursement. You could check out net health’s new tip sheet to learn four ways that outpatient therapy providers can increase patient engagement in 2020 at

Tannus Quatre (15:25):

So interestingly what's not driving the positive reviews is strictly about outcomes and the quality of care, which is really what we're all about at the end of the day. Right? We kind of started with that. What's driving positive reviews? I would just put it into one word, which is relationship. If you have a strong relationship and within that relationship you identify as part of it, like you're really, really an ambassador raving fan. It's not even if you were to request a happy customer, Hey would you, would you mind saying some positive about me? Absolutely. They're going to want to do that. But, if you think about what really drives someone to take it upon themselves to say, you know what, you are so damn good that I'm going to go out and do a solid for you because I want to help build your business for you.

Tannus Quatre (16:14):

That's based on a relationship. And I think part of it is the identity too, of feeling proud about the fact that like if you get the latest iPhone all right and you're stoked about it, don't you feel kinda good about the fact that you're the one going out bragging about the fact that you're one of the first on the block that's gotten the latest and the greatest in that same sentiment or that same idea is what drives us to go online and be public about positive experiences we have with our rehab therapists.

Karen Litzy (16:44):

And now let's say we're going to get to marketing in a second, but let's say you're a physical therapist, a private practice owner or you're working for a private practice. How do you bring up to your client or your customer like, Hey, I would really love for you to leave a review on Yelp or on Google, when is the right time to do that? And is there any verbiage that we want to avoid?

Tannus Quatre (17:10):

Yeah. Okay. I love the question. The answer is yes, there's a right time. What I coach therapists to be looking for is I just call it the opportunity and it's happening like right now as we speak. By the time we're done with this, it'll have that opportunity will have happened in hundreds of clinics throughout the U S as we speak. That opportunity can come by way of a customer saying, Hey, I feel great today. That's a lead for us, right? That's somebody who's happy and they're expressing that to us. It can be somebody who has achieved an outcome that they had not yet achieved or they met a goal that you had established together and you both acknowledge that in the moment. There's really deep moments too and we've all had them where a customer or a patient gives us a big warm hug and tells us that they love us and they've never ever been in this position before having met us and they're that emotionally bonded to us in that moment.

Tannus Quatre (18:11):

They might even have a tear in their eye. Those are all opportunities and there's infinite flavors of what those can look like. But the first thing we need to do is identify or be trained, really to like see that as truly an opportunity to now build an ambassador. Because now the next step is to empower that patient or that customer to go out and do something that's gonna make them feel even better and it's going to give back to the profession and it's gonna support your business. So once you identify that opportunity, it's a very, in a very authentic and sincere way to say, Hey, listen what you just expressed to me as, as my patient or as my customer means the world to me. And that's why I exist and I want is to help people just like you. Would you be willing to help me help others experience what you're going through in this moment?

Tannus Quatre (18:58):

Right now the answer is going to be a resounding yes. Now it's logistics. Okay? Would you like to know how this is what you can do? Are you on Google? Do you have a Facebook account? Are you on Yelp? You figure out what, what flavor suits your business needs best. We find that most, it's easiest on Google or Facebook because most people are there. But it's simply, Hey, if I provide you with a link and all you had to do is click that link and leave a positive review, would you be willing to do that? Would you make that commitment? To me, the answer is going to be a resounding yes. And we find that to be highly successful at tying the opportunity to the ask and to the results.

Karen Litzy (19:37):

Perfect. Thank you. I'm sure a lot of people will find that super helpful. So now we spoke about why people are coming to you for the first time. What does success look like? What drives those reviews? How we should be thinking about our customers or clients, patients, customers or clients. So let's now tie that altogether and talk about marketing. So how does all of that tie into the way we should or could be marketing our practice?

Tannus Quatre (20:09):

Yeah, I mean in infinite ways.

Karen Litzy (20:14):

It's an easy question, right?

Tannus Quatre (20:16):

Yeah. Well I mean to me that's all the fodder that the best marketing plans out there for large organizations or small should be using, which is do we have our fundamentals right? Do we have customers that we can benefit? Do they say positive things about us? Are there signs of success that they're coming back for more and more? Are they compliant? Are they loyal to us? If you have those two things you can now take that and deliver that out into your community as evidence or social proof that you are the provider of choice. And how do you do that? You know, how can that be constituted within the context of a marketing plan? We believe a lot in content marketing because really everything we do, including this podcast right here, it's all content, right?

Tannus Quatre (21:06):

And content is the best tool that you can be using for marketing. Cause you can use it to draw people near to you. So whether it's taking that a script that we just discussed to generate a five star review online, that by itself is one prong of a marketing plan. That is a content marketing plan that's driven by content that's coming from a happy patient that they're then posting online, taking testimonials or if you use outcomes tools and you're able to demonstrate that you're better in your market than your peers and taking that content and then dripping it out via social channels via the press, via email, name, the channel, it doesn't matter. But by dripping that out there into the community and using that to pique curiosity, curiosity and interest, that's basically leveraging your fundamentals into a very, very strong marketing plan.

Karen Litzy (22:00):

And let's talk about consistency. So we know that it takes a lot of touch points before someone will purchase. Like, I think I was doing some research a couple of months ago and came across this study where I think it took 20 touch points for someone to buy a chocolate bar and it was like 300 before they would buy an expensive set of headphones. And so a touch point can be just like you said, it could be something on social media, could be something they read in, in a publication or a blog or, so we know a lot of touch points are necessary for something that might cost a little bit more money or a little bit more time. Right. So let's talk about consistency of marketing and what, what can we do?

Tannus Quatre (22:41):

Yeah, it's a consistency of those touch points is, is really everything. So, we tabulate that basically in terms of impressions. So how many times do eyeballs or ears meet with the brand that we're promoting. And then in addition to that, you want to have a variety of how those touch points are experienced. So it would be one thing to have you just to use your examples. Let's say it's 20 touchpoints or  300 touch points through email. You think about that, that's going to have one type of impact on you, right? And that impact might be, I'm getting too much email. Okay, well but if you, if you get to that 20 or that 300 points and it's through a combination of certain percentage of email, social media, I'm getting some through the podcast, a little bit on the new station.

Tannus Quatre (23:34):

I'm getting, you know, something in my snail mail mailbox at home. All of those different touch points aggregated together. It's really how all the big brands do it. If you think about that when we buy an iPhone or we buy a Nike or something like that, we don't just see him in sports illustrated or the Apple store, we see it in multi channels every single day. We'll see. We have about 6,000 brand impressions that a customer is exposed to every single day. Right? And in order to permeate that as physical therapists, we have to have true consistency and volume when it comes to touch points, what that exact number is, if it's 20 or 300, it's going to depend on a lot of variables that are going to be unique to your market or your practice. But the key is you have to be consistent and you have to be, you have to be multichannel.

Karen Litzy (24:27):

Different spokes in that wheel, right. In that marketing wheel. It's not just snail mail or it's not just a Facebook ad here and there. It's a lot, especially in a world where people are bombarded on a daily basis by stuff. Right?

Tannus Quatre (24:45):

Yeah, no, absolutely. Yeah. So, so then I will sometimes get the same question, like, how many times do I have to, you know, touch a customer with a piece of collateral? Or how many times do I have to market to an influencer or a physician before I can expect them to do X, Y, and Z ? And that's the wrong question to be asking because there's no straight answer. It's iterative. If you track your data, you're going to know for you exactly how much budget and how many impressions you need to see in Facebook in order to generate a lead, right? It's going to look different maybe for email, but the key is to really understand your own business and don't be afraid to try something new. If you're not doing email campaigns, which I would suggest to you're doing right, try email campaign, track your conversion rates and see if it's something that's working for you.

Karen Litzy (25:38):

And you know, we'll start wrapping things up here a little bit, but if you could give a physical therapy, let's say a private practice owner, we'll use that. What would be, and again, knowing there's a million tips, but what are your top few tips on how to market efficiently and with integrity and to not feel like a used car salesman?

Tannus Quatre (26:06):

Yeah. okay. A couple of things. So the first thing is believing in yourself and your value proposition. That's the biggest threat that we have to our profession is that sometimes we feel like we're too expensive or we feel like there's too much cash that's owed up front from a patient. And we start to second guess ourselves so that in any marketing channel we were not as effective. Okay. So, so that would be the first thing I would say is really understand and believe in your value in everything you craft around that's going to have a lot of authenticity, sincerity, and passion and that will be felt and heard. Okay. And I think the second thing that I would probably offer is know your lane. There are if you take some of the big brands out there, they have resources to be able to succeed at a certain scale that doesn't work at a smaller scale.

Tannus Quatre (27:05):

Okay. So just because it can be effective to have the name of your company splashed on the, you know, the outfield fence, you know, for a major league ballclub doesn't mean it's right for you. Right. so knowing what your lane is and a lot of times if I kind of now bring it down to kind of the micro level and talk about a small private practice, a small private practice trying to do a whole bunch of different marketing things, man, it's going to be hard to do. And probably what's going to end up happening is you're not going to really hit the bar on any one of those things. So I would much rather counsel a private practice to say, Hey, we're going to dominate these three areas. We are going to lead our community with workshops.

Tannus Quatre (27:54):

We're going to do better than anybody else with holding workshops in our facility. We're going to do it consistently. We're going to pour the resources on and make sure that every single month we're doing workshops and we're also going to dominate Instagram. You know, if you said those are the two things, because that's, you know, it, it comes naturally to you. It's channels that you're familiar with and it was just those two things and you didn't do anything else. I think you're going to have more of ability, more of an ability to have success. And if you don't have success or you do to be able to understand and tweak your success if you choose those lanes because they can work for you. And I see far too many people trying to do a little bit of everything, throwing spaghetti at the wall to see what sticks and the reality is you don't meet the threshold anywhere and you really don't know what's working anywhere. So you don't know how to, how to tweak things and make them better over time. So I think that the authenticity and believing in yourself and really knowing your lane and choosing to stay in that lane are the two things.

Karen Litzy (28:55):

Some advice and it's, you know, if we put it into our client language, we would never give a patient 10 exercises on the first time we see them. We would give them maybe one or two so they can master those. Because if you are trying to do 10 you end up doing none. So I can understand that. If you're a small business owner, I'm a small business owner. If I tried to do a million different marketing ideas, I'd be like, forget it. This isn't, I'm not doing anything. I'm done. No more marketing. Yep.

Tannus Quatre (29:24):

And, and, and, and that's kinda what happens. It's a lot of back to you mentioned consistency. It's a lot of starting and stopping. When you try to do too much, it's you say, okay, I'm doing a lot of everything. I don't know what's working or what's not. So pivot, try something else. It may or may not be more successful. Right.

Karen Litzy (29:38):

Great. Great advice. All right, now it's a question I ask everyone. Knowing where you are now in your life and in your career, what advice would you give to yourself as a new grad right out of PT school?

Tannus Quatre (29:52):

Okay. love the question. Leave fear at the door. I spent too much of the early part of my career, probably the first five to seven years or so. Asking for a lot of permission. Thinking that there was a lot of things that weren't quite right for me and that there was some excuse or some magic wand that other people had to achieve things that I thought were really compelling or intriguing. Instead of just getting out there and saying, screw it, let's just fail fast, fail often and like get on the path to success. So I think that's the one thing that I would have told myself to do out of PT school.

Karen Litzy (30:33):

Excellent advice. And that could be at any stage of life. Great advice. So now where can people find you? Tell us a little bit more about your company and where they can find it.

Tannus Quatre (30:42):

Yeah, absolutely. So I am proud to be part of the net health company, so I can be emailed at You can also find me on all of the social channels at Tannus Quatre.

Karen Litzy (31:02):

Awesome. Well, thank you so much for taking the time out and in the middle of CSM, and hopefully this isn't too loud for all of you listening. I don't think it is, but thank you so much, Tannus. This was great. And again, if anyone wants to reach out to Tannus, we will have all of those links in the show notes at so thank you.

Tannus Quatre (31:22):

I love it. Thanks for having me, Karen.


Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram  and facebook to stay updated on all of the latest!  Show your support for the show by leaving a rating and review on Apple Podcasts

Mar 9, 2020

On this episode of the Healthy, Wealthy and Smart Podcast, Jenna Kantor guests hosts and interviews Domenic Fraboni on content creation for social media.  Domenic Fraboni is a physical therapist in Los Angeles, California and lifestyle consultant focusing on mindset, movement and meals through online coaching.

In this episode, we discuss:

-How to choose the right social media platform for your target audience

-The importance of developing engagement with your content

-How to stay authentic and avoid the negativities of social media use

-And so much more!


Domenic Fraboni Instagram

Domenic Fraboni Twitter

A big thank you to Net Health for sponsoring this episode! 

Check out Optima’s Top Trends For Outpatient Therapy In 2020!


For more information on Domenic:

Domenic Fraboni is a Doctor of Physical Therapy and Certified Strength and Conditioning Coach. He earned this after graduating from Mayo Clinic School of Health Sciences in Rochester, MN IN 2018. He is a member of the American Physical Therapy Association (APTA), attending many events nationwide to advocate for the advance of the physical therapy profession as well as accessibility to higher quality of care. As a recent member of the APTA Student Assembly Board of Directors and active advocate for healthcare reform, Domenic likes to focus his efforts on systemic healthcare change. He was an avid coach, unified partner, and volunteer coordinator for Special Olympics. He now has relocated to Los Angeles where he coaches people into their bodies using a unique approach of Health and Lifestyle consulting in the areas of mindset, movement, and meals through his company, The Wellness Destination. Domenic focuses his services on the true and authentic connection he hopes to create with patients, clients, or those who looking for help on their health journey. Then he may be able to help empower individuals overcome some barriers and create true progress and independence in their lifelong healing journey! 


For more information on Jenna:

Jenna Kantor (co-founder) is a bubbly and energetic girl who was born and raised in Petaluma, California. Growing up, she trained and performed ballet throughout the United States. After earning a BA in Dance and Drama at the University of California, Irvine, she worked professionally in musical theatre for 15+ years with tours, regional theatres, & overseas ( until she found herself ready to move onto a new chapter in her life – a career in Physical Therapy. Jenna is currently in her 3rd year at Columbia University’s Physical Therapy Program. She is also a co-founder of the podcast, “Physiotherapy Performance Perspectives,” has an evidence-based monthly youtube series titled “Injury Prevention for Dancers,” is a NY SSIG Co-Founder, NYPTA Student Conclave 2017 Development Team, works with the NYPTA Greater New York Legislative Task Force and is the NYPTA Public Policy Committee Student Liaison. Jenna aspires to be a physical therapist for amateur and professional performers to help ensure long, healthy careers. To learn more, please check out her website:


Read the full transcript below:

Jenna Kantor (00:01):

Hello, this is Jenna Kantor with healthy, wealthy and smart, super excited to be here at Graham sessions 2020 with Domenic Fraboni, who I know from student assembly running for that, the board of directors and then also now on social media, which is our big focus because he has been putting a lot of work specifically on Instagram. So I wanted to have a discussion on this journey, I'm going to call you Dom now. Let's make it casual with Dom, so, first of all, thank you so much for coming on.

Domenic Fraboni (00:37):

Thanks for having me and being interested in what I might have to say. It's been kind of a journey this past six months with a lot of changes for me, especially career-wise, location-wise, and the social media thing. You just want me to dive in a little bit.

Jenna Kantor (00:50):

Actually first, let's start with why you chose Instagram, because when choosing a social media platform that you're thinking of a specific audience, so would you mind diving into that so people can start picking their brain and thinking, even if Instagram is where their audience is?

Domenic Fraboni (01:06):

I think my choice in platform had a little less to do with what I was wanting and just have more by chance. You know, I started dating somebody who has a big following and notice some of them started taking a liking in me or an interest in me. And it was at that point that I realized, Hey, Instagram, I've wanted to find a place I can start creating some content, whether it's recording exercises, whether it's just putting out thoughts, thought provoking things for potential clients or potential humans. I'm all about getting access to good information out to the humans so that they can make the decisions for themselves. And we know in this online era and the age of information, I would love to be contributing to what I think can be, you know, more trustworthy information that's online. So I started getting this Instagram following and I'm like, okay, let's do this. Let's put out some content. And I think it worked great for that because a lot of times people go to Instagram for content of that sort. So I'm like, Hey, great marriage. So that's kind of how choosing Instagram as a platform came about more by chance than by my direct choice.

Jenna Kantor (02:12):

How did you figure out what your content would be on?

Domenic Fraboni (02:19):

Yeah, that's another great question. I'm kind of in my purpose moving into this career as a professional. I always said I want to empower people to independence in their journey, right? And then kind of my themes that came out of that were movement. I'm a doctor of physical therapy. So clearly movement is huge to me and how I deal with clients and patients. Mindset. Cause I do also understand that in the psychosocial realm of how we treat humans and how we deal with humans, our mindset, our emotions, our mental state has a lot to do with how we feel physically and how we move and meals. So I'm like, Hey, maybe if my content surrounded those three themes, that can be my stick mindset, the movement and the meals. And it had a little, a little bit of a ring with the three M's there.

Domenic Fraboni (03:03):

So that's where I just started with those three things in mind and trying not to question myself was the biggest thing going in where you asked, Hey, how'd you know what kind of content to put out? I knew I had these people following me and that they might be interested in what I have to say. So my first step was just doing, it was starting to put out content and asking questions. If you ever have a time online where you have people following you and you don't know what they want, ask them. And so I started asking questions. I was very lucky to have people around me who had kind of gone through a transition like this into putting themselves out there. And a lot of what they said is just do it. You know what you're good at, you know what you're passionate about. These people have started following you for a reason, the ones that need to hear it will resonate and the ones that want certain things, we'll let you know when you ask. So I started asking questions to the people that were following me and they also just started putting out content and realizing what it was that people resonated well with.

Jenna Kantor: (04:04):

And for you, what were your measures that you are using to go, Oh, this is what they want to see from you?


Domenic Fraboni:

So I like to say that and a lot of people in social media want to try to separate the success of their posts and their media from the likes and the comments and that stuff. And it can get really kind of cloudy in our head as, Oh, why did this not have as many likes as this? And so really early on when I started doing this, I tried separating myself from likes. Everyone wants a lot of likes on their stuff and it really is not likes on your posts that mean people are engaging with it or connecting with it. The things that I really started to realize is the more direct messages, the more DMs or the more comments that people are connecting with are saying like, Hey, I love this.

Domenic Fraboni (04:56):

I tried it. It feels this way or I'm glad you shared that. Thanks so much for sharing more about yourself, whatever that means that I'm connecting with them personally in some manner. And so I liked to kind of dive into those ones that got a lot of personal direct messages or comments. And I'm big when it comes to feel and the energy between an interaction with people. So when I got interactions back from people that fueled that same purpose or energy, that was the reason I put that post out. There we go. Like those are my metrics. And I live in more of a subjective world myself because research makes me cringe a little bit sometimes. But it's the field that you can't get away from. So when I had people responding to me that made me feel something, I understood that maybe they took something away from that that made them feel something inside.

Domenic Fraboni (05:43):

So try to steer away from becoming obsessed with likes or comments and really steer towards and into the things that, you know, people feel something when they read it and will connect with it and reach out because of that. And I feel like I've helped to engage my audience a little more.


Jenna Kantor:

I love that. And with all the content that you're doing, how did you figure out how often you're going to be posting?


Domenic Fraboni:

Yeah, so like the frequency is huge too because consistency breeds trust, you know, people, although we are putting out this free content and it does take time to put together, you know, people like following, you know, people are content providers that they know are going to be there for them or that they know are going to be there and continue to put that out. So I'd say the first thing was like, okay, I need to be consistent.

Domenic Fraboni (06:35):

And initially when I was starting this, I had a little more time on my hands and I was, I decided, okay, I can take Sundays off and I'll post six times a week. And then I realized as I started getting more coming onto my schedule that that was a bit tough and so I landed on doing something about three times a week, three to four times a week and making sure I'm very consistent in that, but then also engaging when possible and making sure that those connections that are made aren't just done because I need to make my three posts a week again is all has to come from this intention inside me, so whether it ends up being two times a week or six times a week, I know that it's all still coming from this great energy that I trust and in behind what I'm putting out.

Domenic Fraboni (07:18):

Again to create those relationships, whether online or whether in person or whether just through DMs or comments. We are creating relationships and connections with these people in some way and so if the post I can put out has a slight influence on that energy that might drive them to be open to different options, then that's what I'm going to put out. I've landed somewhere in that realm of three or four days just based on how much other work I have in my collective sphere right now. But I think that's plenty for me to continue that frequency of engagement to make sure people know that I'm going to show up.

Domenic Fraboni (07:54):

Do you have to know everything to start something on Instagram? Yes. If you're not an absolute expert, then you no, absolutely not. And I think if you look through Instagram pretty quickly, you'll realize that not everybody is an absolute expert or knows everything in what they're posting. And I hear a lot of PTs or specifically younger PTs who will see other pages and be like, what the heck is this? Like, this isn't how it is or this isn't how you should do that exercise. Or like, wow, they aren't even paying attention to this. And my thing to them is like, we'll record an exercise and put it out or record a video of yourself doing it and say like, this is how I do it. Not to bash or be against that person. I'm very, very much so against calling people out. I put my air quotes over that even though we're on audio, but calling people out or having turf Wars with other people because you don't agree with them. We don't have to agree. We do also just have to understand that there are a lot of people that are open to those other routes. And this isn't for PTs.

Jenna Kantor (08:56):

This is for people.

Domenic Fraboni (08:57):

Yeah. So leave your ego at the door, leave your ego away from your phone and put out great content that you know you can stand behind and you won't have to worry about that as much.

Jenna Kantor (09:10):

I love that so much. What has been the biggest lesson you've learned since really diving into your consistency and all your content on Instagram?

Domenic Fraboni (09:19):

Yeah. Be authentic and trust yourself. It's really empowering. Well one, when you find that empowerment within you just to say like, I know what I know and I know where that comes from. And when you sit in that space, no matter what you put out or what someone says about it can impact that. And so yeah, I spend time on posts that I put out and they don't go anywhere. Maybe I have a slight bid or a question in my head like what happened there? Why did that not get that following? But I don't emotionally attach myself to any expectation on that. So the biggest challenge is the expectation of yourself or the comparison bug that might come out. Instagram's doing this thing where they're taking away the ability to see likes on a lot of posts now, which I think in a lot of aspects is great cause there are a lot of people in these younger generations that are going through anxieties and depressions because of this technology addiction, which is a whole nother topic.

Domenic Fraboni (10:17):

And that's the initial reason I never wanted to get into this cause I knew technology draws on these very addictive processes to get people to continue to use and to continue to abuse those processes until literally we are physiologically addicted. And that's why I stayed away from it. And instead knowing that that can happen and the intent from where I'm coming, I know that we can use these processes that may be addictive to get great information out to people and to help them understand and have access to that kind of stuff. So yeah, my biggest challenge, a challenge is going back to your initial question was you know, comparison and seeing what other people are doing, which is why I brought up the likes and like, Oh they got that many likes and they have this many followers and this and that. You know, like you start wanting to do that in your head again, shut those things down right away because you don't know what their purposes are, where the people that follow them are coming from or what they're looking for. And so be authentic and try not to get that comparison bug on your shoulder.

Jenna Kantor (11:18):

Boom, Shaka Laka I love that. So where can people find you on the Instagram?

Domenic Fraboni (11:24):

So if you type in doctor, just drDomDPT, it's drDomDPT, you can find me. I put out stuff on movement, mindset and meals. And my goal is to empower you to independence in your journey. Cause everybody could use a little bit of good information to maybe open up what other possibilities could be on your path.

Jenna Kantor (11:45):

I love that. So thank you for everyone who tuned in to listen to this podcast. You can also get that information on where to find Dom in the bio as well. Dom, thank you so much for coming on.

Domenic Fraboni (11:56):

Thanks. This has been amazing. Jenna. I love getting to see you here at Graham sessions and thanks for interviewing me.


Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram  and facebook to stay updated on all of the latest!  Show your support for the show by leaving a rating and review on iTunes!

Feb 24, 2020

LIVE from the Graham Sessions 2020 in Nashville, Tennessee, I welcome Erica Meloe on the show to discuss how to create a brand ambassador. Erica Meloe is a board certified physiotherapist in private practice in NYC. After a decade solving financial puzzles on Wall Street, Erica took her MBA and her problem-solving skills into the clinic. She specializes in treating patients with persistent unsolved pain and her mission is to raise awareness of the physical therapy profession to a level like no other.

In this episode, we discuss:

-The lack of public understanding of the role of a physical therapist

-How to turn your patient into your brand ambassador

-Inexpensive acts of kindness that will make you memorable

-Why you should network outside of your profession

-And so much more!


Erica Meloe Website

Tought to Treat Podcast

Why do I hurt? Book

Velocity Physio Website

Erica Meloe Twitter

Erica Meloe Facebook


A big thank you to Net Health for sponsoring this episode! 

Check out Optima’s Top Trends For Outpatient Therapy In 2020!


For more information on Erica:

Erica Meloe is a board certified physiotherapist in private practice in NYC. After a decade solving financial puzzles on Wall Street, Erica took her MBA and her problem-solving skills into the clinic. She specializes in treating patients with persistent unsolved pain and her mission is to raise awareness of the physical therapy profession to a level like no other.


Erica is co-host of the podcast "Tough To Treat: A physiotherapist's guide to managing those complex patients." She is also a thought leader in the profession and helps her patients, as well as her colleagues, empower themselves to lead and live with purpose.


Erica has also been featured in Forbes, BBC, Women's Day, Better Homes and Gardens, Muscle and Fitness Hers, and Health Magazine. She is also co-host of the Women In PT Summit, held annually in NYC. Erica is actively involved in spreading the word on social media and at her website


Read the full transcript below:

Karen Litzy (00:01):

Hey everybody, welcome back to the podcast today. I am here with physical therapist, Erica Meloe and we are live in Nashville, Tennessee at the Graham sessions. And for those of you that don't know, Graham sessions is all about bringing up big bold ideas, things that might be controversial, things that may be we're not talking about as much in the profession and it's like a big think tank. And so today Erica and I are going to try and take that in, miniaturize it down to a podcast. So one of the things that really I guess gets to Erica is the lack of knowledge of what we as physical therapists do, how we operate and how we can help people. So Erica, what are some things that you have maybe even experienced? I'm sure this comes out of your experience as a practice owner and as a physical therapist for many years. So I'm just going to hand it over to you and let you kind of talk about some of the things that really get to you. And if you have any suggestions or solutions for other physical therapists or the general public that we can do to perhaps mitigate this situation.

Erica Meloe (01:14):

Well, thank you Karen. Thank you for having me on the podcast. Graham sessions is wonderful in Nashville. I've never been to Nashville, so I know it's quite nice. One of my mentors or business coaches asked me a while ago, what can't you shut up about and what I can't shut up about? I mean, there's many things, but this so irritates me is that people still, consumers and other healthcare professionals do not understand what we do at all. They don't understand. They think we're all exercise. And I know that this is a topic that's been beaten around for many, many years. And for me it's just, it drives me crazy. And I'll just tell you a story related to Karen. I had a patient of mine who just texted me. I'm an out of network practitioner and she has a certain like a deductible.

Erica Meloe (02:03):

She has to meet. She's like, well, I'm going to wait to see you. I'm going to wait to see. I'm going to go meet my deductible. I'm like, well, why don't you meet your deductible with me? Am I not as my profession? Not as valuable to you in your mind. And I think as a profession we need to start when we can talk about the marketing and the branding, but that's not what this is about. We need to start at the grassroots level with our patients. I mean our patients are our voices and we need to develop relationships with them and we need to actually make the ask. I think we sometimes in our profession, we're not shy, but we don't make the ask and I'm guilty of this. We don't make the ask of our patients.

Erica Meloe (02:50):

What is your view of me as a therapist? What is your view of me as a profession? How can I get a seat at the table? For example, you know in a discussion in Washington, how can I get a seat at the table? You know, at an AMA conference. I know a lot of physical therapists out there are speaking at other non PT conferences. But I think it first starts with our patients developing, we talked about you know, a lot of these business and leadership skills, these soft skills and yes, those are very important. But the relationship with our patients, the patients will get that word out. I mean there are time and time again, we both experienced it. You treat so-and-so and the word gets out. This physical therapist is different, this is what they do. And I think that starting with the interpersonal relationships, relationships matter, I think it was on Twitter, somebody mentioned recently that she spent 40 minutes on the phone talking to an insurance company or a doctor and was that worth her time? And you know, she got a lot of comments and it was like relationships matter and that's value to the patient.

Karen Litzy (04:02):

Oh, absolutely. So I agree with you. It's all about relationships and those relationships, that Alliance that you create with your patient, that patient then goes out and they become your ambassador and not only an ambassador for you, but an ambassador for the profession as a whole. So instead of saying, which we heard today, people say, I went to PT and it was crap and they didn't do anything. But instead, wouldn't it be great if all of us PTs are forming these relationships, are treating patients with the latest evidence, are not wasting people's time, are making people feel better. Or I would even argue making people more functional, getting people to an elite level of sport. And that's what physical therapists can do. And I feel like a lot of patients, if they have gone to a physical therapist and they say, I did, they just put a hot pack on me and then some Estim, then do my exercises. And then I left. And you know who that patient was? My own dad. My own dad was like, well, why would I do that? He's like, I can put a hot pack on at home and go to the gym. Well that's not quite the care that your talking about.

Erica Meloe (05:21):

Right. So that was your dad. So you know, he would never say anything to you like you know he would not basically say, you know, all physical therapists are like that because you're his daughter. So you know, I talk about, you know, building relationship with your patient and your patients. Number one are your advertising or your marketing and your brand. You know, we can spend a lot of money and we, you know, a lot of people do on all of these business courses and that, you know, marketing and the branding and the social media and that's all great. But if you don't have a relationship with your patient, it doesn't matter.

Karen Litzy (05:58):

What are some tips that you can give to the listeners to create a good relationship with your patient.

Erica Meloe (06:03):

But say, you know, and I speak from experience and seeing other therapists work over my years, go the extra mile for your patient. Go. There are many times in patients, for example, they're going, they'll email me, they'll text me and on weekends and I answer those text messages and I answer those emails and they are like, thank you so much for answering an email on a weekend. And yes, that's a very basic example, but actually matters to these people.

Karen Litzy (06:37):

Well, the basics matter. That's the simple little things that you can do that takes two seconds of your time.

Erica Meloe (06:45):

And also just listening to your patients. And yes, I do have a tendency to run a bit late when I see patients, but I will tell you, Karen's laughing cause you know, but if someone asks you a question and you're 10 minutes late for your next patient, you don't just say, I can't answer it now. You know, and this is obvious, but that patient, they may have gotten a hundred percent better with you, but they're, Oh, they're going to remember it. That last encounter. You need to make every encounter matter, whether it's listening to the patient, whether it's you know, listening to them about something that's unrelated to physical therapy. And going that extra mile. And asking the patient, you know, what do you want from this relationship? It's a relationship and it's a trusting relationship. And, once again, you know all the branding is fabulous, but they're your voice.

Karen Litzy (07:49):

Yeah, absolutely. And I think it's also important to remember that this isn't a relationship of you being above your patient. It's a partnership relationship.

Erica Meloe (08:07):

And what do partnerships do? You know, they give and they take and there's a sacrifice, but I would offer this advice is your patient is your patient for life. Right? It's like that lifespan practitioner that we talked about so often and they should be treated as such. For example, when they leave your office for, let's say you've seen them for 10 visits, their back pain's gone and they're kind of good to go, but they're not really, once again, we don't discharge patients, you just, you know, see them and then they come back whenever they've got something else going on. It's not a word I like to use that. It's funny, I often say I don't use discharge anymore. I actually say you know, I'll see you if you have any other problems, just just come on back and I will keep in touch. I actually think using direct mail, and I've tried this, said this before really helps.

Erica Meloe (08:52):

I actually send birthday cards out and thank you cards and thank you cards after I have a a new patient, I will send a thank you card. Thank you so much. Nice meeting you. And patients are saying they come back and they're like, that was a great touch. I really appreciated your card. Honestly go into your database. I’d get an Excel spreadsheet of all your birthdays of all their patients birthdays. It is an easy thing to do and then just note them down and write them, go on a Sunday, spend an hour and a half doing that. It will matter. I know, it's funny because I had an assistant of mine do that and I was like, Oh, she has a birthday very similar to mine and you know, and, and they actually do appreciate that.

Erica Meloe (09:37):

And you know, I've been a patient myself and I, you know, we hope we can get the odd email and everybody's about, you know, the email marketing. Yes. However, it's not the same.


Karen Litzy:

No, it's definitely not the same. And, and I also can appreciate those tips that you just gave, listening to the patient, sending a birthday card, a thank you card and helping them kind of understand what we do and taking the time for them. These are not huge things. You don't need a certification for it. You don't have to spend money for it unless you get a stamp or something. It's very easy, accessible ways for everyone to enhance that relationship.

Erica Meloe (10:33):

Right. I think someone mentioned today that you might not be the best therapist in the world, but if you've developed a relationship with your patient, that's golden. And I received something from one of my coaches recently and it was a card and it said the best is yet to come. And I was like, Whoa. I was so touched by that. And it took her what, maybe five minutes to write that and not even, and that, and I remember that. I remember that. And when someone is sending that to you before you have to renew a coaching program or before you have to do something, I'm going to renew. I'm going, of course I'm going to renew because that was a great touch. You know, that's the customer service that people forget that we actually need to do in our field.


Karen Litzy:

Well, it makes you feel quite simply that you matter. Yes. And isn't it great that we as physical therapists can give to our patients the gift that they matter because they might not be getting that elsewhere. So if you can do that for your patient, they're your brand ambassador for life.

Erica Meloe (11:20):

Absolutely. You know, and when I started early on, you know, as a business owner, I was actually afraid to ask my patients for referrals. You know, I really was. And to this day it still is hard, but it comes out a bit easier now, you know, if you know of anybody else that could need my services, I really enjoy treating the difficult patients. Just, you know, send them my way and it comes out easier that way and we all have a different view, but they fade like you, you will do that.

Karen Litzy (11:54):

And I remember thinking to myself, Oh, I don't want to do that. It sounds so slimy. Like used car salesman. I don't want to do that. I don't want to be that person. And I remember somebody saying to me, but you're not slimy. So it would never come out that way. So if you're not slimy and gross and you ask someone, Hey, listen, I love doing this. If you know someone, definitely send them my way. I'm accepting new patients anytime. Like it's only slimy I think if you're a slime ball.

Erica Meloe (12:17):

Exactly. And it comes out very you know, with integrity, right? And it's not, of course not because, and if you say it with the passion, like you just did, you know, I love to treat these patients. I love to treat patients just like you. How special is that, right? That you make them feel special and they'll be like, Oh, of course, you know, it's like asking for reviews on a podcast. Oh, I didn't know I had to write a review. You know, can you write me a review? Boom. They don't understand it. And I think that is a good relationship. And once they realize that you'll be in the top of their brain and then they're going to be like, well, that experience was very valuable to me. You know, the birthday cards, the, just developing the rapport, rapport and just establishing relationships that, where it's a, you know, a given a take, but it's almost like a marriage in a way. I mean I'm not married and I certainly know I'm experiencing that, but when you have business partners or podcast partners, it's a given a take. And the ones that last the longest are the ones that, that work together. They collaborate. That's the best recipe for success.

Karen Litzy (13:24):

Right? And exactly what Erica just described is how we as physical therapists can help the general public know what we do, right? So it goes back to the thing that gets Erica every time is people don't know what we do, but there are what 300,000 physical therapists in the United States? It's a lot of people. And so if we can make a difference with every person, then can that cause a little ripple that can become a wave.

Erica Meloe (13:50):

Right. And I would also urge patient physical therapist to go to conferences that are not physical therapy related. Go to a leadership conference, go to a medical writing conference. Go to an urology conference or a women's health conference or that's the wheel. You'll develop relationships and you'll be the brand ambassador cause you'll be the only physical therapist there.

Karen Litzy (14:23):

Very true. Right. Great advice. Well what are the big things that you want the listeners to take away from this?

Erica Meloe (14:29):

That it's the small things that really matter. It's kindness. That's my word of the year by the way. I remember had the word of the year, that's my word of the year. Kindness. It's the little things that matter. Sometimes we need to go back to business 101 like direct mail that actually does work. You know, it really does. That's the main thing. And don't be afraid to collaborate with nonphysical therapist acupuncture as they're developing a relationship there. Cause you will educate them, you really will. And you have to be passionate about this. If you don't, if you're not as passionate about it as I am, you'll do it like half assed in a way. And you know, so, but start with your patients and pick a few patients you really like and you, you know, send birthday cards, send thank you cards, do it for one or two months and see if you get any return on your $1 investment. It's nothing.

Karen Litzy (15:27):

Great advice. And now what advice would you give to yourself knowing where you are now in your life and in your career? What advice would you give to you as a new grad right out of PT school?

Erica Meloe (15:40):

Stop overthinking. I analyze, overanalyze everything and that's good and bad. And I think that if I were coming out of PT school right now, it's not the latest and greatest social media course or marketing course or branding course. You could easily do those via YouTube. I mean, and obviously, you know, but it's really about what are your strengths? We talked about this at the women in PT summit. You need to play to your strengths. Like I like to problem solve. That's one of my strengths and so I would suggest anybody coming out of PT school, do a deep dive into what your strengths are, there's many StrengthFinders is a great one. I would really do a deep dive into looking at what your strengths are and play off of those. Get really good at those and you will find ways to apply those in physical therapy.

Karen Litzy (16:36):

Fabulous. And where can people find you?

Erica Meloe (16:38):

Oh gosh. Online. We've got an my and I'm in New York city right across from Bloomingdale's and all my Facebook, Twitter, Ericameloe. My podcast with my wonderful cohost, Susan Clinton. Tough to treat. And my book, Why do I hurt? Discover the surprising connections that caused physical pain and what to do about them. That's on Amazon, Barnes and noble

Karen Litzy (16:50):

Awesome. And just so everyone knows, we will have links to all of Erica's information under this episode at so Erica, thank you so much. Thanks so much for listening and have a great couple of days and stay healthy, wealthy, and smart.



Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram  and facebook to stay updated on all of the latest!  Show your support for the show by leaving a rating and review on Apple Podcasts!

Feb 19, 2020

On this episode of the Healthy, Wealthy and Smart Podcast, Jenna Kantor guests hosts and interviews Keaton Ray and Scott McAfee on how to develop a successful business partnership.  Keaton and Scott are MovementX business partners.  MovementX is on a mission to heal the world through movement.  We believe that if you can move your best, you can live your best.  We are doctor-founded and patient-focused to help bring more convenient, transparent, and personalized physical therapy care to the world.

In this episode, we discuss:

-What is MovementX and how is it revolutionizing physical therapy practice?

-The importance of identifying the strengths and weaknesses of your team

-Why you need different channels of communication in a partnership

-The key elements of a successful business partnership

-And so much more!



Movement X Website

Movement X Instagram

Keaton Ray Twitter  

Scott McAfee Twitter



A big thank you to Net Health for sponsoring this episode! 

Check out Optima’s Top Trends For Outpatient Therapy In 2020!


For more information on Keaton:

I am a passionate physical therapist and wellness/fitness specialist in Portland, OR specializing in reducing pain, increasing strength, restoring mobility and balance, and optimizing performance. I've worked with clients across the lifespan from those who have never exercised a day in their lives, to those who are afraid to exercise because of pain, to advanced athletes looking to take their performance to the next level.

For more information on Scott:

Dr. Scott believes in a world where anyone can move & live their best. The problem is that with today's healthcare system, finding the best care, avoiding crowded clinics, and dealing with insurance can be frustrating. That's why he chose to do things differently. Dr. Scott's practice is 100% mobile–he provides care in the comfort of your home, gym, or office. He brings a mobile treatment table and helps you decrease pain, increase strength/mobility, prevent injury, restore function, and coordinate your care plan. Wherever & whenever you need care, he can be there. It's convenient, valuable, & personalized to whatever you need. Dr. Scott works with a wide range of people, from youth athletes & avid runners to active grandparents & busy businesspeople. Call or text the number above to get directly in touch with him, and you can have a free phone consultation about what health goals you want to accomplish!


For more information on Jenna:

Jenna Kantor (co-founder) is a bubbly and energetic girl who was born and raised in Petaluma, California. Growing up, she trained and performed ballet throughout the United States. After earning a BA in Dance and Drama at the University of California, Irvine, she worked professionally in musical theatre for 15+ years with tours, regional theatres, & overseas ( until she found herself ready to move onto a new chapter in her life – a career in Physical Therapy. Jenna is currently in her 3rd year at Columbia University’s Physical Therapy Program. She is also a co-founder of the podcast, “Physiotherapy Performance Perspectives,” has an evidence-based monthly youtube series titled “Injury Prevention for Dancers,” is a NY SSIG Co-Founder, NYPTA Student Conclave 2017 Development Team, works with the NYPTA Greater New York Legislative Task Force and is the NYPTA Public Policy Committee Student Liaison. Jenna aspires to be a physical therapist for amateur and professional performers to help ensure long, healthy careers. To learn more, please check out her website:


Read the full transcript below:

Jenna Kantor (00:00):

Hello, this is Jenna Kantor here with Healthy, Wealthy and Smart. I'm here with Scott McAfee and Keaton Ray and I am tired. We are at Graham sessions 2020 and I am so lucky to be interviewing the two of you on your partnership with movement X. So first of all, thank you so much for coming on. It's an honor to be speaking with both of you. So first, would you mind explaining what movement X is and then dive into how your partnership began?


Keaton Ray:

Sure. So movement X is a group of United providers across the country who are providing care in an inspired way. So we refer to it as the 11 star experience. We're going above and beyond the five star experience and providing care where people need it most, when people need it most, whether that's at their home, at their gym, at their workplace, on the track and field at their doctor's office. We're showing up and providing care that makes a difference. So improving lives on both sides of the treatment table for the provider and for the patient.

Jenna Kantor (00:58):

All right, and now your partnership.


Keaton Ray:

Sure. So where to begin? So Scott and I first connected on movement X in 2016 or early 2017. Started with a phone call. I knew that Josh D’Angelo and myself couldn't do this on our own, so we called up some trusted partners that we had known closely through the APTA. Scott was one of the very first people we talked to and immediately had a connection over the mission, which is you know, help people move their best so they can live their best. And I'll hand it over to Scott who can explain the transition from that first talk about movement X to him, actually quitting his job, moving across the country, dropping everything to help us with our vision.

Scott McAfee (01:50):

So it was a very exciting time for me. I was just finishing up my residency program in Southern California. And I loved the people that I was working with. I loved my coworkers. I love my patients. And it was really an amazing residency experience at this hospital. However, I was somewhat displeased with the with the environment of dealing with insurance companies and being somewhat limited in my ability to truly and deeply care for people that I knew I had the potential to as a physical therapist. And after my conversation with Keaton, I got really, really inspired of what the opportunity looked like for physical therapists in this more mobile cash pay model. And it was I think about a week after I had passed my residency when I knew, wow, there's some real opportunity here.

Scott McAfee (02:52):

And Josh D’Angelo one of the cofounders along with Keaton he had been in the Washington DC area for seven years, was very well connected out there. And at the time right when I was finishing up my residency, I was very comfortable down in Southern California. I had a very strong network. My life was just going straight according to plan per se. And I've never quite learned at any point in my life from a point of comfort and I wanted to flip that on its head. So I decided to move all the way to the East coast to join forces with Josh D’Angelo in Washington DC in addition with Fred Gilbert who moved from Alabama to Washington DC and that's how the partnership began and we began expanding from there and it's just been an absolute wild ride since

Jenna Kantor (03:49):

I love it. And I love how you two interact with each other. You're both good friends as well as definitely business partners. How the heck did you get to that point? Cause I would love for you to first go into your struggles and then what you did to implement something that would work between the two of you.

Keaton Ray (04:08):

That is a good question. So all of us, everyone who started the company actually started as friends way before we ever started at business partners. And that is both one of our deepest strengths as well as probably one of our greatest challenges as well. But from day one, it was intentional on our part to learn each other's strengths and be open to each other's weaknesses and communicate if not over communicate about each one of those. So there is times when Scott and I probably are just at each other's necks, including other people. I get frustrated on a daily basis with everyone and they get frustrated with me. And that is okay, that is normal. But what we've done is we've gone through intentional work where we set aside hours at a time, both on the phone and in person to be open about those strengths and be open about those weaknesses. And each and every one of us over the past two, three years has just grown because of that intention that we've put into growing each other. So it is not easy. It definitely changes the relationship, but it's worth the intention.

Scott McAfee (05:12):

And Keaton and I, we both go back to the student assembly board of directors, although we never served together. I learned so much about how I function on a team in that environment. And I would imagine that you learned the same. And I think once you truly understand yourself and then also once you truly understand and appreciate and realize the mission of what your team is trying to accomplish, that how you get to the end goal of accomplishing that task is irrelevant. You just have to get there. And yes, you are going to agree on certain things you're going to disagree on probably even more things if your team is actually functional. But at the end of the day, as long as you are on a team, it can get to the end goal. That's what matters most. And from there you walk out of the room, no matter what discussion happened inside of that room, all with the same mindset of, Hey, this is our goal. We may have disagreed on how we got here, but now we're all in agreements. Hey this is what matters most. And, you have a clear sight of where you're going.

Keaton Ray (06:27):

One thing I'll add to that, the other two areas of strength. You said it perfectly, Scott. I think one is putting infrastructure into being able to build a communication pathway. So we have a lot of various company languages that we use that help us recognize when we're falling into several habits that may affect the growth. So one example is the six thinking hats. So six thinking hats. You know, the red hat is the emotional hat, the white hat is the fact hat. The green hat is the innovation hat. The yellow hat is the optimism hat. The black hat is the devil's advocate hat. Josh D'Angelo would be so proud. I just remembered that. And so sometimes when we're in a heated conversation or we don't see things eye to eye, we need to recognize, Hey, I'm wearing my red hat right now and you're wearing your white hat. No wonder we're not seeing each other. And various communication pathways like this have helped us to recognize where we're falling short and where we need to improve. And so without those types of things, it would be a lot harder to grow as a team.

Scott McAfee (07:25):

I love how you brought that up as an example because not only does that help us make decisions in the board room per se with business it's also helped me make personal decisions, look at problems that I'm facing in my own life from many different angles, right? Hey, if I had a green hat optimist view of this versus a devil's advocate, why would I talk myself out of this? I think I've been able to look at things from somewhat of a stoic and very objective point of view rather than getting to red hat emotional about certain things. And it's also helped in personal relationships as well. So as much as you can grow together in the boardroom, I think you take away so many different things on a personal aspect as well. And yeah, I love that analogy. That was something that Josh D’Angelo initially introduced and has just been so helpful.

Keaton Ray (08:19):

One more. The last thing I'll say too is if you ever want an ego check, join a group of six. We started with six incredibly innovative, intelligent, outspoken leaders. Sit yourself in a group of six outspoken leaders and have them debate your mission and your vision and your processes and everything in the background there. There is no space for ego when you are working with this large and this capable of a team. So you cannot be a solopreneur and accomplish what we're trying to accomplish. So we've all really worked hard in our egos and it's not always easy, but every single person on this team has done a great job.


Jenna Kantor:

Would you mind sharing your own personal things you've learned about exploring how you work? I think that'd be interesting for people to hear. You're like, I am actually a person who's like this, I would love for you to share that. So then people could even learn how you are so different.

Scott McAfee (09:16):

So I might take a second to think about that. And that's something that I have learned about myself is that it often times helps me to take a second and think of getting my thoughts together on how to approach a certain question or an issue or how to solve a problem. Rather than to just speak my mind immediately. But I will say that right off the bat that going into this team, I'm in just awe of everybody who I get to work with on a daily basis. And people often ask me, Hey, why did you move to Washington DC? It wasn't only for this like larger mission and this larger purpose. It was to have conversations late at night with people who inspired me who I just looked up to in so many different ways. And that was a goal of mine when I was actually looking for different colleges to apply to. I was like, who could I surround myself with and have just really deep and insightful talks late at night with and I just feel so fortunate to be able to do that as part of this team and as our youngest member on the exact team that we have, I oftentimes do try to just be a sponge and take in as much information and inspiration from my team as possible.

Keaton Ray (10:41):

I was laughing through Scott's excellent explanation because sometimes I think we can explain each other's work habits at this point better than we can explain our own. And so I am the opposite of Scott, although it's gotten, I have the team probably operate the most similarly. But you know, there's differences between everyone. So I am very blend and I should take more time to stop and think first. But if something's on my head, it is right out in the open. And so one of the things that we've really worked on as a team between Scott and I, but also between all the team members is managing conflict. So some of us on the team are much more comfortable with conflict. Me being one of them, while others have a little bit more of a reservation around conflict. Now compared to other people, everyone is excellent at managing conflict, but it's a personal comfort as to how you actually deal with that.

Keaton Ray (11:31):

So I would say while Scott says he's much more, you know, maybe has to think about it in, in the background a little bit. I am much more of that writing your face. Oh, I don't agree with that. Or Oh, I totally love that. You know, kind of person. So a lot more forward facing. But what Scott and I have as an extreme similarity is that we are the doers. We're like, let's do it tomorrow. We have idea. Great. Okay, I'm going to stay up all night. We're going to crank this out. We're going to have a product tomorrow. We're going to launch it, we're going to test it a little bit and we're going to redo it. Whereas Fred and Josh tend to be much more of those visionary. Like, let's stop. Let's look longterm. Let's think of how this affects this. And, it is a wonderful combination because all of us compliment each other so well. You can't have one leadership style without the compliment of the other, but it can lead to frustration. You're moving too fast, you're not moving fast enough. You know, back and forth. So the communication puts us all in alignment and we're stronger because of it.

Scott McAfee (12:30):

Yeah. Actually one of the core values in our company is passion times purpose. And you can't have one without the other. And the way that I think about that is you cannot have action without strategy as well. And that's one thing that Josh and Fred are so instrumental in teaching us and teaching me and even keep me, is inspired me in so many different ways to behind everything that I do. Always have a strategy and don't skip steps in the action that you want to take. So I think that's very important.

Jenna Kantor (13:03):

I love that. I love that very much. What made you decide to hire out to figure out how to work better together? How did that, I'm sure alone cause you hadn't figured it had something in play like you do now. How did you get to that agreeing point to go, okay this is who we're going to invest in to improve our communication, to improve our partnership? How'd you get there?


Keaton Ray:

Yeah. So I think what you're referring to is the consulting work that we did for a team development. So we actually got incredibly lucky. We got chosen by a graduate program working on human resources and team development as their trial team to take a deep dive look into each one of our personalities and our work habits and then do basically a report. So we each had a one-on-one like hour long talk with this consulting firm and they went deep into our work styles.

Keaton Ray (13:53):

We'll look it up, we'll look it up. And so then they came back at us and basically gave us a very honest report about how our team is functioning and then gave us assignments on how to dive deep and improve the report essentially. So it was a really hard activity and emotionally draining, but it was so bonding and we're so much stronger because of that consulting work we did. You have to recognize your weaknesses. We knew we're not perfect, nobody's perfect. And so we're willing to invest in the team to improve because without this team, the mission of this company doesn't go anywhere.

Scott McAfee (14:33):

So it was a graduate program at Georgetown university.

Jenna Kantor (14:42):

Yeah, that's very cool. I love that you guys said that is still looking it up to see if she could get more information. And I want to find this information for the listeners in case there is somebody starting a business who might want to look this up and see if this program might help them as well. Because seeing how you two interact, like I said, there really is some magic, dare I say Disney magic happening between the partnership and I think that is absolutely spectacular. Did you find the name?


Keaton Ray:

So it was Georgetown's graduate program. Robin Goodstein graduated from that program and started her consulting firm called Balcony consulting. So anyone looking for team-based collaboration and consulting, she's incredible.


Jenna Kantor:

Now what are your biggest challenges that you have and the easiest things for you guys overall? Cause you guys have grown together, but what are just the constant things that you expect to be like, okay this is a little challenging and this is like easy.

Keaton Ray (15:58):

So this is a hard question. That's a great question. But I think that the easiest thing that we have now is a baseline understanding of how each other operate. The first few months in definitely year plus was just learning each other's habits, learning each other's needs and learning each other's emotions. And now I think we have such an intricate understanding of how we each operate that it's much easier to move the company with speed. Knowing that, I think the hard part is, is we're now in a place with the company that we're really truly starting to grow and we're going to run into barriers that are unlike anything we've ever had. And so, so far we've been able as a team to come together and hustle and make this thing work and create an amazing movement. But we're going to max out of our own knowledge. And so we're going to have to find new team members who come into our company who do not have the same intricate knowledge of one another. So now it's not just managing each other, it's managing other people and having them fit into the culture as strongly as we do.

Scott McAfee (17:00):

I think that's perfectly said because we agreed too much. No. because it's going to be so special and like I said, such a wild ride ahead as we do grow and with as many things that are going to change and as many new obstacles that we're going to face, I truly do believe that we do have a very strong foundation and like you said, baseline understanding and respect for each other and how we both operate. And that goes for everybody in our team and in our community. The more that we can better understand how we operate and all speak the same language they all have the same core beliefs and core values and share so much of the same culture. If you know from a deep level that binds you together, I definitely believe that no matter what obstacle may come your way, you can adapt your team in a very nimble way, in a very strategic way, in order to accomplish that. We're with as many problems as we face and with as much as we have accomplished you know, the sky's the limit. And, I think there's so much growth waiting to be had that it's just so important to have that foundation before you have anything else.

Jenna Kantor (18:21):

I love it. Thank you so much. You too, for coming on here at this crazy, magnificent time here at Graham sessions, you two really set a great bar that is possible for anybody to achieve at their business partnerships. So thank you.

Scott McAfee (18:36):

Appreciate those words, Jenna and I couldn't echo the same thing about you and Karen. You guys are great. This podcast has inspired me when I was a student. So I just feel very fortunate to have the opportunity to speak to your audience and hope that we've spread something valuable worth listening to. So I appreciate you

Keaton Ray (18:58):

Agreed all around. Thank you so much for this opportunity. The one thing I'll leave the listeners with is if you want to build a team and you want to grow a mission, you have to be vulnerable. You have to put yourself out there and let people see what you do know, what you don't know, your hesitations, your fears and your vulnerabilities. Because without that, there's no way you can connect with people enough to build something as meaningful as we're trying to do. So be vulnerable. Put yourself out there, let go of your ego and you're going to create an amazing company culture.

Jenna Kantor (19:37):

Thank you so much. I was wondering where can people find you online if they want to try to reach out to you?

Scott McAfee (19:44):

So we are on Instagram @movementXinc and we are a online also

Keaton Ray (19:55):

Note, our company name is movement X. No space, no dash, but our website is


Jenna Kantor:

Wonderful. Thank you so much. So thank you listeners for chiming in to this great discussion. This will also be in the bio as well. If you want to just check that out too, if you're having a hard time remembering what was just said on how to reach out to these fantastic individuals. Thank you so much.


Keaton Ray:

You can also reach us at We want to hear from you. We're always willing to hop on a phone call.



Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram  and facebook to stay updated on all of the latest!  Show your support for the show by leaving a rating and review on iTunes!

Feb 3, 2020

LIVE on the Healthy, Wealthy and Smart Podcast Facebook page, I welcome Chris Napier on the show to discuss the science of running.  Chris Napier is a Sport Physiotherapist with a PhD in running biomechanics and injury prevention. He has an appointment as Clinical Assistant Professor in the Department of Physical Therapy at the University of British Columbia.

In this episode, we discuss:

-How to bring a wearable to market for running retraining and injury risk reduction

-What to look for when investing in wearable technology

-The importance of translating the research to both the clinician and athlete

-Science of Running: Analyze your Technique, Prevent Injury, Revolutionize your Training

-And so much more!


Science of Running: Analyze your Technique, Prevent Injury, Revolutionize your Training

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A big thank you to Net Health for sponsoring this episode! 

Check out Optima’s Top Trends For Outpatient Therapy In 2020!


For more information on Chris:

Chris Napier is a Sport Physiotherapist with a PhD in running biomechanics and injury prevention. He has an appointment as Clinical Assistant Professor in the Department of Physical Therapy at the University of British Columbia. In addition to working on research projects, Chris continues to be a practicing physiotherapist with Restore Physiotherapy and Athletics Canada. He has competed at the national level as a successful middle-distance runner, earning medals at the Canadian Track & Field Championships in 1996 and 1997. He is also an accomplished marathon runner with a personal best time of 2 hours, 33 mins.



Read the full transcript below:

Karen Litzy:                   00:01                So welcome everyone. So for those of you who are watching live, thank you so much for taking the time out of your day and coming on to watch and learn. Oh good. I'm just making sure that it works. So I just had to check on my iPad to make sure we're live and we are. So thanks so much for taking the time out. As we go along. I may ask you just to kind of write in the comment section where you're listening from. If you have any questions, by all means, definitely, definitely ask. Now is your chance, I'm sitting here with Dr Chris Napier. He is an expert. He is a new author. We'll be talking about his book, the science of running in just a little bit, but Chris, just to kind of allow people to get to know you a little bit more. Why don't you kind of give the listeners and the viewers here a little bit more about you.

Chris Napier:                 01:05                Sure. well thanks again for having me on Karen. I feel like I've really made it big time. Now. I'm on the Karen Litzy podcast. It's huge. So thanks again for having me on. So I'm a sport physiotherapist. I've been practicing for almost 20 years now. And, I've worked with a range of sports. But I sort of ended up coming back to the sport I'm most passionate about. The one I love which is running. About 10 years ago I started really focusing more on running and it was basically because I'm a runner myself. Out in the community running with the various sort of recreational races training with different clubs and so then and talking to people who are running all the time. So it really sort of just made sense for me to kind of work a bit more clinically in that field.

Chris Napier:                 02:00                And at the same time I was getting interested in pursuing more research. And so I started my PhD in about 2012, 2013. And I focused on running and I was really interested in being able to quantify aspects of running in terms of running form and biomechanics. So my PhD was on running biomechanics and sort of clinical interventions using gait retraining to prevent injury. And so I finished that in 2018 and I've moved now more out of the lab so to speak out of the biomechanics lab but still interested very much in the mechanics of how we run. And I'm now working with a group of engineers at Simon Fraser university doing my postdoctoral fellowship there where they actually develop a wearable. And so we're doing some really cool stuff there in terms of actually developing potentially products that will be available to clinicians and to runners to measure their gait.

Karen Litzy:                   03:13                Very cool. And I will also add that you are sort of at the helm of the third annual world conference of sport physiotherapy in Vancouver this year. It was an amazing event. You and the team you guys did such an amazing job and I'm sure that's the feedback that you've have probably got from the conference, from the people who attended. So I just wanted to give you guys some more accolades and a nice shout out cause it was a really, really well run conference with some great info.

Chris Napier:                 03:48                Yeah, that is the feedback we've had, which was fantastic to hear from across the board. And, I'm really looking forward to our continued support for your therapy candidate conferences, which will be a biannual event and as well the next world Congress, which will be excellent, I'm sure as it's being hosted in Denmark.

Karen Litzy:                   04:08                Yeah. Yeah. That'll be fun. And that's in 2021. So that'll be a good time. And again, if you're watching live, I know I saw a couple of viewers watching live at the end of this, hopefully we're going to give away Chris's book. It doesn't come out until February 4th, but if you write your name or a comment or where you're watching from in the comment section, you're automatically in the running for a free copy of the science of running by Chris Napier, which is very exciting. So Chris, let's talk about wearables. So when I think of wearables, to me it makes me think of like a Fitbit or maybe an Apple watch or something like that. So in your introduction, you'd said that you're working with a lab as a postdoc. So when you say wearables, is that what you mean or are you talking about something else?

Chris Napier:                 05:11                Yeah, so I mean a wearable is really a broad category. And you know, for anyone who follows the consumer electronics show, which was just recently in Las Vegas you know, I think that area is huge right now across the board. And, we think of it very much in the health lens. But really a wearable, wearables, anything you can wear on your body that tracks something whether it's, you know, your heart rate or your breathing rate or your pulse or your blood pressure or skin temperature or joint angles, impact forces. I mean, it goes on and on. Really anything we can measure through something we can wear. So, you know, by nature it's something that's portable often, you know, connect with some sort of app either on a Bluetooth device or we'll sort of record onto the actual hardware itself or download later.

Chris Napier:                 06:15                But you know, that's the other side of it is, you know, beyond the wearable, the actual interpretation of the data and the visualization of that and that sort of thing. That's a whole other field as well. But the lab I'm in is looking at wearables that can measure health-related metrics. And so some of the projects we have going on there are looking at recovery from stroke or looking at you know, more fine motor function, that sort of thing. And my area specifically is looking at an application to running.

Karen Litzy:                   06:53                And so when, you know, I think about application to running and you think about, you know, perhaps using a wearable to enhance someone's running, whether it be their running gait, their endurance, their times. And what I think of right off the bat is a running analysis where you've got someone on a treadmill and you've got multiple cameras and they've got dots all over them and all their joints, which is not something that every clinic has the ability to do because those setups can be quite expensive. So what are you doing within your research that might be a little different and offer clinicians something that might be more practical?

Chris Napier:                 07:40                Yeah, so what you described there that sort of motion capture 3d motion capture analysis which is sometimes done on an instrument, a treadmill, which will give you force information as well as the joint position movements. But that was my PhD. So that's what I did. I looked at basically a snapshot of people running and then assume that that's how they ran when they left the lab. Which is a big assumption, right? And so what we're doing is we're trying to get those same measurements but in something that can be worn outside of the lab and in the natural environment which gives us it opens a whole other world to what we can measure. We can measure things where, you know, rather than on a treadmill, which might be unnatural for a lot of people, we can measure them running on the road or through trails or uphill or downhill.

Chris Napier:                 08:40                We can measure how their mechanics changed throughout the course of a run. You know, so we can see what happened when they start to get fatigued. We can measure in a race situation you know, when people perhaps run differently cause they're pushing themselves to their limits. And we can also measure over time, over a weeks or training blocks so we can see what happens to people's mechanics. As a more chronic sort of fatigue sets in. So there's a lot of stuff that we can study. And, in our lab we have sort of the ability to embed some of these wearables into garments. And so essentially we're developing smart garments. And we published a recent paper looking at using a set of running plates to measure hip, knee and ankle kinematics during running. And, we developed this and I think it compared to the gold standard, which is still the three D motion capture and these tights do very well at measuring that movement. Which is exciting cause then, you know, we can start to produce these and runners can start collecting data wherever they run.

Karen Litzy:                   10:01                Yeah. Which obviously seems a little bit more practical than, like you said, just being on a treadmill. We know running on a treadmill is definitely different than running on the road or the track or real life situations. And is that something that a, let's say your average physical therapist practicing PT like myself, if someone comes to me with a running related injury and I mean, I don't have access to a three D running analysis, is this something that I would be able to say to this potential patient he lives in? I have some wearable technology that you can use that might give us a better picture as to what's happening when you're running.

Chris Napier:                 10:49                Yeah, I mean, we're not there yet, but that's certainly where we're going. So, you know, I guess potentially we could, we could put this pair of tights on a runner and we could track their hip, knee and ankle kinematics while they run either on the treadmill in the clinic or we could send them outside and have them go for a run and come back. And or you know, these could be something that the clinic can loan out or rent out and maybe patients keep them for a week so we can track their running mechanics over the course of a week. And then that could potentially be uploaded to a cloud or brought back to the clinic and downloaded so that you can look at their data over time. And what we're using our strain sensors to be able to measure kinematics.

Karen Litzy:                   11:38                And what does that mean? What's a strain sensor?

Chris Napier:                 11:40                Well, essentially these are thread like sensors that the amount of strain produced can give us an idea of how much movement is occurring.

Karen Litzy:                   11:52                That's sort sewn into the fabric.

Chris Napier:                 11:54                Exactly. And we've done, you know, a lot of the research we do is looking at where we need to place these and how many sensors we need and that sort of thing. And so that was the big work sorta involved in developing these tights is to figure out how many, you know, can we get away with just having three or four sensors which reduces the you know, the cost of energy and also the amount of processing involved and where can we put those to optimize you know, the metrics we're looking at. But you can also then add inertial measurement units or I am use which have accelerometers and gyroscopes in them, which can then add a whole other layer so we can look at you know, impact. We can look at angular philosophy and things like that. So, you know, we're looking at integrating those things right now as well.

Karen Litzy:                   12:53                And all of that can be so knit fabric of a pair of tights.

Chris Napier:                 12:57                Yeah, yeah. We're talking about pretty small.

Karen Litzy:                   13:01                That's wild. And so, you know, you did a study kind of taking these tights and looking at, well, how many sensors do we need and where do they need to be placed? And was this sort of a preliminary study, cause I can understand the need for knowing how many sensors you need and where to place them and then kind of recruiting a larger amount of runners to kind of study to see does this do what it says it's going to do it in a nutshell. So right now, just so that the viewer isn't, so that I myself get a better idea. So right now you're sort of in that developmental stage where you're looking at where to place them and how many, and do they work?

Chris Napier:                 13:48                Yeah, we've done that. So basically this study was that, so we were happy with where they are and the number for what we want to measure. And so now what we're doing is can we use these to give us information about you know, the fatigue state that runners are in. So, you know, when we're getting into machine learning and that sort of thing as well with this. So you know, can we classify a runner as being fatigued or not? For instance, based on the information we're getting from these tights or, you know, and then as I said before, like, can we get these out now and actually get people using them so we can start collecting large data sets. You know, that's where it gets interesting. Can we get these out to hundreds and thousands of people to be able to start collecting data on those numbers and really start to refine the technology and perhaps see some interesting patterns.

Chris Napier:                 14:49                And you know, there's some of the studies coming out of refurbish lab in Calgary have been doing that. They use the now defunct Lumo device, which I am used situated on the waste. And they've done some really interesting work with Christine Claremont leading that and Learn Benson looking at sort of classifying situations or types of runners based on the data they've gotten from those devices. So we'd be looking at maybe doing some similar work with ours.

Karen Litzy:                   15:30                Yeah, I mean, very cool. And, I guess the next question is why should we care? So as physical therapists or even as runners, like, yes, this technology is cool, it has the potential to give us a lot of data and a lot of information, but why do we care about that?

Chris Napier:                 15:54                Yeah, exactly. So, you know, I think first of all, we have to figure out, is this going to give us information? That is I think we can be happy that it would be reliable, but really we're looking at the validity. Are we getting information where we're going to see patterns that lead to injury. And that's again, that's kind of where we're going with this. But at this point we can't say that that's where we need those large numbers. And hopefully I think that's what we will find is that we can kind of see trends. I mean, there may be a time where, you know, these are sold in running stores and people just wear them and then, you know, they get injured and they come in and say, Hey, yeah, here's my data.

Chris Napier:                 16:41                Check it out and, you know, see if you can figure out why I got injured. You know, maybe we'll get to that point. But I think for now it offers the clinician a chance to be able to analyze someone's running gait. So you get that kind of objective information. And then maybe they can use that over sort of repeated visits if they're looking at trying to retrain someone's gait or if they're looking for you know, some changes due to the intervention that they're applying, whether it's strengthening or gait retraining or something else. So I think that it gives us another tool really to measure something dynamically that, you know, until now we could only really do in a specialized biomechanics lab, which as he said, is very expensive and time consuming and really maybe only giving us a snapshot.

Karen Litzy:                   17:40                Right. Right. Versus being able to see the bigger picture of a runner. Yeah. Yeah. Very cool.

Chris Napier:                 17:49                And also, you know, maybe some of the work I'm doing is looking at monitoring, training load and you know, if you're kind of familiar with the training load research there's this sort of concept of internal and external load. And you know, the external load might be the number of kilometers or miles that you run in a week or the number of minutes that you run in a week. And the internal load would be some sort of intensity measure or rate of perceived exertion. And so, you know, my interest is, can we get a bit more specific perhaps about that external load. So we're not just looking at minutes or miles, but we're looking at you know, cumulative impact and that actually got a paper in review right now where we looked at that using the run scribe sensors, which are little pods you put on your laces on your shoes and they can measure shock, which is sort of a result of impact force results in acceleration when you hit the ground.

Chris Napier:                 18:56                And we looked at whether there's a difference between looking at just a cumulative minutes, you know, run versus number of steps versus cumulative shock. And we found differences and with the cumulative shock we're going to know a deeper analysis. I'm not sure where we're looking for, are there changes depending on the type of run that the person did. So is it more specific measure? When someone is changing the terrain they're running on or changing their intensity on a regular basis? If someone goes and runs the same route every day at the same pace, then we're probably not going to get more information by a cumulative shock. But if they're running in trails one day and roads the next day and then they're doing interval workout or then they're doing a long run we might get more information out of cumulative shock or some similar measure as opposed to just the minutes or miles that they run.

Karen Litzy:                   19:56                Right. Yeah. So just adding another element to, again, the overall picture of that runner. So like for example, like you said, you could have someone who says, Oh, I ran, I run 10 miles, I'm just making this up 10 miles every week and I haven't changed how many miles I run. But yet they're coming to see you for patellofemoral pain. Or maybe they're coming to see you with anterior shin pain. But what you're not getting is, well, I run the same amount, but this time I did on a trail and this time I did it on concrete and this was on a rubberized track or something like that. So I would assume that with that shock, you would be able to kind of see the difference and then as a therapist say, Hey, I don't want you to stop running, but maybe let's stop doing X, Y, Z.

Chris Napier:                 20:52                Yeah. It allows us not only to look at what has happened, but also to prescribe in the future. Right. So potentially we can then say, okay, we need to keep that cumulative shock below a certain level or, you know, increase it gradually. And so if that's something that they can monitor on their own outside the clinic. Great. and I've done that a little bit with some people just more experimentally at the moment. But I've had people who are really interested in sort of tracking that. They've done that and it's actually been quite successful so far.

Karen Litzy:                   21:24                Yeah, no, it sounds very reasonable to me as a therapist and certainly as I would think for the runner because, you know, oftentimes when runners get injured and first of all, they're told to not run. That doesn't go over very well.

Chris Napier:                 21:42                No, no.

Karen Litzy:                   21:46                And it's also not just the running, but it's part of stress-relief. It's part of what makes them happy. And so to be able to say, Hey, listen, we're collecting all this data on you and this is what we found. This is what you can do. I feel like it gives control back to the patient or to the runner so that we're not spinning. Right.

Chris Napier:                 22:07                Yeah. There was a great paper just published last month that essentially looked at what their runners do when they can't run. Right. So if they're injured and they can't run, what do they do? And the answer was, Oh no, they didn't do other activities. They just say they just want to run. And that sort of, I think validated your feelings. You know, when you talk about cross training and, you know, go get on the bike or go on a full run or a swim. But I mean, the greatest thing about running is you can put on some running shoes and head out the door and you can fit it in anywhere, anytime. So it becomes much harder to fit in that exercise when you have to go to a pool or go to a gym, get it done.

Karen Litzy:                   22:51                Yeah. And then I would think it must be even harder for some, not all, but some runners to get back to running after an injury. You know, there's fear involved there. They don't want to get injured again. They may sort of taper back to the point where maybe now they're not even happy with their running.

Chris Napier:                 23:16                Yup. Yeah. And often, you know, we prescribed like a walk run program to get someone back in because it's sort of graded impacts. Right. So again, looking at that key middle of shock is what we're trying to do there is gradually someone back in to doing that. Even if they've kept the fitness even if they have been on the bike or something like that when you get back after prolonged period off of running, it's still, it can hurt, right. Of the impacts you don't get in other activities. And so again, that's where, if we can measure that and monitor it, I think that's a big advantage.

Karen Litzy:                   23:53                Absolutely. Now before we get to the book, which I want to get to in a second, are there any other cool tech things when it comes to runners that may be you've worked with or that you've seen? Maybe not, you know, in the lab that you are in, but that might be coming down the pipeline that we can as runners or as healthcare providers we can kind of get excited about. And the answer might be a lot, but you can just pick.

Chris Napier:                 24:26                Let's say a lot of the kind of more research grade or maybe not a lot, but some of the more research grade companies are starting to shift I think a bit more to a clinician or consumer level products. And one reason for that is the hardware is just getting cheaper. So, it's possible. And then also I think you know, the ability to fit these into or integrate these into apps where you have the visualization side and you can actually easy interpretation of the data. I think that's you know, we're going to start to see more and more of these devices available in clinical settings and consumer settings. And I think one that comes to mind is I measure you, is basically an IMU inertial measurement unit that now owned by VI con, but you know, they're starting to I think offer products that are a bit more clinician friendly where you can get real time feedback.

Chris Napier:                 25:40                You can stop these on someone's tibia and have them run in the clinic and get some real time feedback and visualize it and give feedback if they're reaching certain thresholds. So if you're trying to keep them and you're trying to get them to run softly, for instance, you can get them to run. And this'll give you feedback when they're going over a certain threshold. Another, a Vancouver based company that I'm doing some research with. It's called plant Tika. This is actually their product here. It's just an insole. So you can just pop this into your shoe lacing. So on your shoe and in the bottom of it, I don't know if you can see here, but there's an IMU here. So it's very thin. Obviously it fits right into the insole and you don't really feel it when you're in there.

Chris Napier:                 26:30                But it's a very strong piece of hardware and you can pop that into your shoe. And I say, well, that it's actually measuring that it measuring accelerations so it's got an accelerometer, but it's measuring that impact at that point where it's hitting your body so it's right underneath your heel. You know, and so we're doing some interesting work where we're looking at different footwear and how that changes the impact at that point, because today a lot of the research is using ground reaction forces, which are measured underneath the shoe, right? That's the shoe round interaction. Or they're using to bill accelerometers, which are, you know, measuring that force once it's gone through the foot and the ankle complex and is reaching the tibia.

Karen Litzy:                   27:21                Some of those courses have already been disordered right through the ankle or through the shoe.

Chris Napier:                 27:30                Yeah. So this is a cool tool and I think they're really keen to start using this. They're targeting clinicians because I think this is an easy one that you know what, I'm using it in the clinic right now where people come in. And when we did the gait analysis, I just slipped these into their shoes and just cause it's that much more information. It visualizes asymmetries really nicely as well. And, and they're also looking at beyond running. They're looking at you know, ACL rehab and that sort of thing as well.

Karen Litzy:                   28:02                And are there any things you can think of that let's say your average physical therapist needs to watch out for? Right. So you have a lot of, cause I know you had mentioned more research based consumer products. I'm assuming that there are products out there that might not be the best things that we as consumers, you know, without naming names obviously, but things that we look at when we're looking at a company that's selling one of these like wearables and what their claims are.

Chris Napier:                 28:35                Yeah. So I think first of all, the hardware has to be good. And when I say that, I mean you need to have a high enough sampling rate to be able to measure what you want to measure. So, you know if you have an accelerometer, that's a sampling it 60 Hertz for instance. If you're trying to, we capture that and you're gonna miss peaks of data and steps. And so it's just not going to be something that's reliable. You know, if you're measuring it at up at the waist crowds, then it's okay because we don't need high as high frequencies at the waist. So no for that we need to how you need to have a product that can sample at a high enough rate and there's papers out there that have looked at that, you know for kinetic and kinematic information, that sort of minimum requirement you would need.

Karen Litzy:                   29:36                And what would that be? Do you know, off the top?

Chris Napier:                 29:38                Perfectly genetic information and it's about a, you need like 500 Hertz for it could be more like 200 Hertz, you know, for the kinetics is going to depend on the placement for sure. But typically you want to aim for something that's about 500 Hertz, you know, a lot of consumer level products wouldn't have.

Chris Napier:                 30:00                And then also something like the dynamic range would be important. And that's just essentially how many Gs they can measure. And so if your using a something that only measures up to 10 G then when you put that on your shoe and you're trying to, and, and there's impacts that are up around 20 G, then you're really not going to be capturing sleep. Right. It's missing that information again. So that, I mean, that's something to be wary of thought of it outside of the hardware would be looking at the output you get. And so some of these outputs you get are very general. You know, typically you'll have like a, you know, I put on my Garmin watch and go for a run and at the end of it it tells me I need to rest for, you know, 36 hours before my next effort or something like that.

Chris Napier:                 31:00                And you know, I never really sort of regard that it doesn't really doesn't make sense. I can interpret that much better myself than relying on my watch. It also spits out a bunch of other metrics. You know, some of them might be useful. Others I would just sort of disregard and I think that's where, you know, probably clinical decision making comes into it. And having a knowledge of the activity and the person in front of you don't overly reliant on just sort of what the metric is outputting.

Karen Litzy:                   31:40                So if you have, let's say a certain wearable on and it gives you again, making something up like 10 different kinds of outputs. I don't even know if that's possible, but you want to kind of take, is it sort of like you're taking what you need as it relates to what the patient's going through? Or are you buying something that says, Oh, it can give me all this information, so I'm just going to use all of it.

Chris Napier:                 32:11                So, I mean, someone like me, I like raw data because I can play around with it and I can plug it into things. I can graph it and I can do whatever I want. And it's that raw data is, you know, the highest frequency and so the best data I can get, so that's what I want. But most clinicians don't want that because they won't know what to do with that data. Right. So it's gotta be processed somehow. And so that processing you can lose data and you can lose focus and you can have misinterpretations along the way. And so it can be something is it can be processed down to the point of where something might give you an efficiency score, right. Which is, you know, unit and listen in essentially meaningless where it says, you know, your efficiency on that run was good, average or bad.

Chris Napier:                 33:08                Yeah. I mean that's something completely processed down to the end where it gives you this kind of, you know three categories. I mean, what does that really tell you? Probably not, or it could be somewhere in between. And so I think that's the hardest part here. And you know, what would be appropriate for a clinician isn't necessarily going to be appropriate for a consumer. So I think again, we're going to start to see products that are aimed more at clinicians and at more consumers as the hardware gets cheaper and more widely available and people are going to kind of sort through and find things that work for them.

Karen Litzy:                   33:52                Right? Yeah. So I guess it's when it comes to the output, it's kind of like food. You don't want things to be overly processed it’s not good for you. Okay. Cool. Well now let's get to the book. So I'm just going to read. So the book again for people watching the book is called the science of running and it will be available on February 4th, but you can go to anywhere books are sold, Amazon or what have you and you can preorder. But I'm just going to read a quick description. I won't read the whole thing, but I'll read a quick description. Science of running goes further than any other running book to intergrate the anatomy. And physiology of the runner showing how running in walls and affects every system of the body, including the effect of oxygen on the muscles. The book breaks down the runner's stride, scientifically showing what's going on under the skin at every stage of the running cycle. Highlighting common injury risk based on a readers natural gait and showing how to correct them, takes a head to toe approach to 30 key exercises for runners, annotating the muscles, ligaments and joints involved, and showing how to perfect precision in those exercises to optimize their benefits. Sounds great.

Chris Napier:                 35:12                I could have used more time.

Karen Litzy:                   35:15                He probably did that in a weekend, but I mean, this is a very involved book. It's not like just a pamphlet.

Chris Napier:                 35:24                No, no, it, it was a lot of work. I won't deny that. And it was a really interesting process for me. Essentially it's like what we just talked about sort of bullying down that kind of raw data or the raw science and being able to filter down to a level that's interpretable by kind of the general public or the, you know, the average runner. Cause that's essentially what this is. It's a handbook for runners about their bodies, right?

Karen Litzy:                   35:55                So this is for the average person runner and for the clinician, right? So not like overly overly technical, but technically simplified.

Chris Napier:                 36:08                Exactly. I mean it's not simple. There's a lot of information in there, right. And we've done our best you know, with the artwork and that sort of thing to be able to explain the science behind all of this. But there's a lot of information in there. I mean, it's not a textbook. And it's not an academic book, but it's very much for runners and clinicians, I think to have on hand. You know, whether it's in a clinical context, if you want to be able to explain, you know, an injury to a runner or you know, explain what you mean by you know, what's happening during running stride. There's a lot of you know, artwork and chunks of text in there that can kind of help to explain that. And for the average runner, I think it's sort of something that they can keep on hand and use you know, if they're training for a race or just in general or something to kind of, you know, refer back to over, over and over again. And there's also a whole chapter full of training plans. It was co-written by my coach Jerry Zack and again, that's a very comprehensive chapter there.

Karen Litzy:                   37:31                Fabulous. And so I'm going to say it again, so for the people that are watching if you leave a comment or a reaction, you're automatically in the running to win a copy of this book. So please, you know, give a thumbs up or a heart or throw in and whatever like where are your lists, where you're watching from or listening in from. Because we'll pick a winner and I'll contact you when we're done with the interview and everything. But so when you talk about a book like this is there ever sort of misinterpretation of by someone to say, Oh, it's a book on how not to get injured when you run? This is a book on preventing injuries?

Chris Napier:                 38:22                Yeah, I mean, yeah, I mean for anyone familiar with the research on running injuries, that's a pretty murky field at best anyway. I think what I tried to do in this book was present what the research does tell us and kind of show, you know, let's take foot strike for instance. Cause everyone knows about, you know, foot strike pattern and you know, we talked about, okay, what happens when you were first strike? What happens when you forefoot strike? And rather than taking the approach that one is inherently bad and we'll give you an injury we talk about, you know, how they affect your stride and where those forces go and that sort of thing. To be able to educate the runner on that rather than talk about, you know, this particular way of running will prevent injury. There's also a large section we've got about 30 different strengthening exercises in the book where you can you know, go through and again, it's a little visualize with artwork showing different stages of the exercises on specific running, strengthening exercises that you can do in the gym or at home.

Karen Litzy:                   39:42                Awesome. Well, it sounds like it's a great resource for clinicians and the runner alike and are you going to, after doing this, and this was, I'm sure an arduous task that took quite a while. Are you going to write a followup in the works or are you like, Oh my God, let's publish this book.

Chris Napier:                 40:02                I haven't really even opened this book yet. I got it. About three weeks ago, and I don't think I might've just opened at once to kind of flip through very briefly. So at this point I'm ready just to kind of keep it on the shelf and see what happens. But no, nothing in the works right now. I'm focusing on some other things right now and if that opportunity comes up, you know, down the line then perhaps a look at that then, but this was a very interesting process to go through. I have no regrets. I think it's pretty cool to see, you know. But I think I'll take a little break for awhile now.

Karen Litzy:                   40:47                I get it. For you, as now an author, what was the best part of writing this book for you? Might've been like, as a person, as a clinician, as a researcher, what was like the big positive for you?

Chris Napier:                 41:03                You know, in research we're always talking about knowledge translation, right? You have to kind of get that research to the end user. And how you do that. It's often very difficult for research. This gave me a lot of tools I think in my own field of how to get that research to the end user, whether it's a clinician or a runner themselves. So that's been really useful. Also I think working in the clinic it made me really think about what are the exercises I think are most valuable or what is the most useful thing that a clinician would get out of this book? You know, I'm often sort of pulling out a textbook to try and explain something to a patient who is in the clinic because they've got an injury and I'm talking about too much too soon or some of that. And I want to graphic where I can say, look, this is why too much, too soon is bad, or this is why, you know, running the way you're running might've led to this injury. And I'm often sort of ending up doing Stickman drawings or something to try and illustrate.

Karen Litzy:                   42:14                Well we all do that.

Chris Napier:                 42:16                Which is fine. But you know, this gives me a resource and hopefully others a resource in the clinic to be able to sort of say here like this is what I'm talking about and here's a nice sort of visualization and in some kind of bullet points as to what I'm talking about.

Karen Litzy:                   42:34                Yeah. That's great. So I feel like it, to me it sounds like it's made you maybe a little more present, a little more thoughtful about what you're doing with runners and why you're doing it. Great. And I'm assuming that's also the goal of the book is have people be a little bit more present, understand the way their body works. This is for the runner, the way their body works and why they're doing what they're doing. And for the clinician may be taking a larger analytical view in as to the person in front of them, the runner in front of them, and maybe why they're getting the injuries that they're getting. And some options on how to rectify that situation.

Chris Napier:                 43:16                Yeah, I mean, I think runners, runners are typically type a people, right? And they, you know, they get really into running and they want to know more and they want to learn like, okay, what's you should I have and what's, you know, what's the best way to run and what's the best way to train? And you know, so they're on Google and they're trying to get all this information. There's tons of conflicting information out there. Even from, you know, some of the top sources, right. Sort of the top sources for that. So again, hopefully this is something that kind of boils it down. It's very evidence-based and something that runners can rely on as a resource for all things running.

Karen Litzy:                   44:01                Sounds great. Now listen, before we wrap things up, I have one last question. It's one that I ask everyone and that's knowing where you are now in your life and in your career. What advice would you give to yourself as a new grad right out of physio school?

Chris Napier:                 44:18                So I would right out of physio school, I think just get your hands dirty and see patients, try and get lots of different experiences. If you're interested in sports, volunteer with teams. You know, don't expect payment right away for those things. Get out and work with people and put in the time and you'll learn a lot and those will turn into opportunities in the future. I think getting out and I'm not saying no to things is a big, big thing. And I think that's how I kinda got involved in working with professionals and sort of national team athletics. It's because basically one opportunity led to another. And I didn't say no along the way and so it just, you know one thing snowballed into the next thing. So I think you know, that's probably my advice. Just get out, start getting your hands dirty and get the practical experience and don't say no.

Karen Litzy:                   45:26                Awesome, great advice. Now, where can people find you if they have questions and they want to find more info about you and about the book, where can they find you?

Chris Napier:                 45:35                Well, the best place is on Twitter. I'm fairly active on Twitter and they can find me @runnerphysio on Twitter and they can contact me through that. Also if people have, you know, wanting to access any of my papers, that sort of thing. They can reach me through my email address which is I'm happy to send along papers or if you have any sort of specific questions, I'm happy to answer them if I can.

Karen Litzy:                   46:07                Awesome. And what we'll do is when this broadcast ends, I'll go back in and I'll put a link to your Twitter and to some of the papers that we spoke about today and a link to the book. So people want to preorder the book, go for it. For all the people who are on and who had some reactions or comments. I will pick a winner for someone to win Chris's book and you'll be hearing from me. I'll get in touch with you via Facebook. So, Chris, thank you so much for taking the time out and coming on to do a live and then it'll be on the podcast as well but to do a Facebook live. So thank you.

Chris Napier:                 46:45                Well, thank you. I've enjoyed it. It's been a good chat and thank you also for all your work in the lead up to the world Congress with all your Facebook live interviews with a lot of our speakers. Cause that was really great to be part of that.

Karen Litzy:                   47:02                Yeah, that was my pleasure. It was great. So everyone who's on and watching. Thank you so much and have a great couple of days and stay healthy, wealthy and smart.


Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram  and facebook to stay updated on all of the latest!  Show your support for the show by leaving a rating and review on Apple Podcasts!

Jan 27, 2020

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome TaVona Denise on the show to discuss burnout in physical therapy.  Atlanta-based business accelerator, success coach and avid cyclist, TaVona Denise lives and breathes by the motto, “success is 80% mental, 20% skill.” With certifications in life, weight and wellness coaching, her specialty is helping new entrepreneurs get past fear and overwhelm, get their business up and running, so they can help change the world.

In this episode, we discuss:

-Burnout in physical therapy and the tools you need to take the next steps in your career

-Why a gratitude practice can help shift your mindset and elevate your to-do list

-The importance of a coach that can identify your blind spots and keep you accountable

-How to channel your fears and build confidence so you can tackle your biggest goals

-And so much more!



TaVona Denise LinkedIn

TaVona Denise Facebook

TaVona Denise Twitter

TaVona Denise Instagram

TaVona Denise Website


A big thank you to Net Health for sponsoring this episode! 

Check out Net Health's 4 Ways to Increase Patient Engagement!


For more information on TaVona:

Atlanta-based business accelerator, success coach and avid cyclist, TaVona Denise lives and breathes by the motto, “success is 80% mental, 20% skill.” With certifications in life, weight and wellness coaching, her specialty is helping new entrepreneurs get past fear and overwhelm, get their business up and running, so they can help change the world.


Shortly after finishing college she started her first two businesses, but found herself burned out because they were not using her gifts. TaVona then used her skills as a physical therapist to start a physical therapy contracting company. Finally her own boss, the problem was, she basically created a job for herself, which was not the life she had envisioned.


It wasn’t until TaVona found the world of coaching, that she was not only able to successfully lose 80 pounds and keep it off, become an award-winning athlete, and build the business that would eventually provide the lifestyle she wanted.


Speaker and author of, Unstoppable Success: How to Finally Create the Body, Business and Lifestyle You Want, TaVona teaches entrepreneurs the steps she used to create lasting success as a lifestyle, in weight loss and in business. She believes there would be less addiction in the world if people were courageous enough to walk in their purpose. She is on a mission to help people find their zone of genius and make money by making a difference.


Read the full transcript below:

Karen Litzy:                   00:01                Hey TaVona, welcome to the podcast. I am so happy to be interviewing you live here in Nashville, Tennessee at Graham session. So welcome to the podcast.

TaVona Denise:             00:10                Thank you for having me. Karen, I'm so excited to be here and to be speaking with you today.

Karen Litzy:                   00:15                Yeah, and I'm excited to have you because what we're going to talk about today is when a therapist, we'll stick to physical therapy, but this really could probably apply to most people in healthcare, let's say. But we'll stick with physical therapists because that's what we are. That's what we know. And we're going to talk about when, as a physical therapist, you kind of hit that crossroads in your career where you're not sure if what you're doing is what you want to continue to do. So TaVona, yourself as a physical therapist and as a coach, I'm sure you've seen this quite a bit. So can you talk to when therapists get to that crossroads and what you've learned from interviewing over a hundred different therapists?

TaVona Denise:             01:03                Yeah. Well, it's a fascinating thing. I started to notice whenever I would remember to ask somebody, like, what year, how many years have you been in the game? What's going on with you? When they're coming to me for life coaching and they're thinking about making a change. The number 15 kept coming up. Every time I would write it down, they're like, yeah, I'm at year 15 I don't know if I was attracting them because that's about when I started to feel like, okay, I've been doing this 15 years. I know my job inside and out, backwards and forward, and I don't think I can do this for the rest of my life. And at that time I wasn't even 40 so I have plenty more work, work years left and I can't keep doing it. And so I just find that, especially for the women, either it's 15 years if they've gone straight through and sometimes it stretches to 20 if they have gone back into part time to rear their children.

Karen Litzy:                   01:56                Okay. And in talking with all of these therapists, have you found any common themes that they get to this 15 to 20 year Mark? And they're like, Ugh, now what?

TaVona Denise:             02:09                Well, that's exactly what they say. It's like, now what? I know my job, I don't necessarily want to keep practicing in this way. I feel stuck. I don't know what to do next. And part of the problem is they do not have a passion for research, academia or management. And so many of them are thinking, well, should I leave the profession? And if so, what does that look like? What does that mean? Am I throwing my degree away? And so what are the options? There are several. I think one of the things that we have to do is take a look at, well, why did you get into the profession in the first place? And can you reconnect with that? Are there aspects outside of what you're doing that you can bring into what you do now to help judge it up and renew it? To me, some people have reinvented themselves and said, okay, well maybe I don't necessarily want to stay on the rehabilitation side, but maybe I want to practice prevention and wellness. So I think for some people that's an easier transition because they get the sense of I continue to use my degree and leverage it to do something that still helps people.

Karen Litzy:                   03:20                And if let's say I'm coming to you and I'm saying, Oh TaVona I just, I don't know what to do, I'm really stuck. I'm getting, you know, I'm starting to feel like I'm not making a difference anymore. So how would you, we can kind of go through a mock coaching session here. So what are some things that maybe you would want to ask me or want to know from me that maybe can help me figure out what to do next or what's your process like?

TaVona Denise:             03:51                It really, really depends. Just like in an evaluation situation, like no two people are alike. So it depends on how they present, how they come to me. But I really want to know what do they enjoy at their job and what do they enjoy as a person working in a profession. Because sometimes there's an opportunity for a person to create a position for themselves or to create a program. And some of the clients that I've worked with have become what I call intrepreneurs. They have taken their skills, their expertise, their specialties, and then develop programs within the organizations that they work in, which it's a challenge. It's not as risky as being an entrepreneur and going off and doing it for themselves. They get to stay in that environment and not lose the years of service and PTO and all the perks and things. It's kind of like playing with the house's money so they get to do that. Sometimes it's a matter of just feeding the hobbies and things and taking time for themselves that they're not doing. Because we always hear the analogy of you have to put your own mask on first before you serve others. And so as caregivers, that's what we do. We care for others and sometimes we are forgetting to care for ourselves. So sometimes that's the approach we take. I find a lot of people, and this is also a strange one that I'm thinking about. A lot of people need to declutter their homes.

Karen Litzy:                   05:14                Yes. 100% yes. I'm just going to say yes to that. I'm Marie Kondo in my home like five years ago and I have to tell you, decluttering my home kind of decluttered everything else for me, even part my practice and my thought process and I was able to then expand and do things that I couldn't even imagine were possible. So proceed.

TaVona Denise:             05:42                Yes, 100% it was interesting, I listened to a coach that specialized in a relationship. It was one time and she was like, you need to make space in your closet for the person that you want to come in and so if your closet is jam packed. There's no room for anybody else. And I think about that too. Now that we're talking about this, the decluttering process I think gives people space, like you said, expand space to think, to breathe. So that, that like every time they pulled into the garage and they see all the boxes in the junk, it's irritating them. And so that's just one more thing. If they can declutter that, that's something that they have control over where it doesn't have to do with the manager sucks, the coworker sucks, the patient's suck and all of this thing, we've got to go to all these meetings, we don't like you can control your space. So I think that's part of the empowerment process and having them have a sense of control over their lives and looking at how we do anything is how we do everything.

TaVona Denise:             06:32                Yup. And so once we take a look at that, then they can use the skills that they learned to, to go into other things. And it really goes into thought process too. So a lot of people are holding on to things that they shouldn't be. It's beliefs that they shouldn't. Stories that they shouldn't, grudges that they shouldn't. And we literally unpack that stuff as they start to declutter their homes. And I also found that when I decluttered my home, I mean I have a garage, but when I decluttered my home, when I would come home after a busy day of seeing patients, I was coming home to a space that was calm and that was peaceful and comfortable. And so I wasn't adding stress of ah, God, I gotta go home, I gotta put this away, I have to do this, I have to, I didn't have to do anything when I got home except take the time for myself and relax a little bit.

TaVona Denise:             07:30                And so for me, I felt like that was really helpful in almost like avoiding burnout, if you will, at that stage of my career, which is about the 15 year Mark.

Karen Litzy:                                           Yeah, I think you made an interesting point about the word have to, whenever I hear someone say I have to do something, my antenna goes up because it's a very disempowering thing to think I have to do something and whatever we have to do, we kind of resist. And so part of the resent and resent, right? So the burnout is coming from this resistance like, Oh, you can't tell me what to do. And so if we can just make that subtle shift to I get to do this thing, sometimes just that subtle shift of people thinking that they have to go to work. And this is really important for those who are considering building a business and they need to bridge, they can't just quit what they're doing in bridge, you know, it requires a lot of effort and energy to start a business as you know.

TaVona Denise:             08:28                And so if we have that resistance and that resentment towards our job, that is actually paying the bills, right? We are exhausted at the end of the day and then there is no mental energy or emotional energy to put into our new baby over here. And so just one subtle shift. If listeners can think about anytime they say, I have to go to work, can you find the shift who I get to go to work and really be grateful and thankful. The things that go into work is providing you the opportunity to practice new skills, to make connections, to pay your bills without worrying about what it's doing to fund the software or the whatever that you need to in order to start this other venture.

Karen Litzy:                   09:09                Absolutely. And I think I'm so glad that you brought up the get to versus the have to, because I admit I'm a have to girl sometimes and so now I am going to remember to say I get to, because you're right, when you get to, you're coming from a place of appreciation and of gratitude and we all know there's a lot of research out there on how gratitude can make you happier and gratitude can make you successful, can contribute to making you successful. And so I think that's a really important shift. And now what, are there any other, let's say little shifts like that that the listeners can do if they get to that point where they're like, Ugh, work, I don't want to do it.

TaVona Denise:             10:00                Well, one favorite exercise I like to give people, especially if people are just zonked at the end of the day and they like to carry work home with them. One thing I have people do is put a journal or notebook. It doesn't have to be fancy or expensive in the car. And so what it does is when you get into the car, you get the opportunity to let your brain have it. Say they get the fuss out, whoever they want to from the day they get to say everything that they didn't get to say. They want it to say they think they shouldn't have said and all of that on paper. And just that bit of detachment from it. They can more easily evaluated and see the truth or the lie of it. And when they do that one, the brain gets to say it and then let it be done. And I've found that many people have thanked me because in their relationships get better cause they don't go home complaining to the partner or the spouse. The other thing that it does is it gives a clear break from the day. So the brain can say, okay, we're done with work. I've said my say and I can go to the gym, I can go enjoy time with my honey, my children, my whatever. And there is that separation.

Karen Litzy:                   11:06                And in your experience in coaching, a lot of therapists, do they return to work? Do they switch gears? Would you, if you were to put a percentage on it, and I know that's probably tough and I'm making you do this on the spot here, but if you were to say, you know, after we came up with better strategies, they found the joy in their work again, or after coming up with better strategies, they were like, Oh, I think I want to do X, Y, Z.

TaVona Denise:             11:34                I think it's so it's an interest in it, but it may be a 25 go back to work and they're excited and they're like, Oh, I'm renewed. 25% is like, thank you for those skills. I want to turn the page to the next chapter of my life and do my own thing. Whatever form comes in. And then there's this 50% that's kind of in the middle and they either don't move forward to practice the skills all the time. And we see this sometimes with fitness and anything in life, right? And I think, and here lately I've been wondering about that person, like what makes that person not move forward? And I've come to understand that that person is very much afraid. So we talked about those over 100 interviews I did last year. And in my note, taking some variation of the word fear came up in 90 something percent of those interviews.

TaVona Denise:             12:34                And I thought to myself, well, what is really going on here? And what I've been thinking about here lately is how we in healthcare are taught to follow certain protocols and we're breaking out of that now, right? So people are not recipes and things like that, but there's still this underlying mentality that we need to have certifications that we need to follow rules that we need to play inside the lines and get it perfect and get it right. Because, I come from acute care background. So things that I do we do could literally kill a person. And so it can be very scary to make mistakes for the rest of us. It's very competitive to get into PT school. We were higher achievers, many of us athletes were used to getting stuff done and doing it well. After you've been in the profession for so long, it can be very difficult to be a beginner again and then be in something that nobody's written out.

TaVona Denise:             13:28                A curriculum to tell you this is how to be an entrepreneur and be successful at it. And so people freeze. And I'm like, Whoa, I know the answer. Let's move forward. What? Why are we not moving forward? And it's something that I've come to understand is what I'm calling the confidence loop. So for example, a person may be uncomfortable in their situation and work, they want to make some kind of change is not really comfortable. They decide that they want to move to the next level. They're going to make some kind of change. The challenge is once they make that commitment, then the freak out occurs and it's like, well, I'm too old. I'm too young. I don't have this. I don't know what I'm doing. So and so failed. Right? So that's the freak out. What it requires is a bit of courage to take the first step and to keep on stepping.

TaVona Denise:             14:18                That part, I call the gauntlet because it's very challenging mentally, emotionally, spiritually, sometimes, physically, depending on what the goal is. But if you can continue taking the moves forward and be consistent, what happens is you find clarity and you find competence. And from that clarity and competence where you know what to do and you know how to do it, people are confident. Like when you know what to do and you know how to do it, you're pretty confident. But when you don't know those things, you're not going to move forward. That can be paralyzing, very paralyzing. The problem is we're so used to knowing what to do. We won't keep invoking the courage to do enough of the things to be clear about what to do in house so that we can be confident. And the interesting thing that I realized about that was that when we were in PT school, that consistency was forced, right?

TaVona Denise:             15:13                We had tests all the time that were given to us when we're in clinicals then should see, I would say go do that manipulation or mobilization or whatever, go take that as subjective like they forced us to do of it. If we decide to do something on our own, it's on us to keep moving through and to be courageous. And so that's what I call that pattern of the confidence loop that I've started to notice is why some people never get started in the first place. And the gauntlet part, that first part where it is where people get stuck.

Karen Litzy:                   15:44                Yeah. And that's why people need a coach sometimes to keep us consistent. Right? Like I interviewed Steve Anderson a couple of months ago, so Steve is one of the founders of the Graham sessions. Like I said before, we're in Nashville and he is now doing executive coaching, not necessarily with physical therapists but with different C suite executives. And he was talking about the need for a coach. And one of them is accountability, which leads to consistency, right? And he said there's a reason why Roger Federer, who is one of the best tennis players in the world. You think, what does he need a coach for? He's already great, but he has a coach because that coach keeps him perhaps motivated and consistent and accountable. Yeah. And it's like, you know, we talk about doing exercises and we tell our patients all the time, you have to do this daily. Every other day. You have to be consistent and yet consistent physically, but being consistent mentally still changes the brain.

TaVona Denise:             16:47                Oh, 100% I think the other reason why coaches in the way that I coach people is in finding the blind spots, right? So one form of coaching is to hold a person accountable. Did you do what you say you were going to do? And that forces the consistency so that you can move into clarity, competence, and confidence. One of the things that I'm very good at and work on with my clients where you were talking about the mental exercise of, okay, the courage, where is the fear coming from and can I help shine a light in that blind spot so that you can see that it's not as bad as you thought it was. So the big example that I have is many times when we would do a total knee or total hip replacements, the moment I would open the door to the stairwell, people would freak out.

TaVona Denise:             17:33                Oh yeah. Because the fear of the fear or the anticipation of pain is worse than actually doing the thing. And so part of my job as a coach is to help coach them around that fear of anticipation of pain and to understand where it's coming from so that they can unlock themselves.

Karen Litzy:                                           Yeah, I mean fear is a very powerful emotion and it can take many, many forms, which I'm sure you've seen, like not all fear is, Oh, I'm not going to do that. Sometimes fear could be self-destructive. We could be self destructive to ourselves or to others around us out of fear. And so if you were to give any advice for people who are at that point where they've got everything lined up but they're not taking the step because of fear, what do you say? Well that's a loaded question, right?

TaVona Denise:             18:43                So going back to the journal is a very, very powerful tool if you're not working with a coach and you're trying to do this on your own. But the simple question of what am I afraid of? What am I afraid of? And if you will, after you asked that question, don't just ask it and just have like in your brain, like actually write it down because there is some power in the scene, the written word, and you giving yourself that distance because once it's on the page and out of your head, you can actually analyze it and see is that true and how can I mitigate the things that I'm afraid of happening? So Tim Ferriss calls it fear setting as opposed to goal setting. So what am I afraid of? What's the worst that can happen? And he borrowed some of this technique from stoicism and he asks you to answer those questions for yourself and see, okay, well I'll be out on the streets.

TaVona Denise:             19:39                Well do I have family that I could stay with? He did. He actually went and did some couch surfing for a while before he took the leap. So he went and stayed on people's couches for a couple of weeks so that he could be in that space of is it actually that bad to have to sleep on somebody's couch or eat ramen noodles or something like that. So like what am I actually afraid of and write it down.

Karen Litzy:                                           So, if I'm getting this concept correctly, and you can correct me if I'm wrong, so you write, what am I afraid of? Kind of write those fears. And then what's the worst that can happen if that fear were realized? Is that what you're kind of writing?

TaVona Denise:                                     Okay, that's exactly right. So what am I afraid of? And what if this actually happened and how can I mitigate it? Got it. And he actually goes and practices it so that he can feel like, Oh, that's actually not that bad. Even if it does happen. And that you may even have more resources than you thought you did if your worst fear were realized. So again, I think it forces you to write things out and say, Oh well maybe isn't that bad.

Karen Litzy:                   20:48                Or maybe it is really bad. I don't know. I guess it could go both ways. I'm not sure.

TaVona Denise:             20:54                Well, they could. So one of my mentors says, whenever you choose to do something or not to do something, make sure you like your reason.

TaVona Denise:                                     So, so many people are one, unclear about what they want in the first place. And two, if they know what they want, they're just not taking action, but they can't articulate why. So I just think if you can just start with that, those two simple questions that will give you a lot of information to get started with. You can find your why right. In some minuscule way in your life. Right? You can kind of find that why, which is often elusive to too many people. Yeah, I can because a lot of people, I think that's another thing that I've found is just the simple act of asking you what do you want? Many people are quick to tell me what they don't want and when they're very clear on what they don't want, but they can't tell me what they do want, they're also not going to make a move.

Karen Litzy:                   21:53                Got it. So all of these little tricks that we play in our minds can work against us in so many ways and we don't realize it until we either, like you said, journal it, write it down, have an external eye, take a look at what you're doing to kind of shine that blind spot right into your face so you know what's going on. And then also just, I think, like you said, decluttering and really getting to the bottom of why at this point in your career, are you feeling the way that you're feeling? Trying to recap a little bit here. Yeah. Is that good? Okay. All right. So now in before we kind of wrap things up, I have a couple other things to ask, those were the key takeaways from our conversation, but what do you want the listeners to really kind of take with them?

TaVona Denise:             22:50                I think we hold ourselves back unnecessarily. So I think it would be, if I were to give you like a step-by-step, if you will, a rough step-by-step is to one, figure out what you want, understand why you wanted, because the understanding of why you want it will help you move in the face of fear. Just like when we went to PT school, we had, there was a lot of fear involved and we moved through it anyway because we had a reason, right? So know what you want, know why you want it. Understand that fear is allowed to drive, ride the bus ride side car, but not allowed to drive the bus. And it's really going to be okay if you think about that confidence loop and I can share a diagram with you so that people can actually see a visual of it. But if you think about it, if you just keep going, you will get there. If you just keep going, you'll get there.

Karen Litzy:                   23:53                Yeah. And I think to that point in a digital age where everything happens at the speed of light, that can be difficult because what if it takes longer than you think it should take? Right. So expectations, let's talk about that for a second.

TaVona Denise:             24:14                Yeah. Because speed of light microwave society, here's something that I've been noodling over here lately. We want our business to take off like in 60 to 90 days. And Jen and I were talking about that today. Oh yes. And I was just thinking about this, like, why is that even fair? You need to learn marketing. You need to learn sales, you need to build an audience. I mean, there's so many pieces that you need to learn. If you would just flip the switch. So from have to versus get to right. Here's another little mental switch. What if it was just like going to PT school? So what's the average length of PT school now? Is it two and a half, three years? Yeah, so let's just say three years. What if you just said, I am going to learn what I need to learn all of these pieces of business and I'm going to not expect anything for three years and if I'm not as consistent as I was in PT school, which is full time, I don't think anybody can work and do PT school. If I am not putting in that amount of hours in that amount of effort that I did in PT school for three years, then I need to add a year for however much time and effort I didn't put in. If we can do that and give ourselves the mental space, time and grace, if we thought about how hard we worked and how long we worked in PT school and apply it to business, nobody should expect anything before three years of full time work and then it'd be great if it happens in a year.

Karen Litzy:                   25:45                Yes, I agree. I think oftentimes people are fed false hopes and expectations in marketing ploys and whatnot, and that's just not how it works. It just, it just doesn't work that way and you got to work at it. And I think I agree with you. I think your expectations have to be realistic and to have a successful business in 60 to 90 days is not realistic. It's just well put, it ain't going to happen. Not a chance. Yes. So expectations are huge. Thank you for touching on that. Okay. Did we miss anything?

TaVona Denise:             26:25                Not that I can think of.

Karen Litzy:                   26:26                All right. Cool. Cool. All right, so then the last question before we get to how people can get in touch with you is knowing where you are now in your life and in your business, what advice would you give to your younger self as a graduate out of PT school? So this is advice to you from you, from future you, to past you from future. You got it?

TaVona Denise:             26:57                Mmm. Don't be afraid to take risks. It's all going to be okay. The things that you think were for you that don't work out actually happened for you.

Karen Litzy:                   27:19                Excellent. Excellent. So again, going, looking back, you can say to yourself, man, I was so upset that X, Y, Z didn't work out. But look where I am now.

TaVona Denise:             27:31                Oh yeah, yeah. If I didn't get that great management position that I thought I was going to get. I wouldn't have gone to Costa Rica to Spanish immersion school if I didn't. If I got the other management position that I thought I was going to get that I didn't get, I wouldn't have written a book. I wouldn't be here talking to you all today.

Karen Litzy:                   27:49                Amazing. What great advice. I love it. Now. Where can people find you and find out more about what you do?

TaVona Denise:             27:55                Yeah. you can find me anywhere on the web at TaVona Denise. I'm most of the time on Facebook, sometimes Instagram and

Karen Litzy:                   28:11                Perfect. And just so for all the listeners, we'll have links to all of that under the show notes for this episode at one click will take you to everything that TaVona has an and can offer to you. So TaVona, thank you so much for coming on. This was great. All right, and everyone, thanks so much for tuning in. Have a great couple of days and stay healthy, wealthy, and smart.


Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram  and facebook to stay updated on all of the latest!  Show your support for the show by leaving a rating and review on Apple Podcasts!

Jan 20, 2020

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Dr. Howard Luks on the show to discuss knee osteoarthritis.  Dr. Howard Luks, MD is an Orthopedic Surgeon practicing in Westchester and Dutchess Counties in New York. He specializes in the management of complex knee and shoulder injuries with a focus on ACL injuries, Patella Dislocations and Shoulder Instability. 


In this episode, we discuss:

-What is knee osteoarthritis and how is it diagnosed?

-Modifiable risk factors for developing knee osteoarthritis

-Indications for a total knee replacement

-The importance of managing expectations for good patient outcomes

-How to strengthen the physician therapist relationship for more patient centric care

-And so much more!



Howard Luks Website

Howard Luks Twitter

Howard Luks Facebook

Howard Luks Youtube


A big thank you to Net Health for sponsoring this episode! 

Check out Optima’s Top Trends For Outpatient Therapy In 2020!


For more information on Dr. Luks:

Howard Luks, MD - @hjluks - is a patient centric, Orthopedic Surgeon who has been in clinical practice for 20 years. Dr Luks utilizes his passion for patient engagement and his expertise in medicine and social media to educate a global audience through his website, twitter, facebook page and YouTube channel.  He serves as a consultant, board member and adviser to many companies in the mobile health, online health platform, and medical decision making start-up spaces. He served on the External Advisory Board of the Mayo Clinic for Social Media - a recognized leader in this space.


“Technology is not about replacing physicians ... instead, we must remember, change brings opportunity — and we must use these changing  times to  scale great physician thought leaders.” - Howard Luks


Howard Luks, MD (@hjluks) is an Orthopedic Surgeon practicing in Westchester and Dutchess Counties in New York. He specializes in the management of complex knee and shoulder injuries with a focus on ACL injuries, Patella Dislocations and Shoulder Instability. 


As an early adopter of Twitter, Howard Luks MD also runs a blog (>100,000 unique monthly viewers), a Facebook Page, a YouTube channel and a personal site to educate, interact and engage a worldwide audience.


Read the full transcript below:

Karen Litzy:                   00:01                Hi, Dr. Luks. Thank you so much for coming on the podcast and really looking forward to this today.

Howard Luks:                00:06                My pleasure, Karen. I'm looking forward to it too.

Karen Litzy:                   00:09                Okay. So today we're going to be talking about osteoarthritis. You had a great tweet thread back in, I believe it was the end of June, beginning of July, 2019 on osteoarthritis and got a lot of positive responses from people and I really wanted to talk to you a little bit more about osteoarthritis. First thing is what it is and what it isn't. So I will hand it over to you.

Howard Luks:                00:40                So the reason why I decided to put that thread up was based on the fact that I keep hearing people become worried thinking that their body is wearing out and that our arthritis is a mechanical process and wear and tear process. So they're going to stop walking. They're gonna stop riding, they're gonna stop running, they're gonna stop their exercise. So in other words, they're going to increase their risk of dementia, heart disease, hypertension, diabetes, and other metabolic disorders because they think they're saving the lifespan of their knee. So in order to get across that osteoarthritis is really a biological process where the articular cartilage is starting to degenerate for various reasons and that their activity actually, if anything is beneficial is what led me to write that whole series of tweets. And I followed up with another one a few months later. That then started to throw in all the exercise patterns and activities that people can in fact pursue, especially with respect to runners. See, since I seem to attract a lot of runners, I wanted to be known that running is not damaging for a knee that doesn't have any significant mechanical issue or is recovering from a fracture.

Karen Litzy:                   02:22                And when we talk about osteoarthritis, oftentimes people will come to us as physical therapists and they'll say, Oh, well, you know, it's bone on bone. That's what the x-ray shows bone on bone. So how do you respond to that? And how should a physical therapist respond to the patient in those scenarios? And in a way that doesn't undermine the physician that referred them to us, but being consistent with the evidence.

Howard Luks:                02:51                It's quite a challenge, right? I mean, yeah. The interesting thing I always talk to our residents about is that, you know, I'm 56 now and I'm just starting to get really good at patient interactions and discussions and conversations in the office just in time for me to retire. And I talk about the fact that words harm, images, harm, and you really can't unsee your MRI or xray report. So it all comes back to communication and education. And that's one of the biggest problems in healthcare today, right? We're RVU driven. You guys are strapped if you're a network, you know, you can't make a living of $40 per hour. And so we're all seeing more people in less time and that really threatens our ability to have a good, actionable and meaningful conversation with people. Yet it's absolutely critical that we do so.

Howard Luks:                04:02                So if I put an X Ray up showing bone on bone arthritis, I then immediately enter into a conversation about how you really treat people, not an image. And that even though they're bone on bone, you know, most likely I'm talking to someone who doesn't have severe quality of life limiting knee pain more often than not, and you know, a bone on bone knee that's relatively dry, meaning it doesn't have a significant effusion, it's really not going to be too terribly painful. You know, the bone itself isn't what hurts, you know, bone marrow edema hurts, synovitis, hurts. But not the bone itself. So I explained that I've run with people that I know have bone on bone arthrosis yet. I explained that I've also replaced knees in those with less severe arthritis because they had severe synovitis or bone marrow lesions that just wouldn't go away.

Howard Luks:                05:16                So it's important to talk about the fact that the xray has only one small part of the overall evaluation and a very small part in determining what the treatment or treatments could be or should be. And that it really it's their story. It's their history, it's what they're telling us. And you know, when it hurts, how often it hurts and how severe that pain is. That's more important in terms of how we craft our treatment plan. And when, you know, I had a patient today actually asked me, well, when, when do you know, as the patient, when do you know that you need to have a joint replacement surgery and we'll stick with the knee.

Karen Litzy:                   05:58                So when your patients come in and they asked you that question or you talk to them about the possibility of a total knee replacement or a partial knee replacement, what do you say and how does the patient know?

Howard Luks:                06:23                Huh, that's a great question. And it's one that I'll get probably 15 times tomorrow so the discussion usually goes as follows. It's, you will know you're going to wake up one day and say, I just can't take this anymore. I've tried X, Y, and Z. I've done my exercises, I've lost weight, I have adjusted my diet. I've tried over the counter medications, Savage's bombs, ointments, suction cups, tape and everything else that their friends have told them to try and their pain is limiting their quality of life. So that's, you know, a very important part of the decision making process is you have to dive into their goals, right? You can run into a lot of trouble with people between 40 and 65, 40 and even 70, depending on how active they were, because you might have someone who's miserable, but it's simply because they can't play singles tennis anymore.

Howard Luks:                07:37                Right? It's like having someone with shoulder pain in your office because they can't hit a second lob as like they used to. You know, that person who's going to be really unhappy with the results of surgery. Same with the knee replacement in someone who can't play a second set of tennis but could easily finish, you know, a three set doubles match. So we have to determine when the patient feels that their quality of life has suffered long enough that they wish to move forward. Then we need to dive into what their goals are. It should be simply that they want to get through their day without this horrible knee pain. Because if it's anything other than that they may not be all that satisfied with the end results of the surgery.

Karen Litzy:                   08:33                Yeah, that makes a lot of sense. There's a big difference between the person who's having trouble walking from, you know, their bedroom to the bathroom or like you said, the person who can't get in another set of singles tennis. They're very, very huge quality of life differences there. Although that second set of tennis might be disappointing. It's different than not being able to walk a block.

Howard Luks:                08:57                Correct. And we know, you know, both of us know there are significant number of knee replacement patients who have persistent pain after surgery and who are not happy with the overall results. And many times that might trace back to false expectations. So it's a really important discussion to have. And we also know there are many different patients out there. You know, there are some who have achiness and pain when they roll out of bed, but by the time they're done with their morning shower, they feel fine. Yet those people, some of those people might tell you that they want to have their knee replaced. So again, it's really important to dive deep into the reason why these people want to move forward and what their goals are.

Karen Litzy:                   09:54                Yeah, I think that's a great point. Thank you for that. And now I just want to go back to one thing. When we were talking about osteoarthritis, one thing we didn't talk about were factors that may lead people to be at risk for osteoarthritis. Do we know what some of those factors are? And if so, are they modifiable?

Howard Luks:                10:14                Sure. So first, you know, the, the big category now that requires everyone's attention is our metabolism. You know, we are bombarded daily now, especially on Twitter with all the ELA facts associated with a typical or standard American diet full of ultra processed foods. I'm not gonna get close to the Quito vegan world and subdivided. However, it's really important that people start to read this literature about the dangers of ultra processed foods. It's very clear that a calorie is not a calorie and that a hundred calories of ultra processed foods versus a hundred calories of real food is going to have very different metabolic affects on us. And we're finding that people with high homocysteine levels have a higher incidence of heart disease, cardio metabolic issues as well as joint related issues. We're finding the same with uric acid levels, which will my car lay with your fructose intake.

Howard Luks:                11:38                So high fructose corn syrup, we find a correlation with lipid disorders and the prevalence of osteoarthritis people's weight will certainly have an impact. A lot of people don't know that what each step you take, you're putting, you know, five to seven times your body weight across the knee with each step. If you're achieving 10,000 steps a day, you weigh 250 pounds, you have an extra 60 pounds on your knee across 10,000 steps. That's a lot of an added weight across that knee. Now for those who do not have osteoarthritis already, that might not initiate the process for those in whom the process has started. An MRI studies on asymptomatic people show that the process has started in a majority of us over 50, then that excess weight and force or stress burden is certainly going to increase the risk of developing a more rapidly progressive arthrosis.

Howard Luks:                12:50                Now by far the most common causes are genetics and people with structural issues. So a varus or Bodine or valgus or knock kneed that will set you up for unit compartmental changes or changes in either the middle or the lateral compartments. Why we seem to see a pretty severe patellofemoral disease and in some middle aged women, I'm not exactly sure, perhaps it's some degree of underlying map tracking. But in terms of the modifiable risk factors, without a doubt, our weight, our activity level, it turns out as we, as we just said, that's right. This is less common in runners. Cartilage likes that cyclical loading and likes to be exposed to force in a cyclical manner. I think we hit on many of them.

Karen Litzy:                   13:54                Yeah. And then the only other thing I can think of is previous surgeries. So we know like ACL having an ACL surgery or ACL disruption, the majority of those people do develop osteoarthritis later in life. Especially if you're, you know, most of them happen when you're younger, usually.

Howard Luks:                14:13                True. So you're absolutely correct. So upwards of 50% of people who have had an ACL tear will go on to develop arthritic changes. Even having just one Hema arthrosis, you know, blood in your joint elevates your risk of developing osteoarthritis because it changes the chemical compounds that's present in the knee. Once that has happened, now you'd go ahead and you add a mechanical issues such as a meniscus tear and your risks really start to go up dramatically.

Karen Litzy:                   14:54                Yeah. And, I mean I have seen patients in their forties you know, who have had multiple ACL reconstructions on their knees cause they were high level athletes in their younger years. And those are people who, you know, we were talking about the people who can't play tennis versus the ones who are having trouble walking down the street. Those are the people that are having trouble walking down the street and they know it, but they're doing everything they can to not have the surgery as well. So it's, it's an interesting group.

Howard Luks:                15:25                Correct. And they're not harming themselves. I don't care if you're limping if you can get away without having your knee replaced, you should do so.

Karen Litzy:                   15:37                Absolutely. Absolutely. Certainly, certainly I think, you know, oftentimes people will hear, Oh, it's knee replacements are not that bad. It's not like it was years ago, but I mean, it's not great.

Howard Luks:                15:49                Huh? Yeah. So there's, you know, the only surgery without risk is a surgery on somebody else. Yeah. If you're assuming an infection after a knee replacement has a low incidence, right. A 0.7 0.8%, but it's a life altering permanent problem. You know, you're going to need one to three operations to try and eradicate that infection. And if it's a nasty bug, it's going to end in an amputation. So, you know, are there a lot of amputations that happen each year because of knee replacement infection? No, but there are not zero. And there are a significant number of people who have persistent pain. I've looked, I perform a lot of knee replacements and I think it's a great operation for the right person. So there are significant upsides to a well functioning knee replacement and the vast majority of people are not going to get infected. However, when you start to push indications and you start to stretch them if you get into trouble with one of those people, that's an awful place for them to be.

Karen Litzy:                   17:06                Yeah. Yeah. No question. No question. And now what I'd like to do is we've got a couple of questions from listeners that some of them are about you in particular and the way that you practice others. Again, continuing on the osteoarthritis subject. So one was from physical therapy and they're all from physical therapists. Gina Kim said, how do you set expectations for patients, especially for active busy ones, that conditions such as osteoarthritis, frozen shoulder can take months to resolve or can be something that you're managing, let's say. Because I would say osteoarthritis is something that you're managing.

Howard Luks:                17:49                Correct. And sometimes the frozen shoulders too. So any of our patients with these longterm chronic conditions can get into trouble, especially when they're used to being high level weekend warrior as an athlete. The, you know, my goal is to keep that runner running. And most runners, if you sit down and say, look, we don't think that arthritis, we know that arthritis is most likely not caused by running. We really don't think that you know, running five miles at a reasonable pace is going to cause her arthritis to worsen more than it already has and more than the normal disease course will worse than that. So we think it's okay for you to keep running. 90% of real runners are going to take that and run with it, so to speak. They are not going to stop. And there's really no reason for them to stop, cut, stop.

Howard Luks:                18:54                Cause a runner that stops running is not a whole person anymore. It's really embedded in our psyche. They're very unique people to deal with. So oftentimes we’re seeing a runner with a little swelling after a run, we're seeing them a little, a little achiness and pain the next day. Perhaps they can't run as fast as they used to or they have pain going down Hill. So they will very readily work with you. So what I will immediately start doing is dive in to their typical week. How many miles are they running? What pace are they running, what zone are they running in? Are they Hills or are they technical trails and the carriage are they road? I don't necessarily push people onto trails or onto roads but I might pull them off a technical trail or off of steep Hills. And I'll try to work with them. Craft a workout pattern and running strategy with them that will lead to very much acceptable or tolerable levels of knee pain. And then once they understand that the etiology of a cause of their arthritis and they understand you really didn't do anything wrong, it's not the running that led them to this point, most are okay and most will fight through again, a reasonable level of discomfort in order to allow them to run.

Karen Litzy:                   20:35                Yeah, and I think that's the last thing you said is so important because oftentimes when people have more persistent pain, and I can say this from my own experience is when, when we, I guess I can say we, I'm part of that group. Oftentimes when we do things and it results in pain, we think that we're causing more damage. And I think it's really important that last point that you made that, Hey, listen, you might have a little bit of pain, a little bit of swelling, but from what we can tell, we know this isn't doing further damage. It isn't sort of creating more wear and tear. And I think that's really important to get across to the patient.

Howard Luks:                21:16                I agree. I mean, if I start to get stress fractures and stress reactions and book painful bone marrow edema, lesions, you know, I'm going to change. But as I alluded to earlier, you know, imagine a runner who stops running out of fear not because of the level of pain. You know, they're now increasing their risk of any number of chronic diseases, right? Alzheimer's and heart disease and hypertension, diabetes and on in the, you know, in the hope that maybe they're going to save their knee and save the knee from what? So if, you know, a lot of them, even if, even if we knew that running caused it, they would sacrifice their need to keep, you know, their head clear from the benefit that they derive from their weekly run.

Karen Litzy:                   22:21                Yeah, they're a motivated bunch, that's for sure. And, and motivated because like you said, it's the running. So when you're a runner, it's your running that allows you to do the rest of the things in your life. That may be work. It may be dealing with family, it may be dealing with colleagues that keeps your head clear. It could be meditative. So you're taking all of that away by saying you just have to rest. You don't, you shouldn't run anymore.

Howard Luks:                22:46                Correct.

Karen Litzy:                   22:47                Dangerous. Okay. Dangerous stuff. So let's go onto another question, Miranda Henry, and I think this is a nice question is how do you see the evolution of the patient doctor physiotherapist role in the care of osteoarthritis? Cause we know we've got baby boomers getting older, osteoarthritis is most likely going to be more prevalent. So how do you see that evolution of care from those roles?

Howard Luks:                23:15                Sadly, in this environment I see it dwindling, which is really unfortunate, right? Because it should be increasing. There should be a direct electronic or otherwise communication between our offices. You know, we both have these five page electronic medical record nightmares that our office produced that we fax to each other, you know, for signatures to send back. Yet it doesn't have much actionable, useful and meaningful information. I have a number of a number of therapists who are my go to people in my region. And you know, we're on the phone a lot. Trying to share details about certain people in terms of progress yeah. Or roadblocks or other issues and what and why they're sending them back or why they're not. And it's, you know, an open channel of communications is just so critical. And we just have to keep in mind regardless of how busy and crazy our lives get as healthcare providers, that it really is a patient's life and wellbeing that's sitting at the end of these phone calls and things that are easily perceived as nuisance irritation. And so yeah, it is worth it in the end to go the extra mile and make that phone call.

Karen Litzy:                   24:51                Yeah. And I think you just answered that with that answer. The next question is what do you see as the best way for that PT doctor patient to align themselves for best patient outcomes? Which I think you just answered. Just having good communication channels and being able to keep in mind that the patient is at the center.

Howard Luks:                25:13                Correct. Yeah. Can't forget that.

Karen Litzy:                   25:15                No, that makes perfect sense. I think you just answered it. And then finally, this is from Mark Rubinstein said what or who inspired you in your holistic approach to promoting health? Combining traditional orthopedic medicine with sort of lifestyle medicine?

Howard Luks:                25:32                Ha. Good one. As I alluded to, as I said before, you know, you start to get much better at determining talking to people, listening to people asking the right questions. You know, my exam starts when I watch them walking in the hallway, you know, before you sit down on your stool, you know more about that patient. Then half the words they're going to say are going to tell you and you learn how to craft your messages and craft your, you know, your treatment plans accordingly and you find out that non-surgical management is often really effective. Then you realize, okay, you're 56, you know, what are you doing to change your life? So, you know, probably about six years ago I started to optimize my own lifestyle for my, not only longevity but health span, right? I want to go to the very end, hopefully running and then just drop off. I don't want to spend my last 10 years on cane's going to doctor's offices, being hobbled, being frail, et cetera. So as I started, you know, a lot of the more recent blog posts that I've written, I've just done in an effort to help me learn the topics.

Karen Litzy:                   27:12                That's a great way to, it's a great way to learn.

Howard Luks:                27:14                Right? Because I'm pulling all these papers and I'm doing all this reading. I might as well write it down on my website and share it. And so it started with my diet and then it started with a sleep. I read Matthew Walker's book and then it started to, it was exercise and muscle mass and atrophy, sarcopenia and everything else written about. And then you start to dive into the metabolic literature and you realize, Hey, you know, this is really important for our patients. And that's another motivation to get it up and get it on the website. And as we all know, it's really hard to change many people's habits, but if they have actionable information, if they have a thorough understanding of why they need to do this I'm getting a lot further with people in terms of committing them to dietary change, lifestyle changes, activity changes than I ever had in terms of success before in my career. And I think maybe it's just cause I'm communicating it better and perhaps cause I'm leaving it up on my website for them afterwards to revisit and share it amongst their family.

Karen Litzy:                   28:48                Yeah. And they can kind of take a deeper dive into it after they leave the office and say to themselves, Oh, okay, now I think this is making more sense. Cause like we've all been to doctors. I mean sometimes you go in and you're like, Oh man, I really wanted to ask this question and I didn't. Or Oh he said this thing but I forgot. And so to have that backup on your website I think is probably really helpful. And like you said, is most likely helping you get some greater buy in from your patients do I think is fantastic. And I think it's also important to note that when you're writing that you're, at least, this is what I get from your writing style, is it's very relatable and approachable and it's so, it's very, I think patient forward.

Howard Luks:                29:33                You'd be amazed at the comments that I get from editors editors or publishers or writers through channels, how unhappy they are with my writing style. I'm like, just, you just have to leave it alone. It is what it is.

Karen Litzy:                   29:50                Yeah. And if it's relating, if it's relatable to your patient population, great. Correct. Great. All right. So before we wrap up, what are the big takeaways you want people to leave with this discussion today?

Howard Luks:                30:06                So yeah, in an effort to save your knee, don't throw the rest of your health under the bus. You're not gonna save your knee. You can't stop arthritis from progressing. You can't cure it. You're not gonna waste your money on $10,000 in STEM cells cause that isn't going to work. You will know the day that you need your knee replaced. And hopefully your surgeon or therapist will help you better define what your goals can and should be following a knee replacement. Don't forget how important our entire lifestyle is in shaping how much pain we are going to have, how long we're going to have that pain and how long we're going to suffer with it. Our sleep matters. Our diet matters, what we stick in our mouth matters and our activity levels matter. If you don't optimize for your wellness today, you're gonna end up preparing for your illness and frailty later. So there's no better time to get moving.

Karen Litzy:                   31:18                Great advice. And now last question I ask everyone is knowing where you are now in your life and in your career, what advice would you give yourself as a newly minted doctor? A new graduate from medical school.

Howard Luks:                31:34                Yeah. you're not as good as you think you are. Right? You know, all these young docs on Twitter, I get a kick out of them, you know, they're great, but, and I wasn't any different. You know, the world is far more black and white when you're younger then as you get older but yeah, pay more attention to your elders. Pay more attention to your patients. You don't always have the right answer, you know, and just be willing to admit sometimes you don't know. And then look for the person with the knowledge and experience who can help you.

Karen Litzy:                   32:22                Great advice. Now, where can people find you if they want to read your blogs and find you on social media? Very important.

Howard Luks:                32:28                Just put my name on Google. I think I own the first 10 pages.

Karen Litzy:                   32:33                Perfect. And we'll also have links under this episode at So if you want to get all of Dr. Luks’ info, it'll be right on the website here as well. Awesome. All right, well thank you so much for taking the time out. This is a great conversation and I hope you have a great start to your 2020. And everyone, thanks so much for tuning in. Have a great couple of days and stay healthy, wealthy, and smart.


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Jan 13, 2020

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Ryan Burklo on the show to discuss financial planning for small business owners.  Ryan Burklo, RICP® is a financial planner, host of the podcast Holistic Finance, and co-owner of Quantified Financial Partners. Through his work as a financial planner, he works with medical practice owners to protect their practice, keep them financially efficient and assist with their eventual exit.

In this episode, we discuss:

-How to manage debt financing and make it work for you

-What is tax efficient cash flow planning?

-Retirement options for small business owners

-The conversations you need to bring up with your financial advisor

-And so much more!


Quantified Financial Website

Holistic Finance Podcast

Ryan Burklo Twitter

A big thank you to Net Health for sponsoring this episode! 

Check out Optima’s Top Trends For Outpatient Therapy In 2020!


For more information on Ryan:

Ryan Burklo, RICP® is a financial planner, host of the podcast Holistic Finance, and co-owner of Quantified Financial Partners.

He lives in Seattle, Washington with his wife and two kids.  After learning his son had a stroke while in utero he became an avid volunteer for Pediatric Stroke Warriors.  He learned much about the medical professionals who cared for his son and truly enjoyed working with them both on a personal and a professional level.

Through his work as a financial planner, he works with medical practice owners to protect their practice, keep them financially efficient and assist with their eventual exit.

His firm and his personal mission is to simplify finances so that you can focus on what you enjoy most.

Read the full transcript below:

Karen Litzy:                   00:01                Hey Ryan, welcome to the podcast. I'm happy to have you on.

Ryan Burklo:                 00:06                Thanks for having me. Appreciate the invite.

Karen Litzy:                   00:08                Yeah. And you know we're getting onto the end of the year and people are starting to think, look back on the year, look forward to next year talking about their businesses and maybe how they can move forward, expand, stay the same. Lots of stuff. But today we're going to talk about kind of the business side of things. And I absolutely love having people like you on the program because I didn't go to school to be a financial planner. I don't, I don't know what I, you know, this is not my specialty. So I love having folks like you on because I feel like I learned so much from you guys, plants and seeds in me that make me think, Hmm, maybe I need to make some changes in my practice. So thank you for coming on. Cause I'm definitely excited.

Ryan Burklo:                 01:06                Yeah, I again appreciate being on. I actually started laughing when you said you didn't go to school to be a financial planner cause I was about to say neither did I. I think very few of us actually go to school to officially become a financial planner. I think it just kind of molds it's weighing falls into our lap. You know, life's events occur in the next, you know, you're, you know, you're in the industry and so it's very interesting. Had you told me that I would be a financial planner when I got out of college, I would have said you're drunk. I love what I do.

Karen Litzy:                   01:41                Yeah. And here you are helping and I should mention that you do work with a lot of medical practices.

Ryan Burklo:                 01:50                Yeah, that's really a majority of our focus is helping medical practices on the business side and merging that with the person side. Cause eventually we all exit our practice in some way, shape or form. And it turns into the personal side. So, you know, the two are married, yet business owners tend to only focus, they focus more on the business side because you know that that's the fun side. That's what they do every day.

Karen Litzy:                   02:19                Exactly. Exactly. And so it's great to have people like you guys to help guide us through that. And now, you know, I've been taught, this has been in the news quite a bit. I had, you know interviewed someone a couple of weeks ago about debt and we hear debt a lot in the news. Mainly the focus is student loan debt, but there's all kinds of debt, right? And when you're a business owner, you may be in debt, you may not be in debt. But my question is, can debt work for you? Can it be a good thing sometimes.

Ryan Burklo:                 02:56                Yeah. Yeah. I mean the quick answer is absolutely yes. You know, you brought up the media and everything we're hearing in the news and right now it's a lot of student loans. But you know, oftentimes there's also, you know, just debt is bad is the mantra and you should pay it off as fast as possible. And in some scenarios that makes sense in other scenarios that doesn't, you know, really depends on what kind of debt it is. You know, credit card debt for the most part isn't the best that I have because it tends to be high interest rate, right? You're getting in the double digits, 16, 17, 20% or so. But then there's other debts. Student loans can be one of them. You know, mortgages on real estate and other debts that are lower interest rates and you have to look at it at, if I'm going to put a dollar towards that debt, if I put my dollar elsewhere, how would that act?

Ryan Burklo:                 03:52                How would that do differently? Right? And so the simple example of that is, you know, right now you can get a mortgage really, really inexpensive, you know, 3.8% or something like that on a 30 year mortgage. And so if your dollar can be put back into the business or put elsewhere and beat 3.8 at a relatively low low risk, well then you'd be better off putting your dollar elsewhere. Cause then you'd be making money on your money so you're leveraging that debt so your money can work harder. Whereas the credit card debt that I mentioned, you know it's a 20% interest rate. Well now I used to be 20% that's a lot harder and the risk is a lot higher.

Karen Litzy:                   04:38                Got it. So, so for instance, if you take on the debt of a mortgage, whether that be, you know, let's say you bought a building for your practice or you bought space for your practice and like you said, the interest rate is 3.8% then that might be a good thing for your business because you're putting that money to better use for you or the equity is in the building is good. Is that kind of what you mean?

Ryan Burklo:                 05:07                Well, to put it in another way, if you had $1 million of cash or $1 million sitting somewhere and you went to buy real estate and real estate was worth $1 million, we get to put the whole thing down, the million dollars sitting wherever it's sitting versus getting a debt and having to pay interest on that debt. You have to analyze what could that million dollars would be doing for you, and if that million dollars could be doing something better than a 3.8% yeah, we were just talking about why would you give the full million dollars to the bank. Got it, got it. And then you have the flexibility between it. All, right? Even if you're, maybe if you're just breaking even some people will get nervous about that too. We'll, again, you've got $1 million. How much more can you do with other stuff in your business because you've got that rather than just giving it to the bank, what type of flexibility do you possibly lose?

Karen Litzy:                   06:15                Got it. Got it.

Ryan Burklo:                 06:16                So that's just a simple example that I like to use. And that's not to say that you shouldn't pay off some debts. It does go by case by case, but you have to look at what your dollar could be doing elsewhere. And does that make more sense rather than only looking at it, well, Ryan, I'm going to pay more interest over 30 years. That's 100% true. And what could that dollar the other dollars be doing over the next 30 years?

Karen Litzy:                   06:42                Got it, got it. So it could mean the difference between investing it into something that's going to give you a higher return or putting it to use elsewhere instead of hiring another doctor.

Ryan Burklo:                 06:54                Well, another position that's going to grow revenue by X percent, that might be the better solution.

Karen Litzy:                   07:04                Got it. Got it. See, this is why, you know, my brain does not work this way. This is why I need someone to kind of break it down and explain it to me as if you were explaining it to like a fourth grader.

Ryan Burklo:                 07:18                Yeah. Well, my industry doesn't like to do that, but we like to confuse people. I try to make it as simple as possible because that annoys the crap out of me.

Karen Litzy:                   07:25                Yeah. I appreciate that. All right, so that's a great way that we can kind of make debt work for us. If you have, are there other ways, I guess that you can make debt work for you? Any other easy, simple examples?

Ryan Burklo:                 07:48                I threw a couple of examples just in that one. It's really about, again, it's just leveraging what you currently have. And so if you can get a loan, well, you know, let's just say we have a bit of a widget maker, right? And the widget maker needs to buy a machine to make more widgets. And they've got, they can go get a loan on it for X percent or they can just buy it in full. Well, what makes the most sense for your business? How are you leveraging your money to make it work as hard as possible for you? So it's a constant analysis of leveraging where the leverage is. Does it make more sense, can your money work harder outside of giving it to the bank?

Karen Litzy:                   08:43                Got it. Yeah. So if you were to pay in full and you can make more widgets and sell more widgets to make more money, that might make more sense than making payments on that piece of equipment.

Ryan Burklo:                 08:54                Exactly.

Karen Litzy:                   08:55                Got it. All right. Excellent. Now I got it. Thank you so much. Sorry for being a little slow on the uptake there. Now the other thing that I really wanted to talk about is this idea of tax efficiency, cashflow. So in going through your website, I saw this and I thought, hmmm.

Karen Litzy:                   09:16                This is really interesting to me because I don't know that I'm being as efficient as possible. So can you explain what tax efficiency cashflow means under the lens of, you know, your small business owner?

Ryan Burklo:                 09:31                Yeah. So there's two sides of taxes, right? There's the taxes that you're going to pay now, right. Where the income that came in the door minus the deductions and everything that we can take as a business owner, what's leftover and what we're going to pay on taxes from that on the business side as well as from the income side and that's based on the rules and laws that are in place this year, 2019 then there's the tax side of what am I going to get taxed on 15 years from now, 10 years from now, 30 years from now, depending on where my money and my assets are sitting. That's the side that most people don't really consider because what they're only considered is I want to pay as little money in taxes this year.

Karen Litzy:                   10:21                Yes, yes. Right.

Ryan Burklo:                 10:24                So the next question you have to ask yourself, okay, 10 years from now or five years from now or whatever time period that is, where do I think taxes are going to go? And obviously we can't predict this. Oftentimes it depends on who's in office and what's going on in the economy, all that kind of fun stuff. But if you're of the opinion that taxes are going up, should you have a lot of money and assets where you have not paid taxes on yet?

Karen Litzy:                   10:54                Yes. All right. I got it right.

Ryan Burklo:                 10:56                Yeah, exactly. Because you've deferred the tax. So essentially if it taxes went up, now you're gonna pay more in taxes. Conversely, it taxes go down within, you wanted to defer the tax. And the problem is, is we don't know. And so much of this is,

Karen Litzy:                   11:11                It's a gamble.

Ryan Burklo:                 11:13                It's a balance is what I put in. So we talked about financial balance quite a bit and it's because we don't want all of our eggs in one basket, right? We don't want all of our assets to be tax deferred because what happens if tax go up? Conversely, like I just said, if taxes go down. Whereas we have our assets in different buckets now we can actually control what tax bracket we're in five, 10 20, 30 years from now. Just like kind of what we're doing right now in terms of lowering our tax bill this year.

Karen Litzy:                   11:47                And so when you're looking at balancing and not having all your eggs in one basket, where would those eggs be?

Ryan Burklo:                 11:57                Yeah, so it depends on what you're building in your medical practice or in your business. If your plan is, you know, take a solo practice, you know, at one doc and you know, the chances of a one doc practice being able to sell it is not very high, especially they're required. They're the ones that bring in the money anyways, right? You can't sell something if you're the person that you're trying to sell. So oftentimes those types of practices, they have to build side retirement accounts. Okay. Right? These are your traditional IRAs, your simple IRAs, your standard retirement accounts. And so you could be putting a bunch of money into those accounts where you deferred the taxes. So that's one asset. But we could be talking about, it's also an event. Conversely, if you've got the multiple doc practice, we've had a couple of partners and maybe it's an inside, say on, you're actually transitioning one doc out. Well, how do you consider the taxation of the business? What's the cost basis, and then how are we going to sell it? Oftentimes in insider sales, what they call that, oftentimes no one writes a lump sum check and says, here you go, doc, you're gone. It's normally let me pay you in installments over the next 10 years. I see. Okay, so now you have more taxes going on there.

Karen Litzy:                   13:27                Oh, cause you, yeah. So you, if you are the doc that left the practice, you're paying taxes on that money that is coming to you in installments.

Ryan Burklo:                 13:37                Correct. And if you're the doctor bought them out to pay that doctor, you need the revenue of your practice to be doing a certain amount. So there's taxations on both sides of that equation.

Karen Litzy:                   13:50                Right, right. Oh my gosh. These are things like, I really thought you got bought out in one lump sum. That's why when you said that I started laughing, I'm like, Oh, okay. Yeah. I guess installments does make more sense.

Ryan Burklo:                 14:04                Yeah. Do lump sum sales occur. Absolutely. That's not, that's not what normally occurs. What normally occurs is here's a 10 year buyout plan.

Karen Litzy:                   14:15                Got it. That does actually make a lot more sense.

Ryan Burklo:                 14:20                So yeah, the steps that I have our clients consider is, you know, which type of practice or which type of business are you, are you wanting to build for one? Are you building the business where you're at? And essentially you just kind of run off into the sunset and business kind of goes with you or you trying to build a practice or a business that you can actually sell. And early on it's kind of hard to know that, but as you're growing, you start to picture, you start to build towards one of those. And once you know that now you can get more efficient with your money and what's going on and where to put it, how to get after it. While it's taking into considerations, obviously we don't want to pay a lot of taxes right now, so how does this all come together in one cohesive plan? That's the conversation that people should be having with their advisors.

Karen Litzy:                   15:14                Great. No, this is great. Yeah. And you know, we, you sort of mentioned the 401ks and setting up for retirement and things like that. And you know, I think we're, like I said, we're going into a new year, we're going into 2020, and maybe there are some listeners out there who are newer practice owners or perhaps they have not thought about their own retirement at the moment because they're building up their business. But can we talk a little bit about how one goes about setting up a retirement plan again, under that lens of a small business?

Ryan Burklo:                 15:55                Yeah. So, you know, really depends on, you know, how many employees we've got. What type of plan do we have any employees that are what we would call a key employee. And so what I mean by key employee, if you have an employee that if  they quit or left and it either cost you a lot of money because they were the customer service side of the business or they were the office managers. So now you've got to go train and hire someone else and go do their work. So you can build in a retirement plan that, that helps keep that employee active and engaged in yours. And you're a business. And that can also be part of that transition that we were just talking about as well. And so, so, so much of it is what is it we're trying to build?

Ryan Burklo:                 16:47                If we're looking with a starter business that you were just talking about and if you've got a couple employees, you know, it's looking at something like a simple IRA. That way it's low cost, easy to set up. You can set up matching type of contributions for your employees. You know, you can do like a 3% type match where you can go as low as 1% in the simple that allows your employees to be able to contribute and you match. Now they don't contribute, then you don't have to match. Right. And it's low cost. The 401K side of things is more, it's better for when you have a lot more employees, like 20 plus because there's more costs involved and it gets a little bit more intricate. That's when you can start to design it and really mess with a bunch of different things. And because you can mess with a bunch of different things, it costs money.

Karen Litzy:                   17:40                Got it. So if you have a couple of employees, I like this simple IRA, a 401k for a larger company. How about if it's just you, you're a solo practitioner. How do you set up, what is your retirement plan look like?

Ryan Burklo:                 17:58                Yeah. Yeah. So you could do a set by IRA if it's just you and you don't plan on hiring any employees you can do the traditional IRA route as well. Then there's Roth IRA, so you can still do that, that standard stuff. The SEP has more, has a higher contribution limit than say the traditional

Karen Litzy:                   18:16                And what does SEP mean? So for people who aren't familiar with what that is exactly.

Ryan Burklo:                 18:27                Yeah. So the simple IRA, well, I'm sorry, you mentioned the SEP IRA, sorry about that. So if you're looking at the SEP IRA, we're looking at a simplified employment. I'm sorry, I've got that all backwards now. The simplified employment pension is what that stands for. So SEP, S E P simplified employee pension. Okay. And the reason they call it that is, is just for yourself. And you're kind of setting yourself up for your own retirement plan, which is why the word pension is in there. It gets a little confusing. It's pension. Most people think of a pension has guarantees. It's not necessarily guaranteed, it's just setting yourself up with a plan for retirement.

Karen Litzy:                   19:10                Got it, got it. So as a solo practitioner, you've got a couple of different options, and again, this is where sort of you're taxed now or taxed then, is that right? Depending on like a traditional versus a Roth.

Ryan Burklo:                 19:28                Correct. So the traditional side is what they would call qualified money. That's tax deferred. You're deferring paying the taxes this year, you'll pay it when you start to pull the money out. The Roth IRA is you're paying the taxes this year on your money, it grows tax deferred and you can pull the money out, tax free passed age 59 and a half.

Karen Litzy:                   19:54                But with the Roth IRA, if you make a certain amount of money, you can't contribute to it. Is that correct?

Ryan Burklo:                 20:02                Yes, there are limitations. There are what they would call a backdoor roth IRA option where you can do, you can kind of go round that rule and there's a bunch of implications there depending on from taxation standpoint. But in general, there are some income limitations to do a direct contribution to a Roth IRA

Karen Litzy:                   20:26                Yeah. And again, does that matter what state you live in or is that a federal thing?

Ryan Burklo:                 20:32                That's a federal thing

Ryan Burklo:                 20:38                IRA's contribution is $6,000 contribution limit below the age of 50.

Karen Litzy:                   20:46                Right, right. Okay. Awesome. And like I have sort of a mix of all of these things, but I've been, you know, kind of contributing to this for many years. So let's say your in your thirties and you don't have any of this setup yet, are you done?

Ryan Burklo:                 21:08                Not at all. No, not at all. I mean, unless, unless you're planning on retiring when you're age 31 then maybe.

Karen Litzy:                   21:17                Right, right, right, right.

Ryan Burklo:                 21:19                You know, step one, have a conversation with a professional that understands what you're building for. And I know we're talking about retirement plans, but you know, I'm really of the opinion of what, what do you have set up for yourself prior to a retirement plan? Like if you don't have, say an emergency fund set up, start there. Like you don't have to contribute to a retirement plan. The retirement plan is not the savior for your financial status. It really isn't like you can have all of your money outside of retirement plan and actually still retire.

Ryan Burklo:                 21:57                There's this misnomer out there that when you have to put everything into a retirement plan and you know, for retirement only purposes, yeah, that's a good place to put money. But what can happen to a 30 year old prior to retirement over the next 10, 20, 30 years? A lot. A lot, right? Practice, growth opportunities, buying a house, selling a house, a bunch of different things. So having your money in what we would call a liquid type of asset where you can actually get after it without having to pay a bunch of taxes and penalties is something to really consider first prior to a retirement plan.

Karen Litzy:                   22:41                Yeah, that makes sense. Because like you said, a lot can happen between your thirties to retirement at 70 or 75. Got it. So setting up that emergency fund and looking at your, kind of what we spoke about earlier, looking at your debt ratios and how can you make that work for you and look at what taxes you're paying now and how you're paying them. And then finally then looking at, well, what do I need for retirement? What do I need to do for retirement that makes sense for me right now because I can put money elsewhere. Like you said, maybe it's into real estate buying a home or something like that. Oh my gosh. There's so much to think about.

Ryan Burklo:                 23:23                Yeah. The biggest thing, I've already said this once, I'll say it again. You know, I was talking about taxes. It's also where your money sitting. Again, don't put all your eggs in one basket. If you have your money in different sovereign account, you know, some in retirement plans, some in just a straight investment, some in real estate, some in savings. When you have that kind of diversification of where your money's sitting, how much more flexible is your life just from a financial standpoint?

Karen Litzy:                   23:52                Yeah, I would think much more flexible.

Ryan Burklo:                 23:55                A ton more flexible because of everything sending or retirement plan and you want to pull some money out to put into the practice. That might be the best thing to do, but you probably didn't pay taxes and penalties. Right,

Karen Litzy:                   24:07                Right. So then you're kind of losing money there. Exactly.

Karen Litzy:                   24:12                No, that makes a lot of sense. Lots of sense. This is really good stuff. Thank you so much for sharing all of this. Now, something that I know you guys do is you look at people's sort of financial wellbeing, if you will, but you also look at the person themselves, right? And so what are some things that maybe we can look at as ourselves at our business kind of reflect upon for next year? Like what, you know, cause I know that your process is a little bit different. You're really looking at not, like I said, not just the business or the cashflow, but you're looking at the person and their goals and visions and things like that. So how do you, what advice do you have for listeners out there who kind of want to get their financial house in order? But I'm sure there are some things to think about before you even have that discussion.

Ryan Burklo:                 25:13                You know, there's maybe two or three things I'll say to you, to your question. The first and foremost, and this is often not spoke about, and this is going to sound probably kind of weird, is what is your philosophy with your finances? What is your value? Right? So in my family, when we'd look at money, right? It's not about, especially in medical practice and naturopath, some physical therapists, right? Like typically you're not getting into the industry to make a ton of money, although that might be a byproduct you're getting into it to help a bunch of people, right? So the value of the money oftentimes when asked that question is, well, I want to help as many people. Well, to do that, my practice has to be very successful.

Ryan Burklo:                 26:02                Like without the cashflow coming into the practice and building that growth in the practice. How are you helping more and more people, maybe it's a different way, but what does that philosophy, what that does that that alone will have you direct where your money's going. Okay. And then step after you have that kind of philosophy. Step two is going to be more around where is it you are currently at? Like, how do we, how would like, you could do a quick net worth equation, right? Like add up all of your assets, checking accounts, savings accounts, retirement accounts, real estate, add up all your liabilities, student loans, cards, mortgages, and then so track the two numbers. That's your networth as it is today. And if you did exactly what I just said, we actually listed out your assets in one column, listed out your liabilities on the other column. You just got a lot of your balance, your balance sheet on one page. How many people I've ever seen that even though that's a simple activity to do.

Karen Litzy:                   27:09                Yeah. Yeah. Great.

Ryan Burklo:                 27:12                And then you can look at what you’re building next year. Okay. If your plan is to hire another doctor or buy real estate or invest in your practice more, what's your plan? How are you currently sitting and how could you possibly do that if you don't have liquid cash and liquidity to do that? Well now you're first, you know, your first step next year. It's actually having some money set aside that's liquid or accessible to do that.

Karen Litzy:                   27:41                Yeah. So really like you said, having your philosophy, your values, and your goals. Look at what you have and what you don't have and see if you can help make a plan for 2020 I think that's great advice.

Ryan Burklo:                 27:57                Yeah, it's, you know, money in America's taboo, right. It's a taboo topic to talk about it. We don't like talking about it. We don't even know half the time we don't even talk to our children about it. Right. And it's a taboo factor. It's a business factor. It's all this wrapped in one and for someone to take, especially as business owners, you know, we're wearing what sturdy different hats. One of those hats needs to be CFO. Right. So in your, hopefully we're taking a day out of the business to look at how the business is financially and that could be an exercise for that.

Karen Litzy:                   28:33                Yeah. I like that. Taking a financial business day.

Ryan Burklo:                 28:39                Yeah.

Karen Litzy:                   28:40                I really love it. I'm going to start doing that. I have to put it into my calendar cause you know, if it's not in the calendar it doesn't get done.

Ryan Burklo:                 28:48                Yup. I'm like you, I get it.

Karen Litzy:                   28:51                Yeah. Yeah. This is great. Thank you so much. Is there anything that we kind of didn't touch upon that you're like, Ooh, I really wanted your listeners to get this info?

Ryan Burklo:                 29:02                You know, the biggest piece that I want your listeners to get and really anyone to get is have conversations about money with someone you know and trust.

Karen Litzy:                   29:14                Yep. That's great advice.

Ryan Burklo:                 29:15                It really is that simple because it starts there.

Karen Litzy:                   29:21                Yeah, you're right. It does. And we don't talk about it enough. I know I'd have, I probably don't talk about it enough and need, probably need a little more guidance and things like that. So I think that's great advice. So have more conversations about money with people you trust is great advice. And now my question that I always ask everyone, speaking of advice is knowing where you are now in your practice and in life, what advice would you give to yourself right out of college? Especially knowing that what you said at the beginning of the podcast here, but as someone said, you'd be a financial advisor. You'd be like, what?

Ryan Burklo:                 30:03                I think it would have been slow down. Mmm Hmm.

Karen Litzy:                   30:08                Yeah.

Ryan Burklo:                 30:09                I was your traditional person that got out of college and said, I want to retire early. And so I hit the ground running and I started just grinding away. And not that that's a bad thing, but you know, as I've gotten married and have kids, I look back at that time and I'm like, you know, I could have done a couple of different things. I'd just slowed down and it wouldn't have affected me in a negative way the way I thought. And even if it affected me in a negative way, it might've been worth it.

Karen Litzy:                   30:37                Right. Yeah. A lot of people say that same thing and it's always kind of slowed down and you know, enjoy where you are in the moment and you are not alone in that train of thought. For sure. Well, Ryan, thanks so much. Where can people find you?

Ryan Burklo:                 30:55                Yeah. So if you want to go to and you can find all the information you could possibly want about me, whether you like it or not.

Karen Litzy:                   31:07                Perfect. And of course we'll have a link to the website at under this episode. So one click will take you all to Ryan's info about his company and their philosophy and how they work. And I highly suggest you click on over there. So Ryan, thank you so much for coming on. I really appreciate it. And we did a nice podcast swap, which I always love to do. So thanks so much.

Ryan Burklo:                 31:35                Absolutely. I appreciate being on.

Karen Litzy:                   31:37                And everyone, thanks so much for listening. Have a great a couple of days and stay healthy, wealthy, and smart.



Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram  and facebook to stay updated on all of the latest!  Show your support for the show by leaving a rating and review on Apple Podcasts!

Jan 6, 2020

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Joseph Reinke on the show to discuss student loan debt solutions. Joseph Reinke is the CEO and founder of FitBUX, Inc which is introducing innovative finance products and technology to the student lending industry with a specific focus on physical therapists.

In this episode, we discuss:

-How family, work and financial goals effect your loan repayment options

-Why refinancing public loans may not be an optimal strategy

-Practical examples of loan forgiveness strategies

-The personal and societal importance of financial literacy

-And so much more!



FitBUX Website

FitBUX Courses 

A big thank you to Net Health for sponsoring this episode! 

Check out Optima’s Top Trends For Outpatient Therapy In 2020!


For more information on Joe:

Joseph Reinke is the CEO and founder of Fitbux, Inc. FitBUX is introducing innovative finance products and technology to the student lending industry with a specific focus on physical therapists. Thus far in FitBUX’s beta test, they have helped PTs develop financial strategies on over $11mn in student loans. Joe has been in the finance industry for over a decade and is one of the few CFA Charterholders in the world who has experience in both wealth management and business valuation (globally, there are only 120,000 CFA Charterholders). He has hosted numerous live chats about student loans with SPTs across the country, presented at the California Student Conclave, appeared on podcasts, and written numerous financial blogs.


Read the full transcript below:

Karen Litzy:                   00:01                Hey Joe, welcome back to the podcast. I am happy to have you back.

Joe Reinke:                   00:07                Glad to be here. It's been a few years. I know that we see each other at different conclaves and different events and stuff, but it's been a few years since I've been on the podcast.

Karen Litzy:                   00:16                It has. I know, I'm happy to have you. And, we'll talk a little bit about what a difference a couple of years make in a second. But the first thing I want to get to is student loans. So let's talk about first, cause I know you have a lot of data on this. You have a huge data set within fit box. So what is the average debt? And we'll stick with physical therapists. We don't have to go across the board, but the average debt for physical therapists loan debt.

Joe Reinke:                   00:45                Yeah. So PTs or student loan debt. So we now have about 7,400 students and our platform, it comes out to about $900 million of student loan debt. The average is about $144,000 for PTs. We have some other graduate students that we also work with too. Before PTs, it's about $144,000 in debt. And like you just said too, it's like a moral, I know when we first came on the podcast years ago, we had like $30 million or something like that on the platform. And when I tell people we have like 850 $900 million down there, like, you know, congratulations like you know all the growth that you've had. And I look at it, I'm like, that's disgusting. Like the fact that there's graduates and it's like, okay, $900 million of debt, that must be a lot of people. It's like, no, that's only 7,400 people.

Karen Litzy:                   01:35                Yeah, it's criminal, it's criminal. So let's say you've got 900 million in loans, the average of $144,000 which is mind blowing. So what are the options for these students coming out to help repay that loan?

Joe Reinke:                   01:54                And the first challenge is trying to figure out how these things even play a role in the bigger picture. But then the government doesn't do us any favors. So right now there's nine different student loan repayment options and it's a minefield trying to figure out which one you should use. How does it play a role? Like what happens if I do this? What happens to my retirement, what happens to family planning? Can I get a mortgage? All these different things. And instead of just being like, okay, I'll pay back my loans, here's the answer. You've got gotta dig through all these things and that's where people get lost. So what we've done is simplify that into two strategies. Either you’re going to pay off your loans, or B, you're going to go on some type of loan forgiveness strategies. And the pay off loans is really dominated by the headlines of refinancing because that's what we get bombarded by in terms of advertisements.

Karen Litzy:                   02:38                And what exactly does that mean when someone says they're going to refinance?

Joe Reinke:                   02:43                Yeah. So refinancing means you go to a brand new lender and they offer you a brand new rate and a brand new loan and you're literally replacing your old loans with a brand new loan to get a lower interest rate. Okay, so like I know PTs they get bombarded by low road, which is one of our partners, but they get bombarded by a low road because a low road has a partnership with a PTA. So they just get bombarded. So we get everybody, everybody comes to us and like, well, I'm thinking about refinancing. I was like, well, why? It's like, well, I've got these things. That's what I see in my mailbox. And on the other side of that, they hear all these headline news articles about loan forgiveness and public service loan forgiveness and whatnot. So those two things dominate the headlines. But really it's even upload from that is either you're going to do a payoff strategy or loan forgiveness strategy.

Joe Reinke:                   03:34                And what I mean by a payoff strategy is what we typically think about when we get a loan. Like you get a mortgage or a car loan, you make payments over a certain amount of time after that, it's over. You could do different things to be strategic with that. Like instead of doing a 10 year plan, you can do a 25 year plan. So you can make prepayment strategically and save money. You can do refinancing, you can see if refinancing is right for you. And those are the big things with the payoff strategies is just figuring out what's the most effecient way to make my payments. Now, unfortunately, one of the problems is that the loan servicers don't always apply your prepayments correctly, so you got to stay on them and make sure they're doing the right thing. But that's, that's a whole nother topic on that.

Karen Litzy:                                           So quick question. When you say making prepayments, can you define what that is?

Joe Reinke:                   04:16                Yeah. So when you have a payoff strategy so most of us on average, so like when a DPT graduates, they actually have between 10 and 20 loans. So when I say $144,000 in debt, it's not just one loan, it's like 10 to 20 loans. They're all different sizes, they're all different interest rates. And so what a required payment is the payments. They add up every payment on those loans and then say here's your required payments. So they might say it's $1,000 a month. So on that required payment, you don't have any say on that. You have to make that payment every single month. And then you don't have a say where it goes. They just throw it across all your loans equally. Okay. A prepayment is like the complete opposite.

Joe Reinke:                   05:06                You have a hundred percent control of it, meaning you determine the dollar amount, you determine when you do it, but most importantly you can determine which loan that you want to go towards. So like if you wanted to pay your higher interest rate loans faster because that would save you the most money, you can do that. So the trick with payoff strategies is just knowing that general idea of the difference between a repayment, a PR, a required payment. And a prepayment is, well, how can I drop my required payment so I can increase my prepayment? Right? And so that's a lot of the tricks that we go through and mix and match the different plans to allow people to do that. And then you throw a refinancing on top of that and you can save even more. So that's really the payoff strategies.

Karen Litzy:                   05:58                Yeah, it would seem to me that everyone should refinance to a lower percentage but like why wouldn't someone do that?

Joe Reinke:                   06:03                It really depends. I'll give you a few examples. We might work with a travel PT for example, and with travel PTs. First of all it's harder because of the stipend. This is for OTs and nurses as well. It's a stipend, so it's actually hard to get qualified because they don't qualify that as income. So like we have nine lending partners, only three of them will do travelers first of all. So that makes it a little bit harder. But in that situation you're traveling so you don't know the cost of living when you're moving from place to place. You don't know how long it's going to be between contracts and you don't know, most importantly what your income's going to be when you stop traveling. So it's really hard to lock yourself into a refinance loan, even though you can always refinance again later, you might not qualify later to refinance.

Joe Reinke:                   06:54                So oftentimes we do do refinancing with that, those types of individuals, but it's more strategic. So instead of doing like a 10 year loan, we might do a 20 year loan and instead of doing all their federal loan debt and refinancing, it might only be three or four of their higher interest rate loans. So just in case there's something there that they can't do they're not obligated to this huge monster payment every single month. So that's one example. Another example we see often times is, I'll give you an example. I just actually talked to somebody today. She had about $210,000 in student loan debt and she's paying it off. Mmm. And my thing was the tail are like, look, you know, slow down. Because when you do your budget and you're doing paper and pencil, all the numbers always looked like they make sense. But this individual just started working.

Joe Reinke:                   07:49                They've never had a budget in their life. They've never had like real expenses in their life. It's like wait three or four months because you might decide that you can't make those payments. You rather do a loan forgiveness strategy and if you refinance, you can't do a loan forgiveness strategy anymore because private loans don't qualify for loan forgiveness strategies anymore. So just different situations will dictate. Does it make sense? And then sometimes the refinance rates are just not that good. So it just doesn't matter. Yeah, exactly. It's like stay there and just chip away at your loans. And I'll give you one more example, Karen. When you refinance, you also consolidate your loans. What that means is you merge your loans into one big, big, big loan.

Karen Litzy:                   08:37                Got it. So for instance, if you took a loan from a bank or a federal loan or whatever, when you refinance did, so let's say you have a federal loan, does that federal loan is no longer a federal loan, it becomes a private loan.

Joe Reinke:                   08:54                That is correct. And instead of having like 10 you might only have one big, big, big loan. So sometimes what happens, you have to understand how federal loans work though too. Like I said earlier, you have 10 to 20 loans, so every time you pay off one of those loans, your required payment actually drops. With the refinance loan, it won't drop because you have one monster loan, you never pay it off until the whole balance is zero. So sometimes people come to us and say, look, what am I goals is to buy a house in five years? And so if that's the case, we might turn around and say, okay, we'll stick in your federal loan. Because if you keep making prepayments and you pay these specific loans off, your required payment would go from $1,000 down to like $500 when you want to buy your house.

Joe Reinke:                   09:37                Why is that a big deal? They use the required payment in the ratios for qualifying for a mortgage. So a lower lower required payment on your student loans, the easier it is to qualify for a mortgage. So that's some of the analysis that we would do to say, okay, well how much does a refi actually save you versus are you better off just trying to drop your monthly payment over time so you can qualify for your number one goal buying a house? And so that's what I meant earlier when I said these things. It is more than just the student loan strategy.

Karen Litzy:                                           You've got to look at how does this thing play a role in the bigger overarching strategy, right? Because oftentimes I would think the student loan debt isn't the only debt. So can you explain how maybe you have to work around other debt as well and how to navigate all of that?

Joe Reinke:                   10:27                Yeah. And I'll give you an example. We just did a poll and we also took some of the data from our members as well. And it was something like 68% have more than one form of debt. So that could be cars, mortgages, credit cards. And again, another example, I just talked to somebody today, and actually we get this probably four or five times a week where somebody calls us to talk about their student loan debt and we noticed that they have credit card debt. Okay. And we're like, look, you want to do this strategically with your student loans to drop your required payment as low as you can and focus on paying off your credit card debt. And it's like, I didn't even think about that. It's like, yeah, credit card debt, socks, get all of that stuff like as fast as you can and use the flexibility of refrigerator loans.

Joe Reinke:                   11:10                That's another reason why you might not run a refinance is because the federal loans are more flexible. There's more options of what you can do. So if you have other debt, it may be allow you to pay that off faster. And that's why sometimes people go into the student loan forgiveness plans also in the short run is the drop that lower payment focus on something else and then go back to their student loan strategy and say, okay, now I'm going to go focus on that. What do I need to do to focus on my student loans now.

Karen Litzy:                                           Got it. So it's all part of a bigger plan. So let's talk about quickly the student loan forgiveness because that's been in the news lately. I feel like there's been rumblings of that. It may not exist anymore, Betsy Devoss may cut it or what's the story?

Joe Reinke:                   11:51                Yeah, so there's actually two different forms of forgiveness. Okay. And this is where people get confused. The actual repayment plan you're on is called an income driven repayment plan. And the government also says that these are things our student loan forgiveness plans. Long story short on these plans, your payment is based as a percentage of your income. And the payments really low is like 300 $400 a month. But for most of us, that means that we're not paying the interest that's being charged on loans, which means the balance of your loan Rose. And that actually will happen for about 20 or 25 years. And then under normal loan forgiveness at that 20 year Mark or your loans are forgiven, but you have to claim it as income and pay taxes on it.

Joe Reinke:                   12:44                So your balance of what you owe will grow because they just add the interest of your balance, just like in your differing interests cause you're not making payments. Happens in these plans. Okay. So then you worked for 10 years or 20 years or whatever, and then your loan is forgiven. So in these plans loan forgiveness, they last for 20 or 25 years. Department of education forgives them. Okay. However, in this country, it doesn't matter what type of loan it is, it can be an auto loan, a mortgage, student loan. If it's forgiven, you have to claim that as income. Yeah, so like let's just use that example. $144,000 is the average person on our platform. If, you're single for those full 20 years, just working, whatever it is, your loan balance might grow, does being worth $200,000 in 20 years?

Joe Reinke:                   13:44                So at that 20th year, the $200,000 is wiped out. You don't have to pay it anymore. But you have to claim that $200,000 as income, which means your ordinary income that you made that year. It's just here it is. You got to pay it. And so the goal on these plans is like the complete opposite. You're not trying to pay it off as fast as you can. You're trying to save for that tax liability as fast as you can. Cause like what we always tell people the number one risk on those plans, you don't know what the tax rate is going to be. That's right. It could be 35% it could be 80% it could be 60% now you also factor in like we just moved from California, so if you had $200,000 plus you made 120 grand because you're, you know, 20 years in as a PT in California and federal taxes, you're going to be in a 35 and 40% federal tax bracket. As of right now, plus a 12% tax bracket in California doubled on top of that. You should definitely move to Texas.

Joe Reinke:                   14:50                But that's a big thing there. So that's normal loan forgiveness. Now there's another form of loan forgiveness. And this is the part that's been dominating the headlines where if you're on one of these plans, but you work for a nonprofit hospital, a hospital, it could be a full time teaching job. I mean you can say I don't even want to be a PT, OT, whatever anymore and I want to go work at Goodwill full time. I mean it just has to be at a nonprofit full time. And if you're on one of these plans working full time and you make 120 payments, your loans are forgiven in 10 years cause that's 120 payments and you owe nothing in taxes. Okay. And so those have been dominating the news recently because there's been 110,000 people that applied and only about a thousand people have gotten it actually approved.

Joe Reinke:                   15:40                And people are like, Oh well that's less than 1% so that's like the big headline. You know, Loan forgiveness is failing. But when you actually dig into the numbers, over 90% of the people that have applied for that, it should never have even applied. Meaning, they don't even work in a nonprofit or they do work at a nonprofit, but they haven't worked for 10 years. Mmm. So they're finding the people for forgiveness and that they shouldn't even been filing it yet. And so that's where the news kind of distorts that stuff. But then at the same time, you have that percentage, two, three, 4% that is told the wrong thing by fed loan servicing. That's the company that, that does this. They're told the wrong monthly payments. They're told that their payments are qualifying even though they're not there. We're told that their employment qualified even though it's not.

Joe Reinke:                   16:26                And so that's where the mass confusion comes in on that. I'm actually shameless plug. We just rolled out a new technology that actually tracks all that for you to make sure if you're on public service loan forgiveness, you're actually doing everything you need to do to get it forgiven. And we rolled that out. We rolled that out specifically because of all the headline news of all this stuff. People getting this stuff forgiven. They have nowhere to go to get the answer. So it's like well we can build this pretty easily. And it took us about three months to ramp it up and build it and it's like here it is and we're actually going to release that. We just got done testing it. It's going to be out in about a week or two. So yeah I'm excited about, it's given me a lot of gray hairs and a lot of sleep aside. I'm excited for it.

Karen Litzy:                   17:07                Well I mean that's such a gift though. That's such a gift for people because there are a lot of physical therapists who work in hospital systems that would be considered nonprofits and so if they can just sign up for that and have something else, keep track of it for you. Like automation is so much easier in our lives. So this is a way to kind of automate your student loan forgiveness programs so that you don't have to keep track cause we've got a million other things that you have to keep track on. Because like you said before, you've got student loan debt, but then you may have credit card debt, you may have mortgage debt or you have a car loan. And so there's so much that kind of goes into this puzzle. I mean to say I did not realize that it was so, all this is so complicated because I graduated like in the stone age, you know, so I didn't really have all, I didn't have $144,000 in loans.

Joe Reinke:                   18:01                Yeah, I mean it's amazing. And, that's why the big thing that I'm excited about. So like the average person that's gotten their loans forgiven so far has basically saved $62,000 okay. That's a lot. We're rolling this plan out for $5 a month and when we roll it out for the full 10 years, we're just charging a one lump sum fee of $300 if you just want us to track it for all 10 years. And it's like, you know, and we did that cause it's like guys, yeah cause somebody has, some of the people that signed up to beta test it for us. They're like dude we pay like a thousand dollars a year for this. I'm like no, no, no, no, no, no. Like the technology doesn't cost us that much to run like this stuff needs to be out there because again it plays a role in a bigger picture and fast forward, we haven't really disclaim this to very many people cause I don't know when it's going to actually roll out but it's supposed to come out next year.

Joe Reinke:                   18:50                Like you said, all this stuff plays a role in the bigger picture. We're developing a technology where instead of just tracking the student loans, we track everything. Like, we help you set up the plan and as your 401k your retirement, your budget, your student loan plan, everything. And so to me, like when we say, Hey look, we're only charging, you know, $5 a month for this thing, it's making sure that it works. So when we roll out that bigger plan, it's like we got this piece checked off. We don't have to worry about it anymore. Cause again, I bring up those gray hairs. It gives me something else to worry about.

Karen Litzy:                   19:25                There's always something else to worry about. So just one little part of it. So now, so let's talk about something that you had mentioned before we went on the air and it's, people don't really understand money.

Karen Litzy:                   19:42                Tell me why you said that and tell me what people can do to better understand it. And on that note, we're going to take a quick break to hear from our sponsor and be right back.

Karen Litzy:                   19:57                This episode is brought to you by Optima, a net health company. Optima therapy for outpatient is a software solution enabling therapists and staff to do their jobs efficiently and accurately. Their software provides anytime, anywhere access to documentation, even while disconnected and workflows that streamline patient care and save valuable time. You can check out, optimize new on demand video to learn what's in store for outpatient therapy practices in 2020 with some of the biggest industry trends along with tips and best practices to successfully navigate these changes. Learn about these trends for the new year at go

Joe Reinke:                   20:36                Yeah, so we have this big thing that like if you watch our courses that we released or go on the new website that we just released, we talk about our method and it's understand, plan, implement those like the big three things. You've got to understand, you've got to have a plan, you've got to have a way to implement that plan. And there's been a lot of chatter because it's political season and we've seen all the stuff about, Oh, this politician is gonna forgive X amount of student loan debt. And then another politician wants to one up and then say, well we're gonna forgive X amount and another politician wants to one up them and say we're going to forgive everything. And so it's like, well, you know, went up in each other to see who can get the most votes for this. And you know, I get the question all the time is what do you think about these policies?

Joe Reinke:                   21:18                And I just turn around and say to people, it doesn't really matter because they're missing the root of the problem. You can forgive all the student loan debt. But like I brought this statistic earlier, over 60% of the people on our platform have more than one form of debt is not just doing loan debt. And it's not like these things like money problems didn't exist before. Student loan debt. I mean just before this we had the mortgage crisis. Okay. Like before that we had savings crisis. We still have people savings crisis, like retirement savings. I mean we talked about baby boomers and stuff like baby boomers. Like it's something that I saw a report the other day that 65% of them don't have enough to last like more than five years.

Karen Litzy:                   21:58                Yeah. And they don't have student loans. And then isn't it true that the majority of Americans don't even have like a retirement plan or don't have that savings?

Joe Reinke:                   22:12                They don't have anything and that they're dependent on social security, which the social security was never meant to be a retirement plan. It's supposed to be a supplement to retirement. But for a lot of retirement age individuals, that is their retirement. And I'll give you even more. I discussed the statistic I was about to write an article about this. Is something like 43%. It's somewhere in the forties, I want to say the low forties. I've got to look at the article again. It's in the low forties, that the super, that percentage of people in this country don't have enough money in their bank account to cover a $400 expense. Okay. So when we sit there and we talk about, Oh, well, you know, if we just forgave student loans, the problems of the world would be over.

Joe Reinke:                   23:03                And it's like, well, no, no, no, no. You know, like, I give this example in a workshop all the time. I used to work a lot with athletes and statistically 60, the 70% go bankrupt within three years of being out of league that's in the NBA and NFL. Well, in those three years that they work and play football or basketball, they will make more money than the average American makes their entire working life span. Yep. They go bankrupt. Within three years, they had the complete opposite problem. They had all the money in the world and they still went bankrupt. So it goes back to that fundamental root of not understanding. And that's actually one of the reasons why, like we used to do, or actually we still, I shouldn't say used to, we do workshops. Oh, it's the last time I came on the podcast, like it was, I don't think we had any workshops before that.

Joe Reinke:                   23:55                And then we started doing them. I've done over 120 workshops at different DPT programs and conclaves different conferences. And that was one of the big things that like, everyone's like, we love his workshops. Well, where can we learn more? And it's like, how, how do you explain this? Understand, plan implementing? And I couldn't find anything. So I was like, well, we're just gonna roll out our own courses. So we rolled those out about two months ago kind of in a soft launch type of beta test. And the feedback that we've gotten off of them is fantastic. So that's like our new thing that we just rolled out was the courses. The next new thing is that that public service loan forgiveness solution and the next year is like the big solution that we're coming out with. So it's exciting. But yeah, those courses, it's fun to see people taking them and being like, Oh my God, like this stuff is, makes so much more sense now. And it's, it's actually simple. That's my big thing. Keep it simple. Don't make it complicated. So, that's the bigger thing when I see the student loan forgiveness hype and all these political things, like it doesn't matter what happens there. You got to get that understanding. You've got to develop your plan, you've got a whole way, have a way to implement it.

Karen Litzy:                   25:02                Yeah. And just so if people want to learn more about it, if you go to the fitbux website, it's under monies.

Joe Reinke:                   25:10                Yeah. That is cool. Yup.

Karen Litzy:                   25:13                What would you say in your opinion and in your work with people, what are maybe one or two fundamental misunderstandings about money that people have?

Joe Reinke:                   25:18                I don't even know. No, I will narrow it down. This is one of the big things and this how we start off our workshops now when we start explaining some of this stuff. So, you know, and this is about a minute or two explanation on this, but then when I was back in wealth management, I would ask people what are your goals? And I started bucking those into three main groups. They would basically say my family goals, I have my work goal and then financial security. And what I mean by like family is like, okay, I want to do this. I wanna be able to buy a house because I want to provide for my family, my daughter, whatever it is. My work, my work, I want to have my work, have a meaning on life and an impact.

Joe Reinke:                   26:07                People like I joke around with all the time. No, none of you went to school because you couldn't wait to have student loan debt. You went to school because you wanted to help people. That's what I mean by career goals or life goals. And then the third one was financial security. And when I started asking people, yeah, rank these, it was always in that order, family, their work and then financial security. But when I would ask him, where do you spend the most of your time? They'd be like, well, I spend about 90% of my time on financial security. I'm like, well, that doesn't make any sense. That's like your third goal. Like that. And then I would ask them, here's like, when you say a misconception, I would say, what is financial security? And they kept telling me a lot of money and I'm like, wait, wait a second.

Joe Reinke:                   26:47                I just gave you that example of NBA players and NFL players. Lottery winners are the same statistics. They all go bankrupt. They have all the money in the world and they can't manage it. I used to manage people money that had millions and they were financial train wrecks. I know guys on wall street that were making million dollar bonuses every year that are financial train wrecks, so that can't be the case. So then I started looking at it and saying, well, what is it? And that's where we came up with the understand plan implements. Like those things is you've got to have a simple understanding. I mean I give examples of people that I know that are, have been barbers for 40 years. I mean they have no college education, they have none of this stuff and they live in San Jose, California, the most expensive place in the country.

Joe Reinke:                   27:30                And they’re millionaires, like they had an understanding, a simple understanding of money. They had a simple plan, you know, and I joke around all the time about my dad. Like when I was 22 years old, like I come home from college thinking I'm like this big investment guru guy, right? Cause I'm a 22 year old punk kid and I'm just like, Oh I'm going to tell my dad. I'm like dad, you know, his strategy was always just, you know, he started a business when he's 18. Yesterday, he started, he bought it from my grandma and you're just put money in the bank and they would buy a piece of property and that's all he did. He never did the stock market anything. I'm like, dad, dad, dad, check this out. Like, if you would have done it, you know, in the stock market it would've been worth like $10 million.

Joe Reinke:                   28:09                And he's just like, I don't give a shit. Like I don't know anything about the stock market. All right. That was his plan. It was simple and it works for him. Great. And then you had a simple way of implementing it. That was a thing that really lacked Mmm. Is everybody that I knew that had an understanding it and had a simple plan, it would taking them hours to implement it because it would have to do their own Excel sheets or they had these files all over the place. I've got gotta do it all by hand, but they did that. But those are the three big things. And so actually that's why people always ask like what's the technology behind FITbux and why do we do this stuff for free? Like why do we actually have people call us? And if we walk through their plan for free because we say the understanding and part is free and then the technology that we're building, especially for next year is going to be the part that helps them implement it. So they have to spend hours and 90% of their time doing that and they can spend that time doing something else. You asked about the biggest misconception that is the biggest misconception is what is financial security? It's not having a lot of money. It's those three things. Understanding, planning and implementing.

Karen Litzy:                   29:13                And if someone, let's say someone were like me, so I don't have any student loan debt or credit card debt or any debt really. So if I wanted to use this technology, like does it apply to someone like me who's like, well, I don't have any debt, but I definitely want to try and buy an apartment in New York city, which we know is like not cheap. I mean, in all seriousness, to buy an apartment in New York city to get a decent apartment is $650,000. Yeah. And that's a lot of money. If I want to get an apartment with two bedrooms, it's like over a million dollars.

Joe Reinke:                   29:43                Yeah. I was going to sell our apartment in San Jose and they got appraised that $900,000. And instead I was like, I'm just going to rent it and it's like $3,000. And then like I tell people, so I moved to Texas cause really I wanted to have a backyard for my daughter. And we bought like, it's like 0.3 acres and it's almost a 4,000 square foot house. It was a way too ridiculous. Like I don't use half the house and it's just ridiculous. And it was like 300 grand but yeah they like the technology but really on the next year.

Joe Reinke:                   30:37                Yeah, definitely for people like you, it's actually for anything, and this is why so many people, we talk about the student loan stuff, but we already have a piece of the technology out to help people plan. And this actually leads to like the number two misconception that I would have to say when we sit down and people talk about budgeting. They used to always come to me and they still come to me and say, Hey Joe, I spend like $1,200 a month on my student loans. Is that a lot? And it's like I have no idea. Right? Because $1,200 for one person might be nothing for somebody else. Okay. And so what that means is when it comes to money, absolute numbers mean absolutely nothing. It all has to be relative. And the way we do that as percentages, so like when people sit down and look at their budget, they always look at absolute numbers.

Joe Reinke:                   31:23                So if you go onto these budgeting apps and all this stuff, it's all absolute numbers and it's like, Oh well I'm going to cut, stop drinking coffee, you know, and boil and make my own coffee. It's like, great, you save $2 you know, a day or $50 a month. Like that might be 0.04% of your budget, but you don't want to learn something about retirement savings and taxes. I can save you like 10% like learn the learn. And so when you start looking at percentages, you start seeing where you should focus your time on. And so that's number one thing. But the number two thing would that allows you to do is then we could sit there and say, look we break this down very easily here, right? So we say the first formula is income minus expenses equals discretionary income. With that discretionary income, you can then do two basic things.

Joe Reinke:                   32:09                You can either build assets or pay off debt and before you even decide what to do with that, we can upload it and say, okay, on average, a new grad PT for example, can take 30% of their gross income and put it to those two groups, assets or debt. You just got to figure out how you want to do that. And so if you have no student loan debt like yourself, Karen, you'd be like, okay, well can I do 30% can I do 35% can I do 40% once you figured that out, then it's, well, now what do I do? Do I do my 401K you know, do I have self-employed income? So can I do a SEP IRA? What about a Roth IRA? What about HSA? What about just brokerage accounts? Oh, well I also want to say for a down payment for the apartment, what do I need to start saving for that?

Joe Reinke:                   32:50                What do I prioritize first? And then that, so that's the part that we'll have the technology that we have built now what we're building for next year is where we can say once you say, okay, this percentage is going here, this percentage is going here, this percentage is going here, implement link all your accounts into the profile. And they would automatically track to make sure you're moving those percentages and that you're doing it correctly. And so yeah, right now we only help anybody with student loans. And then we track the student loan strategy to make sure they're doing it the efficient way. And then next year we're going to roll out the bigger piece of the technology. And that was part of the preview with the courses is the courses talk about all that stuff. And that was like the first phase of what we're launching for next year.

Joe Reinke:                   33:35                We just got the courses down early and we're like, let's get 'em out. Like people are asking for them. So happy to get those out. But yeah, next year if you want to sit down and talk, let me know.

Karen Litzy:                                           I think I might have, I'm thinking about a lot here. So is there anything else that we didn't cover that you're like, Oh, I definitely want to talk about this. I wanted to get this in.

Joe Reinke:                                           Like we've talked about the percentages. The reason why I'm so adamant on that is because then it makes life easy. And what I mean by that is if you say, look, I know 5% is going here, 10% is going to here, percent going there.

Joe Reinke:                   34:21                Well guess what? You get a raise every year, so all you have to do is calculate and say, okay, well no, I just have to increase how much I'm going into those, those different areas. It's automatic discipline. You don't have to think about it anymore. And not only that, but like if you get a bonus or a commission or a tax return. Yeah, you already know the percentages. Take this here, take this here, take this here, put it here, the rest I can go use on vacation. Hell have fun with it and you don't have to think about it anymore. Instead, I see a lot of people being like, Joe, I just got this $5,000 bonus. Like I'm stressing about, do I put it in my investments? Do I pay off my student loan debt? It's like, well, if he's had those percentages that you don't have to think about anymore, you already know what you're doing with it.

Joe Reinke:                   35:00                So that's, you know, one more like they played it was one last thing to add. That's one of the big things is those percentages I strongly recommended. It doesn't matter who you are, where you're at, if you have student loan debt or not. If you're saving for a wedding, saving for college, saving for you know, kids. By the way, if you do have kids and you're saving for college for them, don't do it. Save for your retirement first please. They can fund college other ways. But make sure you fund your own retirement first before you can fund your kids. That's one of the biggest mistakes I see parents make. They want to fund their, call it kids' college education and their retirement is lacking. It's like no on your retirement first on their stuff later. So those are the big takeaways.

Karen Litzy:                   35:42                Awesome. I mean, such good information. I really appreciate all of this. And now this question I been asking everyone lately who come on the podcast and it's given where you are now with your life, your business, what advice would you give to yourself as that 22 year old punk going home to his dad more than he does?

Joe Reinke:                   36:03                I wish I would draw my ego level way before. That was, I was an athlete at that time too. So you get once, yeah, once you stopped playing sports and reality starts hitting then and all of a sudden it's like Mmm, well not on this pedestal anymore. You get shot down a little bit. But no, actually at that time for me, my big thing was I grew up around, you know, the rule of finance because that's what my degree was and everything. I was around wall street guys.

Joe Reinke:                   36:41                I had a plan for money coming out of school, but it was simply just to make a lot of money. And you quickly find out that if your motivation is money, you're going to end up burning out. It doesn't matter what you do. If that could be going to take a certain PT job simply because it pays more because you need to pay off student loans. So I guarantee you, you didn't go to school for student loans. You went to school to be a PT. So if you're going for income and that's your only reason you're going to burn out. Okay. And like I said earlier, I've seen guys making half a million dollar bonuses on wall street that don't even work in finance anymore because they're so burned out off of it. And it took me a long time to realize that you're not money that shouldn’t motivate you.

Joe Reinke:                   37:28                It's whatever you're trying to accomplish, that it'd be building a technology that'd be treating patients. And if all you do is strive to be the best at building that, that certain thing or focusing on those first two goals, I talked about your family and your work and you're really focusing on those, that the monetary side will take care of itself in the long run. Like stuff will happen and take care of itself if that's what your main focus is. And like, I mean, fitbux is the living proof of that. I've said it from day one to our investors and everything. Don't ask me about revenue. Don't ask me about shiny objects. Like we talk about business owners all the time. It's one of the hardest things to do because you see so many opportunities out there. You're like, Oh, if I just do that, just a little shiny object, it's going to make me a couple extra thousand dollars, but it's going to be a distraction.

Joe Reinke:                   38:18                It is not part of your main thing. Now you're chasing money instead of being focused on why you are doing what you're doing. And so that was one of the big things that I had to learn was, you know, it's not about making a million dollars or $5 million or $10 million. It's focusing on what you love doing and the recipe, it will come true. I mean like Karen and you're, you're a perfect example of that. You love doing the podcast, you love getting out there doing that stuff and helping people and guess what you've been successful at doing it. You've been successful as your PT career, all that stuff falls in line. If you're focusing on the right things and money's not the right thing to focus on is the bigger picture. What does money actually represent to you? What does it mean to you? Why do you want it? Because you can have all the money in the world. Do you want it to do something? Focus on that. Do something first and then the money will come from that because you're going to be the best at what you do.

Karen Litzy:                   39:10                Great advice. I love it. And now where can people find more information about you? Contact you find more about Fitbux.

Joe Reinke:                   39:20       As the website. As you said with the courses, it's just underneath money school. If you drop down the header underneath solutions, there'll be money school on there. That talks about our courses. If you want to come on and, you already know for example, that you want to do the student loan forgiveness strategy and you just want to sign up for our $5 a month tracking solution. You just go into solutions and sign up. We have a payoff strategy. We also had the loan forgiveness strategy. If you want to go in and use our refinance service, it's free. All you got to do is build your profile and schedule a call. We'll walk through making sure that refinancing is right for you and then go shop nine lenders. And if you have no idea what you're doing

Joe Reinke:                   39:59                And don't feel ashamed, about 70% of the people that come on our platform don't have a clue where to even start. And that's statistically true cause we asked them have you looked at anything? And they say, I have no idea. And so we, that's all free too. We'll have you come on, you build your profile, we go through the payoff options, we go through the loan forgiveness options. And then depending on which one you feel more comfortable with, we'd go deeper and deeper into how to actually implement that strategy. I mean that's all free too. You just go to the website and click join now and sign up, schedule a call and we'll be talking soon.

Karen Litzy:                   40:30                Perfect. And just so if people aren't familiar, it's So Joe, thank you so much for coming on. This was great info. I learned, I learned a lot. So thank you so much. Glad that we can teach and it's always fun and hopefully we'll see you at another conference or conclave or something soon and I'm sure talk more. And everyone, thanks so much for listening. Have a great, great couple of days and stay healthy, wealthy, and smart.


Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram  and facebook to stay updated on all of the latest!  Show your support for the show by leaving a rating and review on Apple Podcasts!

Dec 30, 2019

Happy holidays to the Healthy, Wealthy and Smart family! This is a special episode where all the amazing women behind the show come together to discuss 2019 and what’s to come in 2020. Thank you for supporting us and we hope to continue to provide great conversations in the new year!

In this episode, we discuss:

-Why you should enlist a team to help grow your business

-How to gracefully ride the ebbs and flows of entrepreneurship

-Prioritizing your mental health to avoid burnout

-New year intentions from the team

-And so much more!



A big thank you to Net Health for sponsoring this episode!

Check out Optima’s Top Trends For Outpatient Therapy In 2020!


For more information on Jenna:

Jenna Kantor, PT, DPT, is a bubbly and energetic woman who was born and raised in Petaluma, California. She trained intensively at Petaluma City Ballet, Houston Ballet, BalletMet, Central Pennsylvania Youth Ballet, RDA Choreography Conference, and Regional Dance America. Over time, the injuries added up and she knew she would not have a lasting career in ballet. This lead her to the University of California, Irvine, where she discovered a passion for musical theatre.

Upon graduating, Jenna Kantor worked professionally in musical theatre for 15+ years then found herself ready to move onto a new chapter in her life. Jenna was teaching ballet to kids ages 4 through 17 and group fitness classes to adults. Through teaching, she discovered she had a deep interest in the human body and a desire to help others on a higher level. She was fortunate to get accepted into the DPT program at Columbia.

During her education, she co-founded Fairytale Physical Therapy which brings musical theatre shows to children in hospitals, started a podcast titled Physiotherapy Performance Perspectives, was the NYPTA SSIG Advocacy Chair, was part of the NYC Conclave 2017 committee, and co-founded the NYPTA SSIG. In 2017, Jenna was the NYPTA Public Policy Student Liaison, a candidate for the APTASA Communications Chair, won the APTA PPS Business Concept Contest, and made the top 40 List for an Up and Coming Physical Therapy with UpDoc Media.

Jenna Kantor currently holds the position of the NYPTA Social Media Committee, APTA PPS Key Contact, and NYPTA Legislative Task Force. She provides complimentary, regularly online content that advocates for the physical therapy profession. Jenna runs her own private practice, Jenna Kantor Physical Therapy, PLLC, and an online course for performing artists called Powerful Performer that will launch late 2019.

Jenna continues to perform in musical theatre and lives in Queens, New York with her husband and two cats.


For more information on Julie:

Dr. Julie Sias, PT, DPT is the Producer of the Healthy, Wealthy and Smart Podcast. Julie received her Doctor of Physical Therapy degree from Chapman University. Julie loves to gain new insights and inspiration from the guests of the show in order to enhance her physical therapy private practice in Newport Beach, California.

For more information on Lex:

Alexis Lancaster is a student intern on the Healthy Wealthy and Smart podcast. She earned her Bachelor of Science degree in Biology, a Graduate Certificate in Healthcare Advocacy and Navigation, and is currently in her final year of the Doctor of Physical Therapy program at Utica College in Utica, NY. Lex would love to begin her career as a traveling physical therapist and hopes to eventually settle down in New Hampshire, where she aspires to open her own gym-based clinic and become a professor at a local college. She loves working with the pediatric population and has a passion for prevention and wellness across the lifespan. Lex also enjoys hiking, CrossFit, photography, traveling, and spending time with her close family and friends. She recently started her own graphic design business and would love to work with you if you have any design needs. Visit to connect with Lex.

For more information on Shannon:

Dr Shannon Sepulveda, DPT, M.Ed., CSCS, WCS is the owner and Physical Therapist at Shannon Sepulveda, DPT, PLLC. She is an Orthopedic and Women’s Health Physical Therapist and is currently the only Board-Certified Women’s Health Physical Therapist (WCS) in Montana. Shannon received her undergraduate degree from Dartmouth College, Masters in Education from Harvard University (M.Ed.) and Doctorate of Physical Therapy (DPT) from the University of Montana. She is also a Certified Strength and Conditioning Specialist (CSCS). She has been a practicing Physical Therapist in Bozeman, Montana for over 6 years. In her free time, she enjoys running, biking, skiing, hunting and spending time with her husband, son and daughter.


Read the full transcript below:

Karen Litzy:                   00:00:07           Hey everybody. Welcome to the last live podcast of 2019 I am your host, Karen. Let's see, and today's episode is brought to you by Optima, a net health company. Optima therapy for outpatient is a software solution enabling therapists and staff to do their jobs efficiently and accurately. Their software provides anytime, anywhere access to documentation, even while disconnected, which is huge, and workflows that streamline patient care and save valuable time. You can check out Optima's new on demand video to learn what's in store for outpatient therapy practices in 2020 with some of the biggest industry trends along with tips and best practices to successfully navigate these changes.

Karen Litzy:                   00:01:14           Learn about these trends for the new year at and we will of course have a link to this in the show notes under today's episode. And I also want to thank net health not only for today, but for being such an amazing sponsor to this podcast. We couldn't do what we do every week without their help. So a huge thanks to net health. So definitely check them out. And notice I said we now it's because of course I cannot do this podcast alone by any means. And today I am so excited to have the powerhouse team behind this podcast for amazing physical therapy entrepreneurs for strong, amazing women who help bring this podcast to life every single week. So in this episode, I'm happy to have on doctors. So they're all doctors, Julie Sias, Jenna Kantor, Shannon Sepulveda, and Lex Lancaster. And what we did was I had a conversation with Jenna and Julia.

Karen Litzy:                   00:02:18           You'll hear that in the first half of the podcast. And then in the second half of the podcast with Lex and Shannon and we talked about what our sort of our year in review, what 2019 did for us as people and as women and as entrepreneurs and physical therapists. And one theme that came across was that we're all doing things that make us happy and that in 2020 we want to continue that and we want to sort of construct the life that we want to see us leading. So that's in our personal lives and also in our life as physical therapists. So the amazing thing is Lex, Jenna and Julie are new grad physical therapists. Jenna and Julie have started their own practices. Lex has her own business outside of physical therapy, helping people with websites and graphics. Shannon, has an amazing practice in Bozeman, Montana.

Karen Litzy:                   00:03:20           She has started her practice about two years ago. It has grown exponentially. So she talks about how she did that. And it's amazing. We talk about what I have coming up in 2020 including an online course to help all those physical therapists or occupational therapists out there who want to start their own practice in a way that feels good to them in a way that's going to make them happy, bring them joy. And also the most important thing as physical therapists is our job is to get people better. And in our conversations in this podcast, we talk about how what we do as individuals not only affects us, but it's exponential. It affects everyone around us, our communities, our friends, our families, and of course the patients that we serve. And we're so grateful to that. And of course, as the host of the podcast and creator of the podcast, I just want to thank all of these women because without them I wouldn't be able to do this.

Karen Litzy:                   00:04:14           There's no way I can do this on my own. Like one of my guests said, Stephanie Nickolich and we mentioned this in the podcast is if you try and do it all, it'll keep you small. And when I was trying to do it all with this podcast, it was keeping me small. I wasn't able to upcycle this as much as I have with the help of these four women. So I just want to tell all of them and I say it in the podcast as well as that I appreciate them. I think they're amazing and I wouldn't be able to do what I do without them. And I just want them to know that my gratitude for this past year of 2019 is so immense and looking forward into 2020. I'm so excited to see what we all come up with. So I hope you guys really take in this episode because I think it's really special and of course to the audience thank you so much for another great year of listening and interacting with the podcast and being able to meet so many listeners all over the world has been a real joy to me in this past year. So everyone, thank you so much. Have a very, very happy new year and we'll be back with brand new episodes in 2020.

Karen Litzy:                   00:05:24           Hey Jenna and Julie, welcome to the podcast. Welcome back to the podcast. Since you've both been on several times. The reason being is because we all work together on the podcast to make it what it is. So well, welcome, welcome. So we're wrapping things up for 2019 and I thought, well, what better way to do that then with the people who make this podcast happen every year and who I'm eternally grateful for and appreciate so much for all of your hard work and your dedication and your fun and your being you. So, thank you guys for everything that you do. And now let's talk about 2019. Right? So we have January, 2019 to now. So a lot of things have happened within that year. So Jenna, we'll start with you. What are some highlights for you that's happened over the past year that you can kind of share with all the listeners?

Jenna Kantor:                00:06:34           Why hello listeners! Good, good evening and sun salutations. For me, I started my own practice literally on January 1st and we were driving back and I got my first patient that day. So literally my practice started this year. That was a big one for me. I also very quickly left all my PRN for those who don't know, that's working as needed, like a substitute teacher at a bunch of mills and I very quickly left all of them and I have been working for myself and it was the best decision I ever made. I have that musical theater background, which I'm sure listeners are quite familiar with, but if you don't know not, you know, and I was really not meant as a physical therapist to be sitting in one spot from nine to five. I really am not built that way and I love that I can make my own schedule, my own life and not feel like I'm really stuck in a location. It's a very, very big deal for me. That was something that was very concerned about as a performer. So I'm grateful to have made that move for myself.

Karen Litzy:                   00:07:49           Awesome. And Julie, how about you? So what's happened from January till now?

Julie Sias:                      00:07:54           So having been kind of mentored by Karen for the past three years, it was nice cause I also actually started my own practice and Karen was helping me along the way and everything. And January 1st yes, had my first patient and everything and it's been going really well, I haven't left my PRN jobs, but I do manage my concierge outpatient practice. And then I also see kiddos as like a consultation kind of gig. And then I work at a skilled nursing facility, PRN right now to supplement all that. But it's been a really exciting year because I finally have had a lot of control over all of my hours and it's been nice being out of school as a new grad.

Karen Litzy:                   00:08:44           Yeah. And Julie, when did you graduate? What was your graduation?

Julie Sias:                      00:08:49           So I graduated in the summer last year and then I took the licensing exam in November.

Karen Litzy:                   00:08:56           Right, cause you had to wait that extra long time to take your licensing exam.

Julie Sias:                      00:09:01           Yeah, so that was when I was just like a licensed applicant in California and I was working at the skilled nursing facility that I did a clinical rotation at. And then after I finally got my license, I was able to do all the paperwork to get a corporation and everything.

Karen Litzy:                   00:09:16           Right, right. And Jenna, when did you graduate?

Jenna Kantor:                00:09:19           That is so cool, Julie. I graduated in May 2018, took my boards in August and then I had a baby. No idea. I felt like, I think it was the rule of threes and I didn't have a three so I made up one.

Karen Litzy:                   00:09:48           That's so funny. Can you imagine now people probably be like, Oh my God, if they get like just a little clip.

Julie Sias:                      00:09:54           That's Jenna's one liner for the episode. We should make a graphic. I had a baby.

Karen Litzy:                   00:10:06           So great that the two of you were able to have a good idea of what you wanted to do and then we're able to execute on that and take action on that because it's certainly not an easy thing to do, especially when you've just graduated and you're trying to, you know, sort of make your Mark and kind of find your way. So to be able to know that before you even graduated I think is is amazing. And do you have any advice? Let's say there are some new grads listening or some students who are getting ready to graduate on what they can do to get some clarity around maybe where they would want to start their career at. And I'll have either one of you can jump in. Julie, do you want to jump in?

Julie Sias:                      00:10:56           Yeah, I'm ready to rock. So it was good to have accountability from you Karen because I kept telling you every year that I was going to do this. So then when it finally came to the time I couldn't really back down. So that was good. Cause then I had told everybody so if I ended up backing down that wasn't really going to look very good. And then I was also really clear with how I wanted my life to be. And going this route is definitely more of like a, it's tough, it's been tough kind of cause it's feast or famine sometimes and that's kind of like the ugly side of being an entrepreneur. But I have to like pause and just be grateful when I think about like my day and I just go, you know what, this is actually my ideal day. I got to go for a walk in the morning.

Julie Sias:                      00:11:54           I saw two patients. Maybe it's not like whether I want to be for like a full time job eventually, but I just have to like take a second and just be grateful. So it's good to have a clear vision about what you want your days to look like and then just know that when you put in the hard work eventually it will pay off.

Jenna Kantor:                00:12:41           Yes.  Amen, this is Jenna. I could not agree with you more. I think that is such a good point with any new practice owner is to stop and essentially smell the roses because it's easy to be, Oh my God, this is where I'm at. Oh my gosh. You know, living sometimes paycheck by paycheck and yes, you're not going to be rolling in the dough right away. It takes time. It takes patience, it takes persistence, all that stuff. But exactly what you said I think is a great way to approach it. I think a big thing, well there's a lot of big things for somebody. Big things when you graduate and you're trying to find a job, but there really is, from what I have seen, I know there's always an exception to the rule. There's really no help with the idea of graduating and getting a job from your school. They are focusing on teaching you what you need to know. You've got to pass those boards, boom, bada Bing. So if you're not going to continue and try to teach at the school that you were just at, you're not going to really get that guidance. The big thing now unfortunately as most of the jobs are at mills, there are places where people don't want to work for a long period of time. That's why they're always hiring. It just is what it is. And you could have this idea similar to me where you want to work with performing artists or say you want to work with tennis players. Say you want to work with geriatric patients only, but not by the hair of the chinny chin, Medicare, chin.  So you have a different vision on how you want to treat your patients. It's not easy to fully see that through when you graduate because you see this number of what you owe.

Jenna Kantor:                00:13:50           So you're in this like fantasy world. You're in school, you're learning like, Oh that's what I'm going to do. You graduate, you see your debt, that number and that number changes everything for everyone you've finished. You're like I need to get a job now. And it's just ah, and then you start work and then I've heard from some people, cause I spoke to a lot of new grads since then, I'm coming to me and I've only been out for a year and four months, you know, since taking the boards and then coming to me, just so fearful of

Jenna Kantor:                00:14:26           what if I quit? And that makes me look like a bad physical therapist. I always say the same thing. I don't care if it's your fourth, your fifth or 10th job that you're quitting. This is your life. None of us are living your life. So you got to make sure you are happy every time. You may get promises that, that they may not keep. And you need to keep track of that so you're not putting it on yourself. When you're not enjoying the job and you feel like you need to suck it up, you're not supposed to suck up life you’re supposed to enjoy life. You can't find that working for someone. You might be happy working at a mill. I'm not saying you wouldn't be, you wouldn't be, but most people aren't, unfortunately. So you're going to go through a journey most likely, unfortunately as a new grad of really having a hard time finding that fully right place for you to work long term.

Karen Litzy:                   00:15:14           And I usually tell people to kind of when you're trying to figure out, well what do I want to do or where might I fit? I usually have people do a couple of different exercises and I mentioned this on the podcast before, but one is like, just make three columns. I'm a big column person, right? So you make three columns in the first, just put like what you love to do and the second column is what you're good at because they could be two different things. Just cause you'd love to do something doesn't mean you're good at it. Like I love to do graphics doesn't mean I'm good at it, but I love to do it but I'm not good at it. And then the third is what will someone pay you for? So if you can kind of find a through line there, I think it helps you to sort of drill into maybe what are your strengths, what are you good at? What do you love? What will someone pay you for? So I always say like, I'm really good at crocheting. I really love crocheting, but no one's going to pay me for it. So it's a hobby. See the difference, right? So you want to make sure that

Karen Litzy:                   00:16:30           you're excluding your hobbies as being your full time job. But you know, for me, I some examples of what I'm good. Like I love curiosity, I love asking questions. I love, you know, networking and being with people and meeting new people. Those are things I really love and those are also things I'm good at. And so I was able to parlay that into a podcast and then parlay that into, through the podcasts and through networking into public speaking and into being asked to different conferences and stuff like that. So just know that not everything has to come from one singular job. You know like, and I think we can all say that here cause we've all got a couple of different things in the fire, stokes in the fire. Is that how you say it? I'm not really sure.

Karen Litzy:                   00:17:22           At any rate I would say to new grads is to certainly find the job that's going to put food on your table and feed your family and feed yourself and feed your pets and feed your kids and feed whoever else is depending on you. But don't discount that this one thing is the only thing you're allowed to do. You're allowed to do a whole bunch of other stuff, you have to give yourself that permission to do that and then you never know where that's going to lead you. Because if I only stuck just to patient care, well I wouldn't have this podcast and I wouldn't be going all over the world speaking and I wouldn't be asked to coordinate social media for conferences around the world. I mean just wouldn't be a thing. But instead I just decided to do what I love and do it well and get paid for it. It's awesome.

Julie Sias:                      00:18:28           Actually I have like a counter to that and that sometimes it's also good not to do what you love as a job cause it can be something that is your me time sort of thing. Oh that's like another counter to that. I was thinking about that maybe if you monetize something, it takes away the fun from it and then it becomes something where like I have to do this to make money versus I get to do this because I want to do it.

Karen Litzy:                   00:18:59           Right. And I think when you reach that point,

Jenna Kantor:                00:19:03           Yeah, I agree. Cut the cord if you don't like it's for me with performing I did. That was before me professionally for many years in musical theater. And I started to, I got into an eating disorder and I had to take a backstep cause it felt like a nine to five job going to these different States and I started doing community theater again to refine and which I did. And then I started working professionally again. So really was just, I realized I was just working at the wrong places. It's not that they were bad places, just not right for me. So yeah, I definitely agree with it's just assigned to cut the cord

Karen Litzy:                   00:19:41           Like Julie said, when you get to that point where I love doing this thing, but now it feels like a chore. I think you have to really do some self reflection and kind of see like, boy this is not, maybe, maybe I made a misstep here, so I need to take a step back and reexamine what I'm doing and let it go. Or you can see are there ways that I can make it even better if I give up some of the controls. Hmm, nice. Right? So I felt what Julie just said is what I felt about the podcast a couple of years ago. This very podcast, I was like, Aw man, I have to do another podcast. But then, and I was like pissed about it cause I was like, Oh, but I have to do this and this and this and Oh now I have to make time for this.

Karen Litzy:                   00:20:37           And I thought, all right, let me take a step back and kind of re-examine what I'm doing here. Cause there's gotta be a way that I can make this better and that I can make it bigger. And the thing for me was asking for help. So once I ask for help and let the control go, now all of a sudden it's, you know, more enjoyable and it's something that I continue to be very proud of, but that I'm not like, Oh no, not again, damn you podcast. You know, so it's instead of cutting the cord, I just tried, I took a step back and tried to look at ways that I can improve upon it and the improvement came with bringing people on board. So that's, you know, another all very valid kind of ways to look at things.

Julie Sias:                      00:21:49           Yeah. Another way to look at it too is that when you were under a lot of pressure, that allowed you to kind of be more creative too, to look for solutions and sometimes you go in directions that you wouldn't have thought you were going to go just because you were under that pressure and boom. That's where sometimes magic happens too.

Karen Litzy:                   00:22:09           That's right. Yeah. I think what Ryan Estis who was on the podcast a couple of weeks ago, what did he say? Like, when you're comfortable it breeds laziness or something like that, I'm really butchering his statement. I was like, boy, I really butchered that one up pretty well. But I remember when you said that, I was like, yes, that's so true. And yeah, it was something to the effect of like if he was looking at it from the point of view of an entrepreneur, that when you get to the level where you know you're consistently making money and you're consistently successful and then does that then breed complacency and does that take away your creativity a little bit?

Julie Sias:                      00:22:58           Yeah. That's not really the magic zone for growing.

Karen Litzy:                   00:23:01           Right, right, right. Yeah. And that's when you need some outside eyes to kind of take a look and see, and like Steve Anderson said last week, what is the role of a coach? And he said to give you those external eyes and ears that opens you up to things that you're just not seeing. And that's for everyone.

Julie Sias:                      00:23:27           Yeah. I actually have a perfect example of this and it was when I was just graduated and I was a licensed applicant and I had gone to all of my clinicals and asked for a job because I needed to make money while I was studying for the boards and stuff. And so ended calling Karen up and I was just like, you know, this one job offer, I got sure, like I'll have guaranteed money and guaranteed hours and stuff, but I just, it's not sitting with me well, I didn't really enjoy that experience as much as I could have. And then you were just like, Oh well maybe that's not the right fit for you. And then I got really creative and asked for referral for another clinic and ended up getting a job that better suited me at that time. So it was kind of nice having you there cause I was in the trenches like, Oh I need to make money right now. And you were just like, no, just take a step back. And then I had all these other opportunities present themselves.

Karen Litzy:                   00:24:24           Right. Right. And Jenna, that's kind of what you were saying. Right. When you graduate, like you said, all you're seeing is like, I've got debt, I need to make money. So you just take what you can. And so, you know, we don't always want to take just what we can, but you know, we want in an ideal world, we want to take what fits from all perspectives, what fits for the employer, what fits for you as a potential employee, what fits for you, whether you want to be an entrepreneur or you know, a part time entrepreneur, full time, whatever. But I think as a healthcare provider, if you find that job that fits, it just allows you to help more people.

Karen Litzy:                   00:25:19           Right? And in the end, we're in the business of making people better. And if you're not in the job that allows you to do that or you're not in the head space that allows you to do that, then the people who ultimately suffer are not you. I mean, you do a little bit, but it's the people that we’re out there to help. We're there to help people. That's what our job title is. And so if you can't, you're not in a good head space to do that or in a good physical space to do that. Then I think it becomes very difficult. Like Julie said, well, I had a great day. I was able to do the things I want to do that keep me sane. So that when you show up for your patients, your clients, you're showing up fully for them. That's where I think the PT profession can Excel for sure.

Jenna Kantor:                00:26:24           When I was filling in for PRN work, I would come in energized, positive. I would walk in and go, let's do some physical therapy. We're going to heal. And like people loved me, or at least I believe they did. I had the patients even though I was a substitute teacher, which is how I introduce myself.

Jenna Kantor:                00:26:45           Like I really bonded with these people, you know, and I have that energy, but Oh yeah. If I had one full day or Oh my gosh, forgot it, two or three, Oh, can maybe have at once. Oh my God. Full days in a row, I would need days to recover, days to recover. Like I was like, I was gone, I was gone. I was like sleeping, like just feeling so tired throughout the day and it really made it so apparent to me that everyone else is doing this six days a week, maybe five, you know, I don't know, depending on there schedule, but I was just, Oh my God, I can't, you know, hence here we are a private practice owners on this call. Yeah, exactly.

Karen Litzy:                                           Now let's talk about what's in store for 2020 new decade. New year.

Jenna Kantor:                00:27:44           It's my birthday. I'm turning 40 years old. That means I'm going to be so mature. February 16th. I like flowers, see's candies and cats and Disney for anyone who wants to know. Yeah, we're getting a dog. But like I'm more of a cat person so, but it has to be cute cats cause there are those presents. But 2020 is going to be awesome. I'm sorry, I just jumped in. But I'm theater people love talking about themselves being the center of attention. It's great. So I am so excited about fairytale physical therapy. For those who don't know, Fairytale Physical therapy is where we bring musical theater shows to children in hospitals and teach choreography that’s secretly composed of therapeutic exercises. This whole past year we've been working on paperwork back and forth with the lawyers to get it done right.

Jenna Kantor:                00:28:42           And we're like almost there every time. Like people ask, it was just us liberal almost there. Right now we're trying to get the right legal name because it's not as simple as you would think. So we're trying to figure out that legal name where they're not straying too far from what we are. And so that's going to exciting. And then for me, I am doing a lot of one-on-one beta tests with performers, for one course an online course for performers to essentially, those are going to be mini courses like say you have, hip tendonitis. All right? Now the majority of non-union musical theater performers do not have health insurance. And if they do, they have extremely high deductibles. So they usually just don't get help. So this is creating a wellness program that will be on that boundary of like, Oh my God, you doing like physical therapy stuff, but y'all do.

Jenna Kantor:                00:29:42           It's about the patients. So I'm creating this for them. The people who don't have that access, they don't have the money, they don't have all that, where it's a program and right now I'm just testing it on people cause it's physical therapy. You have to test on people and see if it works, if they stick with it. And so that's really cool. So I'm literally doing it, I'm doing three different types of injuries, right? No, five injuries right now. And taking different people. They're essentially like patients where I'm talking to them every week and like upping the game and figuring out symptoms. So that's great. Move that over. Now I'm also starting next week, just walking into the new year one on one work with physical therapists who want to work with dancers and figuring out what they want to know to make them the confident, accessible and go to dance PT in their area.

Jenna Kantor:                00:30:35           So I am working with now five, it was originally three 50 minutes ago, became five. I'm working with five and figuring out what they learned and basically giving, creating a course from this. So I'm very excited about two things cause it's where I want my energy to go. I love doing, like we were saying, find what you like doing. I like doing the creation of online stuff. And I've just encountered so many people with limited access to performing arts, physical therapists who specifically know that. And if they do know that our hearts, they don't have the insurance. You know, there's a lot, a lot of people in this world who don't get it. So I'm very excited to be bringing that help to performers at large. Whether it be giving that education to physical therapists or providing a program to them directly so that is exciting!

Julie Sias:                      00:31:36           Jenna, I was like, I'm going to bring like some California chill into the conversation because when I think about 2020 it's more just like, okay, I got my income streams and their proportioned a certain way. I want my business to grow more than the other ones and slowly phase those out. So that's like my intention for 2020 but then every other intention has nothing to do with physical therapy.

Karen Litzy:                   00:32:12           I love it. That's good.

Julie Sias:                      00:32:16           I’ve just been spending too much time thinking about physical therapy this year too much time, so next year I'm just thinking about more time with family, more time exploring hobbies and stuff. Maybe then I'll feel refreshed and have some inspiration to do more online type services and stuff like that, but just going into 2020, I have I don't want to say low expectations, but just I don't want to set too many things, just see where it goes.

Karen Litzy:                   00:32:40           You have sort of more relaxed expectations, so not that they're low. I think phasing out your PRN jobs and increasing your income that’s a big job. And it's awesome. So I think that's a great thing to focus on. That'd be fabulous.

Julie Sias:                                              Karen, you haven't told us about your 2020.

Karen Litzy:                   00:34:09           Why I am going to do nothing? No, I'm just kidding. I'm just stepping back and I'm going to live the life of Riley for the whole year. No, no, no. I am going to continue obviously with my concierge practice because I love it. I would like to take on another independent contractor onto the practice as well. Just to, even if it's just one or two patients a week, you know, just something to kind of help offset the amount of time I'm spending with patients, which I love. But, it's a lot. So oftentimes I get caught up working in the business instead of on the business. So that's something that I'd like to kind of get a better balance of. And I am also in the final stages of putting together an online program. I know I said I was going to do this year, and I did it because I was too fearful and just was too afraid of like, no one's gonna buy it. I'm going to look so stupid. And with that, you know, it's clear that has been holding me back. But I've been working with Adrian Miranda also. So he helped me with some videos and worked with Joe Tata, to help me come up with a great plan. And I've been working with copywriters throughout the year and some business coaches. And so I have a program that I was calling strictly business mastermind, but now I think we're might change it to the private practice mastermind, but that might be changed. I think someone else has a name that's pretty similar.

Jenna Kantor:                00:35:20           You could do PP mastermind, so you could say pee pee like professionally, which would be funny. He'd be mad.

Karen Litzy:                                           Oh boy. I didn't even think of that. Now that private practice mastermind PPM, I may need to rethink this. But we're hoping for like an end of January launch and it's not just me, there's myself, there's lawyers, there's accountants, there's PR professionals, marketing professionals, investment professionals, you know, investment 101 for entrepreneurs kind of thing. Got other successful physical therapists are going to come in and that's just the six week part of the course. So six modules over three months, but then it's a year long program. So each month I have new mentors coming into the group to talk about whatever the group is looking for. Whether that be, you know, practice succession or tax stuff, student loan stuff, whatever.

Karen Litzy:                   00:36:38           So we'll have monthly webinars for the whole year. And then the best part is I'm doing the Marie Forleo model. So Marie Forleo started a B school, which is an online kind of business school, like abbreviated business school that she started several years ago. And once you purchase it once, that's it. So if we do it again and there are things added to it, you're always in the Facebook group. You don't get shut out of the Facebook group after a year. You don't have to pay for upgrades and all that kind of bullshit cause I think that's so stupid. So I'm going with the Marie Forleo model and it seemed to serve her well since she's made millions and millions of dollars and she's just helped so many people. And I think they just know that like, Hey, this is the deal. And so once you buy the program, once you're in it for life and you'll get the benefits of that for as long as you need or want said benefits.

Karen Litzy:                   00:37:41           So I love it. I kind of liked that model. I just think it's, I dunno, it just fits my personality a little bit better, you know? So, we'll come up with a name, and then we'll unroll it hopefully at the end of January.

Jenna Kantor:                                        Karen Litzy’s LIT program. Karen Litzy’s Master class cause you could do lit in LITzy. So that'll be like the fire. Oh, I see what you mean. That's a topless pizza delivery man. I dunno. I just, I was thinking lit. That's red fire color and nothing. What else is fire color? Oh, pepperoni. And then I went to pizza and that's where we got.

Karen Litzy:                                           Well, I thought it was because I am from the pizza capital of the world, which I guess would make sense. That would be amazing. I love that. Yeah. Yeah. Old forge, Pennsylvania. Plug for my hometown, pizza capital of the world. But yeah, so, but that's pretty much. And then, I also am going to take a vacation.

Julie Sias:                                              Where are you going?

Karen Litzy:                   00:39:08           I don't care, but I'm doing it. I don't know where I'm going yet,

Julie Sias:                                              You should go to Hawaii.

Karen Litzy:                                           I love Hawaii. It's so nice.

Jenna Kantor:                                        This morning you, I don't know what it is, but one, I have a friend that's gone on vacation that is when I decided to contact you. So it's not on purpose. It's just so when I'm contacting you I'll be like, wait a second. She's probably obvious. She's in Hawaii. She's in Hawaii.

Karen Litzy:                                           So we'll see. I don't know, but 2020. I am definitely, cause I have not had like proper vacation in a long time. So my goal, one of my biggest goals, and this is not PT related, kind of like what Julie said, but is take a vacation and love that with Brett. He just doesn't know it yet.

Karen Litzy:                   00:40:03           We just have to be after June. He worked for a state Senator in New York, so he's in session until in Albany, you know, you gotta, you gotta do what you gotta do. And then the other thing that I want to do, and Jenna can probably help me with this, is get a little more involved on the legislative side of things.

Jenna Kantor:                                        Love that stuff, man. You want, it's that be the change you want to see in the world.

Karen Litzy:                   00:40:50           That's another thing that I'd like to do, whether it's PT related or not PT related, but just try and push for things that I believe in that should be happening.

Jenna Kantor:                                        So I think this has been the best podcast ever. I think for all of us were overjoyed to have us have cats. Julie, where's your pet?

Julie Sias:                                              She's outside.

Jenna Kantor:                                        There's that dog, a dog and two cats walk into a bar. Thank you so much for having us on Karen.

Karen Litzy:                                           Yeah, this was great. And I'm just so happy to wrap up the year and I'm looking forward to lots of great stuff from everyone and with the podcasts and just kind of keep moving forward and trying to innovate and do some fun stuff. So that's the goal and I thank both of you. So Jenna, Julie, thank you again. Like I said in the beginning, I appreciate you guys so much for all of your hard work and help and making the podcast much better than it ever was. So thank you so much. And everyone we're going to take a quick break to hear from our sponsor and we'll be right back.

Karen Litzy:                   00:42:20           This episode is brought to you by Optima, a net health company. Optima therapy for outpatient is a software solution enabling therapists and staff to do their jobs efficiently and accurately. Their software provides anytime, anywhere access to documentation, even while disconnected and workflows that streamline patient care and save valuable time. You can check out, optimize new on demand video to learn what's in store for outpatient therapy practices in 2020 with some of the biggest industry trends along with tips and best practices to successfully navigate these changes. Learn about these trends for the new year at

Karen Litzy:                   00:43:00           Hey Lex and Shannon, welcome to the podcast for our year end wrap up our year in review. So thank you so much for coming on and being on the other end of things for Shannon and the other end of things for Lex too. So thanks so much. So I spoke with Jenna and Julie the other day and now I have you guys here and I'll say the same thing to you guys that I said to them is that I'm so thankful and appreciative of both of you for being part of the podcast and really elevating it to a new level this year. Cause I really do feel like without your help and without your contributions that it just wouldn't have been what it was. So I just want to thank both of you and know that I appreciate both of you for your work in front and behind the scenes. So thank you so much. And now let's talk about 2019 because now is the time of year that everyone looks back on the year. So I'll ask the same question of both of you.

Karen Litzy:                   00:44:14           Where were you at January of 2019 versus kind of where you are now. So Lex, why don't I have you start kind of what big things happened in your year? Where are you now? So it's way different than where you were in January.

Lex Lancaster:               00:44:32           Yeah. It's pretty crazy to be honest. I was thinking about it last night. This time last year, I was preparing for my last clinical physical therapy school, so I was actually going to New Hampshire. Mmm. I was going to be in an outpatient clinic for 13 weeks. I was super excited because it was my last one, but I was also getting that full 13 weeks in outpatient clinics. I was like my powerful clinical, so super pumped. So I finished that and then I went to graduation and I actually got engaged on white coat night. So that was really, it was awesome. Kyle did a really good job. And then I graduated PT school, it was so awesome. I was so happy. And then the NPTE came around and that was a different experience altogether. I will say that I underestimated that completely. Just the preparation for it as a whole, but then I passed. So that was great. And then now, so I had this dream of being a travel PT.

Lex Lancaster:               00:45:42           So, this past year, you know, I decided I was going to explore that. So right after I passed the NPTE, I accepted a contract with my fiance in Alaska. So we moved 3,500 miles away from home to an Island of 1200 people in Alaska. So now we're in Ketchikan where it's like the rain capital of the world. So I don't look at rain as like, let's keep me inside anymore. It's okay. It's always raining. It's never not raining. And it's pretty dark here. It's pitch black still right now. So we're currently in Alaska and an outpatient clinic. And to be honest, it's been a whirlwind transitioning from student to kind of a PT, but you're just studying for your exam to a full blown PT. It's been hard just because I didn't expect it. You know, I've done clinicals, I'm like, Oh, it's no big deal. It's totally different when you're the person. So I've spent a lot of time in the last 13 weeks just kind of getting used to that and getting the groove and I’m excited. I'm excited to see what the next year will bring because this year was just really, really awesome and I'm really excited for, you know, to see what's next.

Karen Litzy:                   00:46:52           And you also, not to, I don't want to leave this out, but you also have an entrepreneurial streak in you. You have a company that you started this year as well. Am I correct?

Lex Lancaster:               00:47:05           Yeah, yeah. And I shouldn't, you're right. So I guess I initially launched it in like the end of 2018 but this past year has just skyrocketed. I just went from, I mean, I guess word of mouth is kind of the way that it really worked out. And I get to design websites and graphics and I am a virtual assistant, so I get to work with people all over the country and all different professions. I have so much fun doing that and I started it in PT school as I admit. I used to do it when I was bored in class. And then, you know, it got to the point where that was how I took study breaks. So that was the way I decompressed and I found that that was a big stress reliever for me.

Lex Lancaster:               00:47:56           So I explored that option and then I was kind of talking to Shante, movement Maestro and she was like, you know, you could really do something with this because I approached her at RockTape course and I was like, Hey, do you need an assistant? And that was right after I started working for you Karen. So like I was feeling pretty good. I was like, this is fun. I love doing this. And then I decided to do the whole web design business too and big changes for that coming next year. So yeah, it's been, it's been really, really cool. I've learned a lot about a lot of different people and I get to explore that all the time and I love it.

Karen Litzy:                                           Yeah, I think that's great. What would you say to a physical therapy student right now? Who is set to graduate in, whether it be, maybe they're graduating now or maybe it's spring of 2020 given the huge changes that happened in your life over the past year. What would you say to them as they prepare to graduate or maybe they just graduated?

Lex Lancaster:               00:48:48           A couple things I would say I would say really explore your mental health. I think that I didn't take that route when, as I was graduating, preparing for the NPTE and I feel like I truly drained myself to the point where if I could go back, I would invest in, you know, even a coach just to get me out of that sympathetic drive because I feel like my life just kind of, I just devoted all of my time and energy to the NPTE and it really did drain me. And, it was just a lot to manage. So let's say explore your mental health, get that in check and you know, really be prepared to learn a lot and find yourself in whether you're in your last clinical or just starting your job, you know, if you're the smartest person in the room, try not, you know, try not to be that.

Lex Lancaster:               00:49:50           Like there's always something to learn and it's hard to go back to be in the clinic and be by yourself and not have someone to bounce ideas off of that's in your room. Like your CI. It's hard. And I truthfully would say get involved in Twitter. I've found that I've met the most incredible PTs on Twitter and I get so much good advice from them and I'm able to contact, you know, people have specialties that come into the clinic and I'm just like, wow, they could use some opinions on, you know, the vascular aspect and I'll find somebody on Twitter and they are more than willing to help me. I would say just reach out if you have any questions about patients because there are so many PTs on Twitter and social media in general that would help you. So I would say just keep your network huge.

Karen Litzy:                   00:50:36           That's great advice. And you know, I feel like this, the first time I heard someone say take care of your mental health. I mean Shannon, like we've been the NPTE or the boards and on through to our career. Have you ever gotten that? I never got that advice to kind of take care of your mental health. I think it's great.

Shannon Sepulveda:      00:51:00           Yeah. I mean I think it's super important. I mean, one thing like when I was a runner and an athlete and so I always made sure that like I worked out every day cause that really helped. But I remember like, just wait until you take your specialized board exam because then you don't get your results for three months. So it's like three months of like, okay, like is it June yet? You know? And so you don't even like, and like when I took my women's health board exams also I was postpartum so that like added a whole new mental health aspect to it. But I mean I studied for, you know, probably six months, probably pretty intensely for three months. And then you take the exam and it's very similar to the NPTE where you're like, I don't know if I pass this because the questions are similar where you're just like, ah, yeah, I don't really know.

Shannon Sepulveda:      00:51:55           And then you have to wait three months to know if you pass. And so that's really hard.

Lex Lancaster:                                       I'll say a week was really hard. So I give you a lot of credit. Yeah, I know it was a hard, and you walk out and you're like, then I have never felt like I have completely bombed a test, but I feel like I just bombed that and then everyone's like, don't worry, this is normal.

Shannon Sepulveda:                              Oh, it was sort of like, even with like my women's health exam and then I was like, I think I failed that. And then I ended up getting like in the top 10 or 25 it was something like I did really well on it, but I thought I failed it.

Lex Lancaster:                                       It's so odd that our brains do that, that all we remember all of the negative questions. We forget how many good ones there were and then we just kind of wrap around that.

Karen Litzy:                   00:52:51           Yeah. And that's life, right? That's why people always say to like, keep a gratitude journal at night. So then you remember the good things that happen to you every day and you don't get wrapped up in the negative because I think that's, like you said, it's kind of where our brains tend to go. We remember those negative aspects before we'll remember the positive ones. It is amazing.

Shannon Sepulveda:      00:53:15           Yeah. It's the same thing with patients. Like who do you go home and think about the one patient that didn't get better, not the six that you made better.

Karen Litzy:                   00:53:27           Totally. And now, Shannon, speaking of changing lives, so going from January till now, what's been going on? What were your highs and lows and just so everyone knows, I mean they can go on the website, but you're a business owner. You're in Bozeman, Montana. And one of the only women health specialists in the state of Montana?

Shannon Sepulveda:      00:53:53           I'm the only one that's taking the board exam. A couple women in Montana who have done the Herman and Wallace pelvic floor and they're super highly trained and there's other people in Bozeman that are women's health physical therapists, but I'm the only one that's taken the plunge to take the exam. But yeah, so 2018 so I know, I was thinking about this question. So I've been in my own practice for a little over two years. And so I was thinking, I'm like, where was I in January? And so since I take insurance, January is always like dead pretty much, but December is always nuts. I think I was still building my business like last January. I didn't really like have a full schedule. I had been in business for a little over a year.

Shannon Sepulveda:      00:54:45           I changed my last name when I left my old clinic, just kind of to make a clean break with insurance and everything. And so I was still trying to get like name recognition and I do women's health also getting into like the Perinatal community in Montana. And so this year I'm finally like, like doctors know who I am and patients come in, they're like, I got referred by, you're like so-and-so. They said you're awesome. And so I'm getting like all of these women, especially postpartum women, that's generally who I see, who were like, Hey, so and so like saw you, you changed their lives and I'm here. And so I would say like probably well over 50% if not 80% of my patients are direct access word of mouth. And I'm just like, Oh, this is so nice because I don't have to like network anymore.

Shannon Sepulveda:      00:55:49           I don't have to like spend my nights at like local networking events and which I was doing just to get some name recognition and now I feel like I can, I don't want to like totally rely on word of mouth. I still think I need to get out into the community but it's really nice just to like check my phone. I do online scheduling and be like someone's requesting an appointment and another person's requesting an appointment and know that like the patients are coming without me having to like really go out and spend a lot of time, which, and I think doing that really helped me now. I think I had to do that but now it's nice where like it's almost like an exponential growth cause moms tend to talk, which is really nice. And so the word of mouth has gotten really great for me.

Karen Litzy:                   00:56:37           That's awesome. And you know, I think you bring up a really good point that you were in business for a year and you had a patient flow but it wasn't like you were overwhelmed and you know, you didn't have this full, full schedule. And I think for people starting out in business that is so important to realize that you don't start your business and in two months, it's rare it could happen. Yes. You're not usually on a full schedule within a month or two.

Shannon Sepulveda:      00:57:09           No. And I think what was really important was like the time that I wasn't seeing patients, like I took that time to either like have lunch with somebody, like have lunch with a prenatal yoga instructor or like have lunch with, you know, really anybody, a doula and midwife, like whatever. And so I really like had a lot of lunches and coffees just to like meet people. So when I wasn't seeing patients, I was trying to meet people in the community. And I feel like those like one-on-one rather than like the big networking events were really important. And I sent like, it was great for me too because like I want to know who to send to for prenatal and postnatal yoga and I want to know who the good doulas are and who the good midwives and OBs are because I send people their way and who the good like trainers are that understand pregnancy and postpartum because I'm not a trainer. Like I get people to not pee their pants so they can go to the gym and see the trainer.

Karen Litzy:                   00:58:10           Correct. It could be your slogan. And you know something that would work.

Shannon Sepulveda:      00:58:19           Yeah, it was funny cause Shayla, the one that I did the podcast on with the hats she wanted, I got a bunch of my hats embroidered and she wanted me to put on the back leak-free thanks to my PT and I was like, that's awesome. You know, I don't know if people will wear that, but that's a really good slogan.

Karen Litzy:                   00:58:39           That's great. I mean, you're really good at what you do. No, I mean that's great because what do people want? They don't, like you said, like I get them to not pee their pants so they can do other things. It's that simple. You don't have to overcomplicate things. Yeah, but I love that you're still kind of doing business. I call it like business generating activities, you’re not getting paid for it, but it's business generating activities, so it's still like a moneymaking activity. And you're right, the bigger, like Lex said, the bigger network you have, whether that be virtual in your case, because your business is in Bozeman, the bigger network you have a Bozeman, the more people are going to come your way. And so you did all of that work and now you're really starting to see the benefits of it and it's really exciting.

Shannon Sepulveda:      00:59:28           Yeah.

Karen Litzy:                   00:59:29           It's also good that you know the cycles of your business. So you know there's going to be really bit busy but January, not so much. You'd be like, okay, so January I'm going to set aside this time to do X, Y, and Z for my business. And if you know that those are the ebbs and flows because every business has an ebb and flow, then you know you can rely on that. And like I remember for me, my downtime is now around Christmas, new years, not a lot of people around. So that this would be the time where I would take a vacation or I would work on business plans for next year or I would, you know, just get things together. So, so to speak. So I think it's great that you brought up all those points. And Shannon, what would you tell a new business owner, regardless of what kind of PT business you have, whether it's a cash based business or your insurance or a hybrid, what have you learned that you're like, Oh man, I would tell everyone this.

Shannon Sepulveda:      01:00:29           Yeah, I've learned that if you're good at what you do and you get patients better, they will tell other people. And so I don't want to say think of every patient as a referral source, cause that sounds like you're, you know, it sounds like you're categorizing them. But think of every patient as like, this person is very important. It's very important for me to get them better because that's what I do and what I'm good at. But it's also very important for my business because if you get them better and you treat them well with respect and you do everything, they're going to tell other people, especially in a small town. And so like I am very, like sometimes I come home and like after seeing like patients for an hour, so like I see like seven patients and that's a big day for me.

Shannon Sepulveda:      01:01:22           And I am just like compassion fatigue is like full on set in because like I am so engaged for that period of time and with my population it's really important because it's really important for, they just need someone to listen to them. But if you think of every patient that way, it pays back. And every word that you use with the patient is very important. Because they come from like sometimes doctors that say things that I wouldn't necessarily say to a patient and they come in with, you know, thought viruses. Thank you Lorimer Mosley and you know, just talking to them but being really compassionate, you know, with all for your patients. Yes. Really in the end. And sometimes it's hard at like four o'clock at the end of the day, but it's really important.

Karen Litzy:                   01:02:16           Yeah. And I always think of your patients instead of like you said, referral source, cause that is a little, that's, I don't know how to like how would you, I described them as ambassadors.

Karen Litzy:                   01:02:30           So they become ambassadors for my practice. And that's the way that I don't treat them as a referral source. I treat them as an ambassador. So someone who chose because of the care you gave to them, you know, I would love for you to see this friend of mine or my daughter or my cousin or my, you know, X, Y, Z person, my coworker. Because like you said, you're listening to them, you're treating them with respect and kindness and compassion. And so to reduce that to a referral source is, I don't know, I agree with you. I like to use ambassador because they're new, that they want to be part of what you're doing. You pulling them in and saying, Hey, I'll give you a free X, Y, Z. If you refer me to five of your friends.

Shannon Sepulveda:      01:03:24           But because they're choosing to represent you and they're so excited to tell people like that's what is so awesome about what I do is like, like I'll see people and be like, thank you so much for referring your friend. They're like, Oh my gosh, I am telling everybody because like we don't have to pee our pants anymore and we don't have to have painful sex anymore and this is just so great. And I'm like, yeah, it's great.

Karen Litzy:                                           And Lex, you'll get more of that as you practice more, you know, you'll get people coming to the clinic you're in specifically to see you, which you might've already gotten so far is you're in this small town, right?

Lex Lancaster:               01:04:07           Yeah. I actually wanted to say that because you used a word Shannon, you said, or a phrase, compassion fatigue. And I find that as a new grad, I'm learning how, cause that's me every day I do that. And you know, my patients come in and on the Island we don't, there's not a lot of doctors. The practitioners here, you know, they have to go down to Washington to see a specialist. So oftentimes people will come in with, you know, a lot of comorbid conditions and we have to sift through all of that and make sure they've seen the correct people. So there's nothing I love more than getting on the phone with four doctors for one patient. So, and I've found that like, that's caring about them and I'm like, Hey, look, I'm going to reach out to your doctor. And they love that. And, but I do find at the end of the day that I'm exhausted. And so I'm trying to find that balance where I'm giving, giving, giving, but also saving a little bit for myself at the end of the day. But yeah, there's been patients that are like that, Karen, they just, they're like, Oh, I've told my friend. And then that friend comes in and then they come see me and it's just like, this is amazing. And that's why I could see why having your own business, why that's so important. Because that word of mouth aspect, you really can't replace that.           

Karen Litzy:                   01:05:24           Yeah. Yeah. And you know, I think most PTs have that kind of compassion fatigue. And one thing that has helped me is, I remember it was at, Oh, I dunno, it might've been Jason silvernail might've mentioned it on Twitter. I'm not a hundred percent sure, but I remember. So I think it was him saying that the thing that helped him the most and he's in the army, the thing that helped him the most is, is finally realizing that somewhat he is not responsible for a patient's outcome, that the patient's responsible for their outcome. So and that's hard because you're investing your time and your compassion and your emotions into this patient and your skills. But once I realized once I was able to kind of separate myself from like I am not the fixer, I'm there to guide and to coach and to diagnose and treat but not to fix and can separate the fact that I'm not responsible for this person's outcomes, that the person needs to embody that.

Karen Litzy:                   01:06:32           Then the compassion fatigue is less, it's still there because we're all humans, but it's much, much less. And when you instill that into your patients, it's really fun. Like I had a patient who had chronic neck pain for five plus years and came in and he had stopped running, working out, doing this, doing good, going to CrossFit, doing everything. And I said, well, why, why, why do you think that is? And I understand I was the same way. And so we got him back to doing things and I would see him once a week, once every other week now, just once a month. And he's like, yeah, so I had like a week. I was like, I really didn't have any pain. He's like, and you know, it's because he's like, I work out like almost every day now. He's like, so you're here but it's not like what you're doing to me. He's like, I'm working out and that's what's making me feel better. I'm like, yeah, exactly. He was like, what? You gave me permission to work out again? I was like, yeah, I can do this. And I was like, I was like, you got like, that's exactly what you hope to hear is like, yeah, got it. It clicked. And you can tell it like clicked for him at some point that week. Like, I'm helping myself get better. Oh, I see how it works. Got it.

Shannon Sepulveda:      01:07:51           Yeah. And that's, I think really like, it's hard. Like I try really hard not to make my patients dependent on me. Like I try really hard. I was like, my job is to empower you to get yourself better. Like I give you the tools to get yourself better and I don't tend to do a lot of like if someone's in like acute pain, I'll do some manual therapy, but I don't tend to do a lot of manual therapy because aye I can see like sometimes they'll become dependent and my job is to be like, no, you can do this. Like you, you can do this. It's all you.

Karen Litzy:                   01:08:29           Yeah. And all the research that like Lex, I feel like, and I don't know Shannon, you could probably agree with me here, but I feel like Lex and like you guys and your new grads, like you guys are starting out on like second base. I started out, I didn't even start out in the dugout. Like when I started, I feel like I started out in like the showers. Like I didn't even get to the dug out yet.

Karen Litzy:                   01:08:50           You know, with all of this sort of patient forward care and you know, the science behind pain and all this stuff that's this new research that has come out in the last 10 to 15 years. I feel like as a physical therapist it really gives us a headstart if you're keeping up with it. So like you're light years ahead of where I was.

Lex Lancaster:               01:09:14           And I would say a lot of it too is because of people that share things. Because you know, even like on social media, you see something and someone shares, whether it's at a snippet of an article or something, you're like, where did they see that? And then you go read that and you're like, Oh wow, that was awesome. So you know, people post the books that Lorimer Moseley's books and you know, you see those posts, you're like, Oh, I should read that. And you read it and you just gain all this knowledge. And like I said, I feel like a lot of it is dependent on people that share things. So, you know, all the podcasts that are out, especially, I mean, especially yours, Karen, to be honest, I'll say, I look at all yours and I'm like, Oh my God, that's so amazing. So yeah, I feel like we do have an advantage, I would say, especially with the pain science literature, new curriculums like that, that like just the education piece that I give for pain, people just are like, Oh, okay. And then it's like immediate buy-in and it's so easy to just get people to, like you said, get ready to help themselves

Lex Lancaster:               01:10:13           We're very ahead of the pain science literature.

Karen Litzy:                   01:10:19           I know I looked back and I'm like, Oh man, I'm grateful. I'm so grateful. I'm better with these people.

Shannon Sepulveda:      01:10:22           Oh yeah. I mean, I graduated in 2011 and there was nothing really, Oh yeah. I mean, well, in my PT education there was, yeah. I started learning some stuff after that, but there was nothing in my PT education about pain sciences and that was like, so I would have had like didactic until about 2010 early, you know, so I know it's like 10 years ago.

Karen Litzy:                   01:10:59           I know. And like David Butler first published on sort of pain science stuff in 1996. Wow. You guys look it up. It was 96 or 97. And so, you know, we have, they say research to practice takes like 15 years.

Shannon Sepulveda:      01:11:18           There it is. There it is.

Karen Litzy:                   01:11:20           It's amazing. It's astounding to me. And, I find that if you stay engaged as a newer grad, that you really do have such an advantage, and advantage with your patients and I hope that people really no that and can appreciate that. Then new, newer ish grads can really appreciate how lucky they are coming up. As far as information, the information pipeline is so much easier. Now. I won't even tell you, like I had to do the Dewey decimals system. I'm so old.

Shannon Sepulveda:      01:11:56           We were cleaning my house and I had all of my PT books and like my husband, so he works for the US geological survey and he has a PhD and I had all my PT books, what are you doing with these? I was like, he's like, have you looked at these in 10 years? And I was like, no. And he's like, everything's online now Shannon, you can get rid of these. Yeah, yeah. And like everything.

Karen Litzy:                                           I got rid of my mind a couple of years ago. I'm like, what did I doing? And even if it's all these journals, like physical journals in my apartment, I'm limited space here in New York. I'm like, I gotta get rid of these journals. They're taking too much space.

Karen Litzy:                   01:12:52           So let's talk about what's coming up in 2020. So what are you looking forward to? Do you have any goals or expectations or plans, whether Lex, I'm assuming you're going to get married.

Lex Lancaster:               01:13:07           Yeah. So we finally set a date. The wedding has been interesting. So I didn't really want a wedding just because it is, it's overwhelming. It's a lot of stuff to plan. But then, you know, family, they're like, Oh, well you're the only girl. You really should do it. So we set a date for October 17th of next year, so we're going to get married in New York. I've done minimal stuff. I've gotten the venue, really making very slow progress.

Lex Lancaster:               01:13:36           So working on that and then you know, for 2020, you know, I'm really looking at bringing, I just applied for a trade name for my business so I could take my name off it and just make it a new name. So I'm really excited to launch that eventually once I get that all set in stone and really trying to bump that side gig up just because I have found the value in the last couple months of doing things you like to do more often. So Kyle and I were actually talking the other day and you know, we're seeing the value of providers that have their cash based or insurance businesses and these small towns in their hometown. And we're seeing the value here. Like you get to know people, you get to know doctors. I love travel PT, I do, but I'm very far from home so I'm hoping I get closer back to home and we kind of want to land in a spot where we can kind of start our own thing.

Lex Lancaster:               01:14:34           We were those people like we care, we want to reach out to people out. People know us back home. And we really wanted to start our own thing. So we're trying to get back toward, well and try to do that just because I see people, you know, as they have their own business, they make so many decisions that they get to see patients when they want to see for how long they want to see them. And sometimes, you know, I'm very jealous of that right now. You know, there are patients that I'd love to spend an hour and a half way, then I just can't. And so I think that's a major goal right now. It's just to get to that spot. And I understand as a new grad it's very hard. Yeah. I mean, I don't, and Julie did it, so I should probably reach out to her because, you know, everyone says like, it's really hard to do a business on your own as a new grad.

Lex Lancaster:               01:15:21           I should reach out to her because that's what we want to do. And you know, we understand that will probably be hard, especially with student loans and whatnot, but at the same rate, like we're trying to define, you know, what's your happiness worth? And we just kind of find that right now the quality of care that we want to provide is sometimes limited by you know, whether it's because of insurance, a lot of dancers and we're finding it hard to justify their care even though they need it with insurance and people can't afford to do X, Y, and Z out of pocket. So we're trying to find, navigate all of that. So, I dunno, trying to, that's a goal just to get to a place where we can build our own, you know, set of patients.

Karen Litzy:                   01:16:04           Awesome. And you're in upstate New York?

Lex Lancaster:               01:16:08           That's where I'm originally from, but we're probably going to end up back in New Hampshire. Yeah, we both really love it there. And I don't think my parents will be in New York forever, so I think we're just going to go back to New Hampshire area. So we're close to Boston.

Karen Litzy:                   01:16:23           Yeah, I think that's a great goal. And you should definitely talk to Julie about that. And the good thing is you have each other to give each other support. You and Kyle have each other so you can, you have that support from each other. And I think being able to do that with the two of you I think would be really exciting.

Karen Litzy:                   01:16:42           If you build up your side gig, then you can slowly build up your practice. You know, you just to know where you have those income streams coming from. But I think that's cool.

Lex Lancaster:               01:16:52           I'll say after reading Danny McTay’s book, it kind of gave us both a little hope of just that you can do it. It's just you have to decide if you're going to burn the ship or do it as a side gig for a little bit. And I think we're more or less thinking side gig for a little bit, even if it's just something, something to let us treat, you know, the high level athletes that we can't justify insurance-based for right now.

Karen Litzy:                   01:17:18           Yeah. Basically. Yeah. You should talk to Julie cause that's what she's doing. She's sort of building it up slowly. We talked about it for this podcast. So. Perfect. And how about you Shannon? What's coming up for 2020?

Shannon Sepulveda:      01:17:31           I was thinking about this, I'm like, what are my goals? So business is really good, which is awesome. I think one of my goals I need to try. So I really don't want to hire anybody. I do all my own billing, all my own scheduling. I see my patients. I need to try to figure out time management a little more. Because like I'll be in like I take Fridays off and I'm with my daughter and sometimes my son has off kindergarten on Fridays and I'll be like in the target parking lot. And now they know when I stopped the car and I like sit in the parking lot space, I'm like checking my email. They're like, mommy, don't check your email. We need to go into the store. And I'm like, like accepting patient appointments or just like, you know, I need to try to figure out how to do that because I want to do everything.

Shannon Sepulveda:      01:18:26           But for myself. And so it may just be like saying no, it may just be having a wait list and trying to figure out like the feast or famine of owning your own business, like these ebbs and flows where like this month is like just absolutely nuts. Like I had five people call me in the last week trying to get in before their deductible resets. And so like I have like, I'm taking next week off and I'm not seeing anybody but like the 30th and the 31st, I think I'm like seven patients a day or something like that. 31st I have patients to like five 30 on new year's Eve because like, they're like, Oh please. And I'm like, okay, okay. You know, and because I know January is going to be really slow. And it's really hard. I'm staying up till 11 o'clock at night to finish my notes. And so I think either I just have to accept that that's the way it's going to be or do a little bit more time management.

Karen Litzy:                   01:19:26           Or even sounds like maybe just setting your boundaries or boundaries for yourself and something that you're comfortable with. I think that that is something I will say that really helped me is saying, you know, listen, the last patient I'm going to see at night is seven o'clock at night. Like I'm not going to go later than that or I'm going to take at least one day off. Yeah. It may not be, may not be a Saturday or Sunday, but I'm going to take one day off during the week and this past what I've done is that I'm going to take five hours or four hour chunk of time and have that just dealing with business kind of stuff. You not teaching care. So I think if you look at your schedule and kind of set your boundaries, then I think you'll find that your time management just flows within that. Or you can get a virtual assistant.

Shannon Sepulveda:      01:20:19           I know I could do that. Yeah. It's funny cause like for some reason my boundaries…

Karen Litzy:                   01:20:24           Cause you're like me Shannon. I'm the same way. Like, I love to like keep everything close to me, but the moment you can like let just one little bit go.

Karen Litzy:                   01:20:46           You'll be like, what the hell was I thinking? What would be the sooner? But you have to do it on your own timeline and when you feel like you can, you can let go of that. A little bit of control. Like I let go of like a smidge at a time. Yeah. And then for me it was easier then.

Shannon Sepulveda:      01:21:03           It's really interesting because I think about, I'm like, okay, as a business owner it is not worth my time to spend. Like I tried to keep my Mondays as admin days like that is not worth my time to do. It's worth my time to pay someone to do the admin stuff, but I keep holding it in.

Karen Litzy:                   01:21:20           Yeah. Yeah. That's a good way to look at it. If you have whatever your fee is, let's say your fee is, I don't know, I’m going to make this up $200 an hour.

Karen Litzy:                   01:21:31           Right. The task you're doing as an admin at $200 an hour task, $25 an hour task, or maybe it's a $20 an hour task. So, and when you look at it that way, it's like what am I doing? Like I could pay someone to do four hours of work and what I get paid in one hour. Do you know what I mean? So when you look at it that way, the financial offset makes a lot of sense because your time is money. And like you said that that four hours could be an hour that you get to spend with your kids having lunch. So it doesn't necessarily mean it has to be with your business, but or it could mean that's your time for, you can go to the gym or you can do X, Y and you can meet with a doctor or doula or whatever. So you know like that is $200 an hour time spent when you're having lunch with like a possible referral source doing like weird admin stuff that you don't need to do is not $200 an hour work.

Karen Litzy:                   01:22:35           That's what I did and just really like looked at everything, wrote down everything I do and you can attach sort of a monetary value to it. And then once it's down on paper you're like, Oh my God, okay.

Shannon Sepulveda:      01:22:52           I know, I know and I haven't like it's interesting cause I hadn't gotten to that point until this December because like I'm still growing and so that's one of the things that I think I'm going to need to think about like, and I'm just going to see how like the ebbs and flows, like if it is still as nuts as it is right now, then like I got the, because the worst is, and honestly like the billing's not that hard. It's verifying the insurance benefits. And sometimes I can do it online and it's really easy. And then sometimes the online just tells me what their deductible is, not how much they've met. And so then I'm on hold with blue cross blue shield for like an hour while I'm trying to do other notes.

Karen Litzy:                   01:23:40           And what you'll find is like you will grow, maybe not exponentially, but you will grow bringing help on, you know, I did an interview with this woman Stephanie Nicholitch, she's like a high performance coach and she said, you're trying to do it all. Keeps you small. Yeah. And, it's true, but you have to feel ready for it. So it's in your time and you'll know.

Shannon Sepulveda:                              Yeah, I think I'll know. And the other thing is like one day, the other Monday I just like sat in front of my computer and I did my QuickBooks and my billing and I came home and I was like, I don't even feel like I've worked today. Yeah. He's like, I hadn't seen patient, I hadn't had that compassion fatigue. So some of it's like, can I actually handle that many patients? You know, can I give good care when I see my caseload.

Karen Litzy:                   01:24:26           Yeah. And these are the growing pains that you have to deal with and it's a good growing pains, growing pains. So hopefully you'll continue with those growing pains. We hear it out in 2020. I think you will. Thank you. I want to thank you guys because like I said, if you do it all, it'll keep you small. There's no way I could do everything that is required of this podcast to keep it of good quality and to have good guests and good interviews and good graphics and good everything and make the guests feel like we're on their side, you know, and that there putting their best foot forward on the podcast. And I think that's what both of you and Julie and Jenna do is creates a good experience, really positive experience for the people who are on it.

Karen Litzy:                   01:25:28           Like Shannon, we were saying like, people bought those hats and Carol and which I think is amazing. But you just never know how far the podcast is going to go. And you know, yesterday I was with some friends and we were talking about the podcasts and what's it on and you know, it's on Spotify and it's on, well iTunes is no longer a thing. So now it's just Apple podcasts and I looked up under medicine and it's like 52 out of all podcasts. For this fully female run podcasts. That is pretty good I think. Awesome. Yeah, it was really cool to see.

Shannon Sepulveda:                              One of my PT friends in Bozeman. He like just moved to Bozeman a couple of years ago and he referred a patient to me and this was about a year ago and I called him and he was like, yeah, I was like listening to healthy, wealthy, smart. And you were on it. And I was like, Oh my gosh, she's in Bozeman. You were like randomly listening to the podcast and then you were like happy that it wasn't because I was in Bozeman, you were listening to it. He's like, no. And I was like, wow, that was awesome. It was a great moment.

Karen Litzy:                   01:26:38           Yeah. And never know who's out there listening and you never know where, again, the podcast becomes a referral generator. We can call a referral generating. This we could say generates referrals, but it does and you never know who's listening and where it's going to kind of take you. So I think that's so good to hear. And like I was talking with a coach that I had on a couple of years ago and she's like, Oh yeah, I got two clients from you. And she referred one of her clients to be on my podcast, the one who was talking about poop. She ended up getting like three clients from being a guest. Whoa. All right. So I was like, Oh, that makes me feel so good that that's the case. So, you know, keep up the hard work and you know how much that I am thankful and appreciate it and wish both of you have very happy 2020 new decade so thanks again so much. And everyone out there listening. Thank you so much for listening all year and we all wish you a very happy new year and hopefully stay healthy, wealthy, and smart.

Karen Litzy:                   01:27:58           And again, a big thanks to Jenna, Julie, Shannon and Lex for all of their work all year. And of course a big thanks to net health. This episode is brought to you by Optima net health company Optima therapy for outpatient is a software solution enabling therapists and staff to do their jobs efficiently and accurately. Their software provides anytime, anywhere access to documentation, even while disconnected and workflows that streamline patient care and save valuable time. Check out their new on demand video to learn what's in store for outpatient therapy in 2020 you can go to


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Dec 23, 2019

On this episode of the Healthy Wealthy and Smart Podcast, I welcome Dr. Sarah Haag on the show to discuss pelvic health for the non-pelvic health PT.  Sarah has pursued an interest in treating the spine, pelvis with a specialization in women’s and men’s health.  Sarah looks at education, and a better understanding of the latest evidence in the field of physical therapy, as the best way to help people learn about their conditions, and to help people learn to take care of themselves throughout the life span.

In this episode, we discuss:

-Intake questionnaires to screen the pelvic floor for patients with low back pain

-Pelvic health red flags

-How to address pelvic floor health with a conservative population

-Assessing the pelvic floor muscles without doing an internal exam

-And so much more!


Oswestry Low Back Pain Disability Questionnaire:

Sarah Haag Twitter

Entropy Physio Website

Home Health Section Urinary Incontinence Toolkit

Rehab Therapy Operational Best Practices Forum

For more information on Sarah:

Sarah graduated from Marquette University in 2002 with a Master’s of Physical Therapy. Sarah has pursued an interest in treating the spine, pelvis with a specialization in women’s and men’s health. Over the years, Sarah has seized every opportunity available to her in order to further her understanding of the human body, and the various ways it can seem to fall apart in order to sympathetically and efficiently facilitate a return to optimal function. Sarah was awarded the Certificate of Achievement in Pelvic Physical Therapy (CAPP) from the Section on Women’s Health. She went on to get her Doctorate of Physical Therapy and Masters of Science in Women’s Health from Rosalind Franklin University in 2008. In 2009 she was awarded a Board Certification as a specialist in women’s health (WCS). Sarah also completed a Certification in Mechanical Diagnosis Therapy from the Mckenzie Institute in 2010.  Sarah has completed a 200 hour Yoga Instructor Training Program, and is now a  Registered Yoga Teacher.

Sarah looks at education, and a better understanding of the latest evidence in the field of physical therapy, as the best way to help people learn about their conditions, and to help people learn to take care of themselves throughout the life span.

Read the full transcript below:

Karen Litzy:                   00:01                Sarah, I was going to say doctor Sarah, hey, it just feels weird because we’ve known each other forever. But Sarah, thank you so much for coming on the podcast to talk about pelvic health for the non-pelvic health PT. So there are a lot of physical therapists who I think are interested in pelvic health, but maybe they don’t want to like dive in literally and figuratively. So what we’re going to do today is talk about how we as physical therapists can treat people with pelvic conditions, with pelvic issues without necessarily doing internal work. What are the functions of the pelvis, really important for bowel and bladder health, right?

Sarah Haag:                  00:49                I mean, it is very important for survival, sex, very important for quality of life and propagation of the species. So these are all things that matter. But also when people come in with low back pain, when people come in with hip pain, I always find it very interesting that people say, but I don’t do the pelvis. You know, the pelvic floor is only a musculoskeletal structure. We’re not trained in most programs to palpate or to touch. It’s just skeletal muscle. That’s all we’re assessing for really as pelvic floor PT’s. So I just think it’s interesting. It’s like a blurry void when you’re looking at a body diagram.  Oh, there’s your knee. So it’s really important I think to understand what’s there and you don’t have to go there, but you have to know what’s there and know that some people need help there and help them find the help.

Karen Litzy:                   01:34                So if someone, let’s take this person that has low back pain because that’s a diagnosis that we can all agree that we see on a regular basis. So what are a couple of questions you can ask during your initial evaluation?

Sarah Haag:                                          So the subjective part of the initial evaluation that perhaps a lot of people are missing or that can take in that pelvic area. There’s a couple of ways that you can kind of like cheat your way in where you don’t even have to think about what to ask to begin with. If you have a red flag questionnaire, there is a bowel and bladder question on there. So, it’s really interesting because people will sometimes circle yes on those and then never discuss it. Like, wait a second, we asked the question, they said yes, it’s a thing.

Sarah Haag:                  02:22                So there’s your in, it was like, I noticed you, you marked yes on the bowel and bladder changes. Can you tell me a little bit more about that? Most of the time it is not truly a red flag. Most of the time it is not a sign they need to be referred to a physician.  Most of the time it’s like no one’s ever asked me that. Yeah. Stuff is different. There’s your in. And then also if you use the classic Oswestry. So it was modified I think in 2001 or 2002 to take off a sex questionnaire. The second question of the questionnaire and it was revalidated and all of those things, but if you use the original, it’s pretty awesome because now they’re like, Huh, nobody’s asked me about sex. And then you’d be like, ah, I see that this is an issue.

Sarah Haag:                  03:06                One of my favorite Twitter stories is I get a direct message from someone asking me about a patient who was having pain with intercourse and I was like, thanks for reaching out. Absolutely. Can you tell me more about when they’re having trouble and where it hurts? Would you like to know where it hurt their knees in one particular position? And I said, fantastic. You can help with that. So, so it’s not always, it might be a sex problem, but it’s not necessarily that problem. So we have to not be shy about asking those. Low back pain is the most expensive health care problem we have in terms of multibillion dollar, probably millions and millions worldwide. And so of course addressing back pain, we’re still working on the best way to do that.

Sarah Haag:                  03:52                But there’s a high prevalence of urinary incontinence and people who have low back pain. So if you’re seeing people who have low back pain and after, if anyone else went to the pregnancy talk this morning, after vaginal deliveries, the prevalence of incontinence goes ways up, goes way up. So if you’re seeing someone with back pain, if someone has had babies, all you can eat what you can do. So we were like, well I see this in your history cause that’s pertinent history for back pain. Correct. And then it’s like, Hey, I noticed this, any issues with this? And here’s the reason I’m asking because you can’t just go, do you pee your pants? Because people like, do I smell like what happened? Like, so if you’re just like, you know, there is a really high prevalence and the nerves in your back go to your pelvis and all of these things.

Sarah Haag:                  04:32                So I’d be really curious to know are you having any issues in this area? Cause there’s help if you are. And then kind of go from there.

Karen Litzy:                                           And I want to backtrack for just a second. When you were talking about red flags and said some are truly red flags and some aren’t. So just so that we’re all on the same page, what would be those truly red flags?

Sarah Haag:                                          Truly in the pelvic world or in the entire rest of your body world is any unintentional weight loss or weight gain, 10 or 15 pounds over a short period of time. Also like fever, like temperature issues, loss of appetite when you have those other constitutional symptoms that go along with it. So just having some quirkiness with your bowel and bladder, it’s really no reason to panic. But if you have also a fever and also a recent traumatic event, no, no, we want to just make sure everything’s okay.

Sarah Haag:                  05:26                And the cool thing is that if you go to the doctor, it’s like you don’t have a UTI. Everything else is looking fine. Awesome. Then I can help with that. But the red flags, there’s been a couple of great papers that have come out where it’s like, it’s not like if you have pain at night, freak out. No, no. If you have pain at night but also a sudden bowel and bladder change and also, okay, now we need to check in for it. But don’t panic if it’s the only one.

Karen Litzy:                                           And now let’s say you’re using these questionnaires and someone puts on bowel, bladder or someone circles sex as something that they’re having difficulty with. And I love this question because this was something that was brought up last year at CSM. So there was a physical therapist there who said, well, I live in the south and these are not easy questions to ask because people are more conservative or they don’t want to talk openly about their bowel and bladder issues or about sex with their partners.

Karen Litzy:                   06:28                And so what do you say to those people? Those therapists that, are dealing with a population that’s maybe much more conservative and they’re not sure how to approach those subject matters.

Sarah Haag:                                          I always say just always with kindness and with a good intention and with a good explanation. So you can’t not do it because it’s awkward for you. You should be asking for a medical reason, right? So quality of life is in our wheelhouse, right? Like we’re doing all sorts of quality of life questionnaires. Pee in your pants is a huge detriment for your quality of life in many cases, not being able to have sex can impact your relationship with your partner, your feelings of ability to even have a partner, having babies. All of these things that end up being huge stresses, which is gonna make a lot of other things not as good either.

Sarah Haag:                  07:28                Just start simple if you’re asking questions. So if someone comes in with like straight forward knee pain, I’m like, how sex, no, that’s not how, that’s not where we go with that. But if someone’s coming in with low back or pelvic issues, the way I usually approach it is to bring it up anatomically. So this is the anatomy. This is what we’re doing. These are where the muscles go. Most people don’t think about them. And when they’re, if they’re having issues like incontinence or have had babies, those pelvic floor muscles are muscles. Like everything else. We’re going to work in PT. So I’m going to ask you some questions and I try to do it in a spot where you have some privacy. I know some PT places you’re like in the middle of a gym.

Sarah Haag:                  08:06                If you can find a quiet corner, do everything you can to put them at ease. But just to be like this is why I’m asking. And if you can see that resistance be like all right, like it’s not necessarily the number one priority for this treatment anyway, but if those things happen to be issues there is help, it can get better and you just let me know if you have any questions. Cause not everybody wants to talk about it and it’s not my job to convince you to deal with it. It’s my job to help you if you want help.

Karen Litzy:                                           And if you’re a physical therapist that isn’t specializing in pelvic health, it’s a little bit different. Cause if you’re specializing in pelvic health and people are going to you because you specialize in pelvic health it’s way easier, you know, these questions are going to come up.  But for those of us who don’t specialize in pelvic health, then those questions can be a little bit more sensitive. So I just want you to make that distinction there for people.

Sarah Haag:                  08:48                Yeah. And also if you’re going to ask if you’re going to take that step and be like, all right, I’m going to ask about the incontinence. I mean cause sometimes you’re in situations where it is an obvious issue. Other times it’s like, well, based on their history they’re actually at risk for it. Then you can talk prevention, which has always been kind of fun. But just if they give you some information, especially if you got up the guts to ask them, then please, please do something with it. Don’t just be like, oh yeah, so great incontinence noted in the chart. I’ll put it on the diagnosis list, like how the plan and there are some things you can do without doing a pelvic floor exam that can make amazing changes.

Karen Litzy:                   09:49                How can you evaluate pelvic floor muscles without having to go internally? I think that’s a question everybody wants to know.

Sarah Haag:                                          Great question. I’ll be honest, some people don’t want you to touch him there like full stop. And so I will actually give people, I would say it’s kind of like a choose your own adventure. So we can actually, we can all check our own pelvic floor muscles right here. And I would basically talk you through it. You would tell me what you felt. I keep an eye on everything else to see what else you were doing. But it would be very honest that my assessment is going to be, I believe you, it seems you’re doing it correctly. Right? But I have to believe you, but you can actually palpate externally. As a clinician you can actually do it and you can do it in sidelying.

Sarah Haag:                  10:33                You can do it in hooklying and some people will do it in prone. I’m not a super big fan cause I can’t see their faces. And also it can be kind of a vulnerable position. Basically if you just palpate, if you find the ischial tuberosity, you know about where the anal sphincters are. Okay. There’s normal human variation. So I always say move slow and make sure you’re asking for feedback. But you know, mid line is where the sphincters are going to be. We’re not going midline. So you just kind of find that ischial tuberosity and palpate your way around to the medial part of it. And that’s where the pelvic floor attaches. So then you can kind of talk them through, like I’d like you to squeeze and there’s a bunch of different cues.

Sarah Haag:                  11:22                One of the most common cues, especially for the back end, is to like squeeze. Like you don’t want to pass gas and that’s awesome. But if you’re a main problem with urinary incontinence, that’s the back side, back side, not the front side. So how do we get it up there? So another cue that has been found to be very helpful, it’s only been studied in men, but it is, shorten your penis. But what’s interesting is ladies, I know we don’t have them, right? Imagine that feeling, right? So like just imagine like pulling in, right? It totally changed where hopefully if this is a class, it would have asked where did you feel it? But like it, it changes it from the back and biases it towards the front of it. So find a cue that gets them to go, oh my God, I felt something.

Sarah Haag:                  12:07                You’re like, awesome. So if you’re doing a Kegel and like this happens, you’re probably not doing it right. If that’s happening, you’re probably not doing right. But if like I’m Kegeling now and then I let go, you shouldn’t have seen me get taller or tensor or breathe funny. It should be very sneaky. So as you’re palpating on the medial side of the ischial tuberosities your feeling for those muscles to contract. So it’s kind of like a gentle bulge and you can totally feel this on yourself here if you’re comfy or somewhere else. But when you feel it, it’s almost like when you’re feeling like if you have your biceps slightly bent and you kind of like contract and you feel at tensioning and like a little bit of a bulge, that’s what you’re feeling for.

Sarah Haag:                  12:51                Okay but it can always be tricky cause I use the word bulge. Some people will have people push down. So we should also be able to like relax your pelvic floor and push down, like having a bowel movement. That shouldn’t happen when you’re trying to contract. So like when I say bulge, you should feel like a gathering of the muscle. That’s what you’re feeling. If you feel your fingers get pushed down in a way they’re doing the opposite of a contraction. So there they’re relaxing.  It would kind of depend on what they were doing and the cues you were giving. So it could just be like, I’m pushing down like doing a Valsalva. But it is basically a lengthening into the pelvic floor. I don’t know if it’s always a relaxation, so to speak.

Karen Litzy:                   13:33                It’s kind of lengthening. And what is the difference between that Valsalva or lengthening and that small bulge? Like why is that significant?

Sarah Haag:                                          When you feel it, you’ll know it’s significant because if they’re pushing down in a way that’s not a contraction. So if you’re going for strengthening or more closure to hold things in, yeah, you want that kind of like tensioning and bulge. But if you’re actually the problems, constipation, I can’t get things out, you want them to be able to relax and link them.

Karen Litzy:                                           Got It. Okay. All right. So now we know how we can kind of feel our pelvic floor muscles without having to do an internal exam. So once you figure out, and kind of what you said sort of leads right into the next question is if you have someone that’s coming in with incontinence and you are looking for that sort of tightening or gathering up of the muscle, which I think that’s a nice cue for people to understand because bulge can sometimes be a little confusing for people, but I liked the cue you’re feeling the gathering of that musculature.

Karen Litzy:                   14:45                Is that something that you are then going to add into a home exercise program or like once you find that the pelvic floor muscles working or it’s not working, what next? What do you do?

Sarah Haag:                                          Well, so I’ll be honest. It’s always I like him and people are brave enough and the patients were brave enough to be like, sure you can have a feel like let’s figure this muscle thing out. I usually try it in a normal active kid in a normal setting. So not a public one. No pelvic settings are normal too. But in like just a normal like say outpatient therapy, be it or orthopedics or neuro, I would actually have them ask more questions about incontinence before even checking the pelvic floor muscles. Because the different types of incontinence are going to kind of tell you a little bit more about what you should do.

Sarah Haag:                  15:35                So some people have incontinence when they tried to go from sit to stand or when they cough or when they go running. So I want to know a little bit more about when is it happening because if it’s only ever when you’re putting your key in the front door or when you’re running into the bathroom, that’s more urgent continence. Would pelvic floor muscle exercises help? Maybe, but also probably looking at their overall bladder health, which is where a voiding log would come in very handy. And actually a shout out to the home health section and they have an incontinence urinary incontinence toolkit. It’s free for members for sure, but I think it might be free for everyone.

Sarah Haag:                  16:15                So it’s a pdf that actually talks you through the different types of incontinence because the most common form of incontinence urge incontinence, which is you’re an urge incontinence is proceeded by a strong urge to go. So this is one of those things where, so there’s a bathroom at the end of the hall. So if you’re like, I’m totally fine, but then your eyes wander, you’re like, oh, I could go and I didn’t have to go. And then I would get up to go and I got to the bathroom and all of a sudden it’s like, oh, where did that come from? Like all of a sudden it felt like your kidneys did a big dump, but they don’t, that’s not how kidneys work.

Sarah Haag:                  16:59                It’s just how it feels to you. So what that really is, is your detrusor muscle kind of going, I’m so excited. I imagine a puppy, like have you ever like gone to let a puppy out the door? Like, so they’re like, hey, I want to go out and you get up and you make a move for that door. And they’re like so excited. Your bladder is like that sometimes. So that’s more of a behavioral thing because what would you do with the puppy who’s now like, wait, every time I do this, she lets me out. Pretty soon you’re letting that puppy out every 10 minutes because yeah, because that’s what the puppy trains you to do. So that’s kind of more of a behavioral thing. And so that’s proceeded by a strong urge. So it’s not just when you’re going to the bathroom, but if you get a strong, unexpected urge and leak, and that’s usually a lot of people also experience some urgency and frequency.

Karen Litzy:                                           So if you feel like you’re not getting to the bathroom in time, what would be a really logical plan to that?

Sarah Haag:                  17:52                You’d go more often, you’re like, Ooh, maybe I need to not wait so long. But the thing is that then you’re training yourself to go more often, your bladder is perfectly capable of holding more that kind of sensitivity and those signals you’re interpreting or like, ah, no, I should go now. And then pretty soon you’re that person who can’t make it through a movie. You’re that person who can’t make it past a bathroom without needing to go. And you’re the person that no one wants to go on a road trip with because you’re stopping every like hour on the hour and every rest stop. But now is that because your brain is interpreting this as such? I know that there’s a physical manifestation obviously, but is that like have you trained your brain and to feel that way to interpret that as such? I would say yes because most of the time, even if it wasn’t intentional, like it’s kind of like a slippery slope. It’s like I almost didn’t make it that one time. I’m going to plan ahead. And then what starts to happen, especially if you’re like, all right,

Sarah Haag:                  18:54                your bladder is filling up. You kind of feel like you need to go and you go to the bathroom and it came out and it’s like, all right, so that was nice and normal. But then imagine that time where you’re like, hold on, I almost didn’t make it, but you were stretched this much. You’re going to start going when the bladder stretches this much. And then pretty soon if you let it so you’re like, Ooh, now I’m going down here. Now I need to go sooner. And this is one way you can tell this is happening. And it can happen sometimes without ending up with a diagnosis of urgency, frequency or incontinence. But where you get to the bathroom and you feel like you’ve got a goal, but then nothing happened. Goals, like it’s the smallest tinkle and you’re like, I thought it wasn’t gonna make it, but that’s ah, that’s all that’s in there. And so that was like big urge little output. That’s kind of a mismatch. And that’ll happen sometimes.

Sarah Haag:                  19:48                But like if you’re paying less than that, that’s not much more than your poster board then a nice healthy post void residual. So you don’t have to empty at that point if you’re bladder’s saying, empty me now. And that’s all that’s in there. Yeah. So it’s kind of like you’re the sensitivity of your bladder has turned way up. Just like how we would compare that to the pain. So the sensitivity is turned way up so that it takes less of a stimulus in the bladder itself to trigger that feeling of you have to go, even though the bladder is barely full.

Sarah Haag:                                          And there’s actually some interesting conversations with urgency and frequency in that feeling of extreme urge, can that be considered a pain? And so it’s kind of interesting conversation because there is normal, there is a normal sensitivity of normal urge, but when that urge becomes pathological, yeah.

Sarah Haag:                  20:47                Too bothersome. Does that crossover into it? Distressing emotional experience? I would think so. Like can you imagine if you’re like on a train or something like that and you have to really, really, you have, you’re having that urge. I mean, that’s very distressing dressing. That’s very distressing. That’s like you’re suffering. So if you have someone like that what do we have them do? So they keep a diary, which you can get on the home health section and we’ll have a link to that in the show notes. You basically ask them to keep track of things for a couple of days. I tend to keep it simple with what are you drinking and when and when, when are you going to the bathroom? If people are willing to measure, that’s the best, but not many people are willing to measure.

Sarah Haag:                  21:37                So what I try to have them do is to kind of come up with their own plan. And I tell them this is not an exact science because you’re not measuring, but that’s okay because if you have a strong urge, which is kind of a lot, but you have like a little tinkle, that’s kind of a mismatch. If that only happens after your third Mimosa, okay, that might actually be like a normal bladder thing. Do you know what I mean? So we kind of look at things that they’re bringing in that may or may not be irritating to them. We look at are they getting enough fluid and bladder loves, loves water. But the first thing most people cut out if they’re having urgency, frequency or incontinence is water is they cut out their water. It’ll almost always backfires.

Sarah Haag:                  22:19                So don’t do that anyone watching. It also makes you constipated, which you can increase your urgency and frequency. So, so yeah, so surprise. Everything needs to work well to work well. Okay. But yeah, so you kind of look at that and I just look for patterns and then I have people try to change one thing at a time. If all you’re drinking his coffee all day, but actually you have good data, good parts of your day and bad parts of the day. Is it the coffee? Because if you’re drinking coffee all day, you’re probably not going to be very nice to me if I say, how about you stopped drinking coffee? Um, emotional response up. So you just kind of look at it. It’s like, Oh, when does this happen? What do we need to change? And it can really help you narrow down. Is it really urge incontinence? Is it actually just frequency and they’re not leaking like they thought they were or you know, is this primarily a stress incontinence issue?

Karen Litzy:                                           Well, so it sounds to me like there’s not a lot of hands on work there.

Sarah Haag:                                          No, no, it’s more behavioral.

Susan:                          23:27                Do you ever use pelvic tilting to get the posterior versus anterior pelvic floor?

Sarah Haag:                                          So that’s a neat work with from Paul Hodges Group. So however you’re sitting, most of us are Slouchy, just do a pelvic floor contraction, however your brain tells you to do that, do it and just feel where you feel it. But then if you get yourself in a situation where you like get more of that Lumbar Lordosis, and so like you stick your tail out, you get more lumber lordosis and then you do the exact same thing. So you’re not changing your cue. For most people it’s cuts to the front. And it’s kind of neat because one of the things, one of my pet peeves is when we were talking about earlier is my pelvic floor therapist get tunnel vision and are just doing pelvic floor exercises, but not reintegrating it into how they’re, they’re using their body.

Sarah Haag:                  24:18                So if you have a runner who’s a chronic but Tucker and she’s leaking out of the front, obviously, how would it feel if you like got those glutes back a little bit? Because you can’t run and Kegel at the same time. You can’t, you can try. It’s not going to go well. And certainly not for like a 5K and let alone not a marathon. So changing how that is biased because most of us don’t think about the pelvic floor until you have a problem, right? But they’ve been working, right? They’ve been doing their thing. You’re using them when you walk up those stairs you’re using them when you’re getting up off the floor. So they do something, the key goal is like your bicep curl. You want a stronger bicep, you’re going to do some curls, you want a stronger pelvic floor, you’re going to have to do some pelvic floor exercises.

Sarah Haag:                  25:07                But that’s not your management plan. You kind of want to, someone said it yesterday, kind of like the core muscles are there like automatic, like when you get ready to do something you don’t think, okay transversus were good. Like it just all happens and you want to kind of get the pelvic floor back into that system and make sure it’s strong enough and coordinated enough to do its part. So you don’t think about it.

Dave:                            25:37                So along those lines then, would you say that if somebody is more lordotic, they’re more likely to engage the anterior floor and then flat back more of the posterior floor?

Sarah Haag:                  25:47                That tends to be what they’re finding on like EMG studies and what I will see clinically with people if they do a ginormous buttock. It’s really interesting if you’re like, how’s your breathing when you do that and, and how good is your squat, let’s say when you do that. And it’s like, Eh, it is what it is. I’m like, okay, so what if we do kind of take it into where some people, especially if they’ve been told by other practitioners to like watch your Lordosis, it’s kind of huge. Which isn’t really a thing. But you know, they kind of, they’re kind of like going in there, they’re like, I’m so scared but it kind of feels good and then you have them do that movement or try that exercise. Usually they’re like, that was way easier than I thought it was going to be.

Sarah Haag:                  26:30                But again, if it’s not working, then we try something else cause everyone’s anatomy is different. Sometimes if they have a lumbar issue, getting into the ideal position for their pelvic floor, may or may not be easy for them, at least at first. But I think you need to play around with how it feels and how it’s functioning as opposed to, I mean, I’ve been guilty of it in my career of like, ah, you need more or less of what you’re doing with your spine and were just different. So it’s where it works best is where it should be.

Jamie:                          27:03                So for a lot of the outpatient conditions and orthopedic setting, there’s still an emphasis on giving some kind of qualitative documentation to the muscle contraction, whether it’s a manual muscle test or something like that for payment purposes. So what are some strategies or tips for clinicians to be able to take that palpation externally and then relate that into their strengthening documentation?

Sarah Haag:                  27:29                So if you’re just checking externally, like just palpating outside, it’s like a plus minus like, Yup, I felt it. Uh, they couldn’t find it. So kind of plus minus, cause you can’t give it more than that. We also have to remember, so when I write about pelvic floor strength in my documentation, I have a number I can put and you can grade it. You have to do that internally, which is why if you’re like, ah, we need to know more, refer him to a friend or go to the training. But I usually give a lot more information. So like, all right, so they, you know, they had like a three out of four, three out of five squeeze. The relaxation was not very coordinated and kind of slow, but then their subsequent contractions were five out of five.

Sarah Haag:                  28:09                All right. Do you know what I mean? We have to, because of payment and insurance and all of those things, we have to write something down. So what I do is I write down what I find and I’m happy to talk about it. So if you want to deny it, I can talk vagina all day with you. And I have, and their questions usually get shorter and shorter. Um, because really they’re asking for information that isn’t necessarily the most helpful. So if you’re checking an externally plus minus, but also I’ve had people who five out of five but still incontinent,

Sarah Haag:                  28:41                So then they’re like, well they’re not weak but you put down, you’re going to do strengthening. I’m like, well yeah, because it’s more of a strengthening, not just a strengthening with a functional goal attached to that, if that makes sense. So sometimes it’s more words, but don’t be shy about one. Well, first of all, please be honest, be as accurate as you can be, but also don’t be shy about doing the best care and be willing to stand up for it. If it gets denied. It’s not cause you gave crappy care likely. I mean, do you know what I mean? I’m like, I dunno how long you practice, hopefully. Good. But if you get denied, it’s not necessarily key because you gave bad care or even did a bad note. It’s because they decided they weren’t going to pay based on something. Hopefully logical that you can talk about. You can always appeal. So don’t let payments scare you away from giving the best care.

Sarah Haag:                  29:36                Sorry. Another soapbox of mine.  So that was urge incontinence. Stress Incontinence.

Karen Litzy:                                           So let’s talk about that because I think that gets the more airtime, so to speak. So that’s when you see the crossfitters are the weightlifters or there’s a great gymnast pitcher yesterday going backwards where you there backwards over the pommel horse, not the pommel horse. It’s the worse just a horse. A spurt. Like it was, yeah. And you’re just like, that could be photo shopped, but also it probably isn’t. Yeah. Or like we’ve all seen like the crossfit videos where women are peeing and then everyone high fives them because they worked so hard that they peed, which, you know, not normal. We know that that’s been addressed by a lot of a pelvic health physical therapists.

Karen Litzy:                   30:32                So I would like to know first I think we just gave the definition of stress incontinence, but I’ll have you give the definition quickly. But then I’d like to go back to something that the question that Dave had asked about the positioning and how that works within weightlifting or within, you know, waited or loaded movements. But go ahead and give the definition of stress incontinence first.

Sarah Haag:                                          So stress incontinence is basically when there’s an increase in intrabdominal pressure that is greater than the closure of pressure of the urethra. And you have some sphincters as well as the pelvic floor helping keep all of that closed. But if you increase the pressure enough on the insides, and that’s why you hear, and again, it’s primarily women, but also a lot of men after prostate surgery, they cough and you get a spurt or you know, you jump and you feel it come out.

Sarah Haag:                  31:21                Those are usually because the closer pressure has gone down or the intra abdominal pressure has gone up.

Karen Litzy:                                           Okay, great. So now what does that look like? For the average physical therapist who’s not a pelvic health therapist. And let’s say they are seeing someone for hip pain and you ask them, are you ever incontinent? Or if they are, you know, heavy lifters are, they are adding load and they say, oh yeah, but that’s normal. Or they have low back pain and they say, yeah, but that’s normal. Everybody does it at my crossfit box or whatever at my gym. So how do you then, if you’re not you, you are someone who’s not a pelvic health therapist, how do you address that?

Sarah Haag:                                          Well, first of all, what all of us should know while incontinence is super common, it is not normal.

Sarah Haag:                  32:16                Not ever being dry is normal. So we need to get away from this idea that like, well, everyone’s doing it. It’s like does that make you want to do it? Like I feel like, no, I feel like no is the answer. So first of all, just, and sometimes they don’t know that. Like, I know that in some like young girl gymnastic teams, like the color of their leotards are chosen to like, not show the pee because they’re incontinent that young. Yeah. And I see a lot of women as adults sometimes before they’ve had babies sometimes after, right? So like what’s the, what came first? But they’ve had lifelong issues with what’s essentially public flourish. She’s with incontinence, sometimes pain with intercourse, all of those things. Competitive gymnasts, competitive cheerleaders. Dancers tend to be probably the biggest, runners or another group.

Sarah Haag:                  33:12                There’s been some studies, there’s one study and I cannot recall it. I mean, it’s probably like 15 years old now. We’re 100% of this division one female track team reported urinary symptoms. 100%. Like every girl. So common. Heck yeah. Normal. So many girls. Yeah. So the biggest thing if you’re not a pelvic floor therapist is to check out their function. So if they can identify when they’re having issues, it’s when I get to this particular weight or it’s when I get to mile 17. Okay. And I usually throw in, like if I ran 17 miles, I’m not really sure what my body would do. Like I dunno, but it still shouldn’t leak. But if you can find out where that breakdown in the coordination in the endurance and the strength and whatever it is happens and look at what’s happening there.

Sarah Haag:                  34:04                Because if you can run 17 miles or you can lift 200 pounds without leaking, but then you do, you’re not, you’re not weak. Right? Like if you can do all of that, something’s happening there to make this happen. Cause if you can lift 200 pounds in that league, something’s working, it’s just not still working when you try to live 210. Okay. So let, let’s look at what’s changing or number of repetitions. Right? That’s what you’re looking at.

Sarah Haag:                  34:52                So if you collapse your chest and which I would probably do after running 17 miles and I’m like this. And now what happens when I collapse what happens to my bottom half when I collapsed my shoulders? Well my butt just tucked. Cause I’m just trying to get through now. The funny thing is the breathing is also harder. So while I’m doing this as kind of a mechanism to keep going, it’s harder to breathe because nothing’s working diaphragm to have a full excursion, right? Yeah. So, so I like to look at if you’re running fine for 17 miles, I want to see you at mile 16. I want to see what’s changing over that mile. I want to see what you looked through my team. And can you, when you start to get to that point, can you make an effort to change something?

Sarah Haag:                  35:32                Do you notice a change in your breathing when you’re lifting 210 instead of 200 and kind of look at it from that way cause you’re not going to kegel why you do that. What do you mean? Oh well say to like precontract and prime and all these things and, and that’s fine, but it’s like if we go back to the running, you’re not kegeling and all that time your pelvic floor after like 30 seconds is like, dude, you don’t want me to get that tired. Like it’s going to be like, we’re going to stop that now. So yeah. So the way I would approach that, if you’re not me, yes and not going to do a vaginal exam, is you look at their performance. So if they said, I have knee pain when I do this, when I go from 200 to 210, they’re my squat.

Sarah Haag:                  36:13                How they do, they’re looking at the mechanics. You would look at what’s happening, what is different? Cause you know, the joint can do it, you know, the muscles can do it. What’s changing. And you would address that. So it’s really no different if they can tell when they’re leaking, you’re just looking what can, what are the things that can change it? Usually the tail lift and looking at their breathing or two really easy ways to go about it.

Karen Litzy:                                           Okay. All right. That’s great. And, and, and that goes with that. Does that also work with, let’s say instead of you’re not a runner weightlifter, but you’re like a new mom or something like that and you’re okay, but then by the end of the day after you’ve been maybe lifting the baby or you know, doing whatever you’re doing it, it doesn’t necessarily have to be sport related is what I’m saying.

Sarah Haag:                  37:06                I think about like function, but definitely, I mean, you asked about, but no, just everyday if getting out of a chair makes you leak, that’s, but then it’s basically a squat. So you are, you’re looking at the activity that they’re having difficulty with and making small changes got in most cases.

Karen Litzy:                                           So I think the biggest takeaway here for me is that not everything is solved by doing a kegel.

Sarah Haag:                                          I think a lot of non pelvic health PT’s may have that, that misconception that if someone has incontinence, well Kegel time. Right? And that’s all you gotta do. That’s what most people do. If they go to the doctor and they mentioned it’s like, ah, you know, that’s pretty normal. It’s not, it’s common. And then they’ll be like, do some kegels and, and a lot of women and men don’t know how to do them.

Sarah Haag:                  37:53                So then they’re just, I’m squeezing stuff and it didn’t work. And it’s like, Oh, before we get too far, can we check and see how you’re doing them? And I think that’s kind of a beautiful segway. So let’s say you have your new mom or you have your athlete or whatever and you are, you’ve tried some stuff, right? Cause none of this is life or death, right? I mean it’s fine to try some things. So already not doing anything about it. So trying to change up a couple of things is perfectly within your purview, especially again, you’re seeing them for hip or low back. It all, it’s all together. You’re good. But if it’s not changing, if it’s not getting better, if when you ask them, you know, can you contract your pelvic floor, what do you feel? They’re like, I got no idea.

Sarah Haag:                  38:33                And they’re like, but please also don’t touch me there. Or are you touching there and you’re like, yeah, I don’t feel anything either. And I’ve used all my cards but I don’t know what to do. That’s when you refer. Because just like any other things, somebody coming to see you as a physical therapist, you’re going to do some things. And if those things are not working or they’re getting worse, you’re going to try something different. Or call the doctor or refer to a friend. Right? So if you change some things and you’re like, I’m amazing, they’re all better. Awesome. Do they need to go to pelvic floor therapy? I’d say no if their incontinence resolves or their pain resolves. But sometimes with especially we see it a lot more in I would say the more active athletic population is a pelvic floor that’s more like this.

Sarah Haag:                  39:19                So it’s like tight and there’s a hundred people call it hypertonic or high tone or short pelvic floor and all these things and basically in my brain, the way I categorize it is like you should be able to contract your pelvic floor and you should be able to let it go. And we can all get better at that. But if you’re like, I’m here, how good is my contraction going to be? Because I’m not showing you my pelvic floor. Like it’s not going to, it’s going to taste like it’s going to not move very much. But if you get them to relax more or they’re like, oh, I didn’t know that was there, that’s better. Then you all of a sudden you have a good contraction.

Karen Litzy:                                           How do they relax? Do you just say relax?

Sarah Haag:                  40:01                Before somebody tells him to relax, the worst thing to do is be like, can you just relax? So I try to have them feel the difference between contracting and not contracting. Because what will happen and people use what the traps all the time is like. So like, ah, so much tension. All right. Again, telling you to relax your shoulders. Things I didn’t think of that. But if you squeeze and let go like as a little bit of like, Oh, I feel that, oh, oh there’s some more space there. So I start with that. Okay. The pelvic floor. But again, if they’re like, I just don’t know, that’s something that is so easy to feel with a vaginal or rectal exam. So that’s where it’s like, ah, you’re having some trouble. I would recommend, would you see my friend for one visit have this exam, they’re checking out your muscles and just see if he can feel that relaxation and then come up with like cueing or a plan that works for them.

Sarah Haag:                  40:54                Cause it’s not just about like slacking everything out. It’s really feeling that that relaxation, that lengthening of the muscles there and being intentional about it. You don’t want to lie there would hope like maybe it’ll let go at some point.

Audience member:                               So you talked about kegeling and what about dosage or prescription and quality versus quantity and how you prescribe that to your patient.

Sarah Haag:                                          There is no hard and fast rule as to like how many, how much. So that’s where, again, I would have them do some and see how the coordination goes. Cause if they’re otherwise neurologically intact and they’re kind of getting it, how many do they need to do?

Sarah Haag:                  41:57                I would say it’s not unreasonable to go kind of basic strength and conditioning principles of, you know, like I know eight to 12 reps three times a day. That’s an okay starting point. And actually, I don’t know if you know this, so I’m writing a book on incontinence and the PT people have it, but it’s the editor just asked me, she’s like, well, since we don’t have like a hard and fast number, do we, should we put that in there? And I said, I think we do. So that’s a good starting point. Not everyone would be able to do that right off the bat, but also some people be able to do that and they’re not getting better. So it’s kind of like let’s start here and see what happens. And then you can kind of titrate it up and down. If I do an exam on somebody and they can’t contract for 10 seconds, they can only contract for five, I’m not going to have them contract for 10 seconds at home. I would probably honestly in that case, have them go, I need you to make sure you can feel the good contraction. So you actually also asked about quantity and quality. I want quality, because all of us can do 100 crappy ones. I’m not sure how much it would help. So really looking to be like, okay, so I feel that contraction and I’m breathing

Sarah Haag:                  43:10                and I usually actually have stopped counting seconds. I’ve had people go by breath, so if you, let’s do it. We’re going to squeeze our pelvic floors and you’re just going to keep squeezing as you breathe in and breathe out normally. Nothing, nothing fancy. And then keep squeezing while you breathe in and breathe out and let go. And what I hope you felt was a squeeze to start with maintaining the squeeze. Some people will feel kind of like a little, a little wave as they breathe, which is not unusual. But then when you stop the breathing and you let go, you should feel that let go. So if you didn’t feel that, let go. I usually say that’s one of two things without feeling right. I can’t tell without feeling is that you got tired and you lost it or you forgot to let go.

Sarah Haag:                  43:51                So that’s okay. Have a wiggle reset and try again. Because if you’re not feeling the contraction, what are you doing? Like you might as well take a walk because then you’ll actually be using your pelvic floor. I like going with the breath because a lot of people like to hold their breath when they’re like, they’ll do like they’ll just suck at it and it, you’ll feel a lift, but it’s just a vacuum. It’s not really your muscles doing their thing. So by doing the breathing, if you breathe in and out twice nice and slow, it’s 10 seconds. You don’t have to count. So if I have you do four of those, you just have to like count on fingers, two breaths come and arrest for two breaths. So much easier to keep track of. And then people actually do them. Cause if I could tell them to do ten second holds, one, two, three, four, five, six, nine, done. And that’s not really helpful either. So like the too slow breaths. Now you’re breathing and don’t have to count and you’re going to stay honest.

Audience member:       44:57                So trying to bring this into the neuro world for someone who’s post stroke and has stress incontinence or they’ve had neural damage of some sort and have stress incontinence, Are there any PNF techniques where you can incorporate the pelvic floor to help with that?

Sarah Haag:                                          I haven’t had PNF stuff since college. And I’m old. So what I would say is, is if I’m recalling that they go through movement patterns and as you’re doing those things, there are things will be happening on the pelvic floor. It seems to make sense. What specifically, I don’t know, but if you’re kind of working more with that tone in general, I’ve only had a couple of patients come see me like post CVA and feeling their pelvic floors is amazing because while it makes perfect sense that one side might be like hypertonic are nonfunctioning until you feel it.

Sarah Haag:                  45:49                It’s like, wow, that’s so cool. Like once I totally normal springy, they can contract and relax the other side just like they’re, they’re hemiparetic arm. It’s cool. With stuff like CVA or neurological involvement, you really want to make sure you’re on board with the physicians and you know that bladder function is still intact because depending on where the stroke is and what exactly happened or where the spinal cord injury is, you don’t want to mess around with screwing up the bladder or the kidneys. So if they’re not going to the bathroom or they’re only leaking during transfers, that could be stress incontinence or it could be overflow incontinence because their bladder is so distended with the effort. So that’s something you would really want to make sure you talk with their nurse or their attending physician and make sure, so how are things working?

Sarah Haag:                  46:38                Because the other thing we need to remember is a lot of things we’re still working on people who have had neurological insults, right? So once you’re like, okay, bladder is relaxing as it fills, contracting, as it empties, it’s emptied fine. We’re not worried about this being overflow incontinence. I would actually start to incorporate stuff like blow before you go. Where you’re managing it the same way you would for someone not having a stroke, but half of that, the beam continent and actually going to the bathroom it seems, I can make it sound very simple, but I have a slide and of course that I teach where it has all the like the tracks up to the brain and all the tracks who, the spinal cord to the bladder. But we got the sphincters, we got the detrusor, all of this stuff just happens.

Sarah Haag:                  47:25                And when I click the slide from this beautiful simple picture, it’s just font about this big, explaining all of the complex things that are happening so far as we know. So again, as long as they’re, bladder is functioning on that basic level where it knows when to empty and it can empty, I would treat him like a anyone else and not assume that it’s just because of a high tone pelvic floor on that one side. That’s the issue. But if you get that person and you do your PNF, please tell me what happens. And if it changes their incontinence, I would really like to know.

Karen Litzy:                                           And when you’re looking at the bladder function, that is something the physician is doing through an ultrasound, is that how that works? How did they do that?

Sarah Haag:                                          They can do it through an ultrasound so that that they are, they can look mostly at like post void residual.

Sarah Haag:                  48:12                But then also there’s a test called neuro dynamics. And this is a test that involves, a catheter and there you’re a threat. And then a probe and another orifice down there to help measure for intra abdominal pressure. And it’s kind of a neat test. If someone wanted to do it on me for free, I would probably do it. But they’re also looking at an EMG the whole time. So they start to fill up your bladder was sailing so you know how much is in there and you’re awake for this test because they go tell us when you, when you feel the first urge to go and they mark where that is. And so you can see how much fluid is in there. And I’m like, tell us when you get like the, I should go to the bathroom now urge. And they mark that and then they’re like, okay, tell us when you can’t take it anymore.

Sarah Haag:                  49:00                And they mark that. So then they know how much your bladder can truly hold. But also looking at what’s your detrusor doing, which is the smooth muscle around your bladder, what’s happening to your pelvic floor, where is the weakness? And usually when they’re full, sometimes they’ll have people cough to see if anything leaks or if any sphincters happen or sphincters what they’re up to. But it’s, it’s involved. But there’s a lot of good information. And interesting side note is that if you do so, that’s really I think really helpful for like a neurologic population just to make sure. I did have one patient I was lucky enough to work with a PT who became a physiatrist who specialized in neurogenic bowel and bladder and she let me come down to watch  urodynamics of one of my patients who was really against cathing.

Sarah Haag:                  49:46                He didn’t want to cath. So she came down, she brought him down to the urodynamics and as it and cause he’s like, I am voiding 400 to 600 milliliters every time I have a bowel movement. And like that’s pretty good. I mean like most are four to 600 CCS and turns out it was only under very high pressure. He was already getting reflects into his kidneys and after he voided four to 600 CC’s, he still had four to 600 left, which is too much. So even though he was having some output, that was the test that really made it clear to him like, oh, it’s coming out, but it’s not healthy. Like I need to cath.

Jamie:                          50:41                What are some of the considerations that you might go through in your thought process when you’re dealing with a male versus a female pelvic pain or incontinence issue?

Sarah Haag:                  50:53                That’s a lot. I could talk for days on that. Well I’m not sure. When you’re talking about considerations. We need to take into consideration our patient preference and what they’re comfortable with. We can tell when our patients are uncomfortable or we should be able to but then kind of try to work out, they might not want to talk to me about this, but who can I get that they would, cause a lot of people would assume that men aren’t really comfortable talking to females. But a lot of the men who come to see me, just want help, and we’ve had several male students come through and you know, they run into like women not wanting a male therapist to do it.

Sarah Haag:                  51:36                It’s just finding that, right? Just like any other body part, finding the right person to help. But then if we go to, you know, bringing up those subjects, I don’t know that in my brain it’s so, so different. Male to female, you’re going to take into consideration their history for sure. I feel happy saying that because now with we have kind of like a gender spectrum, right? We have people who, who have transitioned in varying degrees and we have people who haven’t transitioned but totally identify with the gender. They weren’t assigned at birth and all of these things. So basically I take it functional. So can you just walk me through the issues you’re having, your questions, concerns when it’s a problem, if anything makes it better, does anything in particular make it worse? And then we problem solve from there?

Sarah Haag:                  52:26                So I guess I didn’t really have a good, a good answer, man. Male to female. Their situations are usually different, but it’s kind of different across one gender or the other. Anyway. Is that kind of answer it? Yeah. Great question.

Karen Litzy:                                           Well, thank you so much. Thank you. I think we covered a lot and I thank you guys for being here and I hope that you guys got a lot out of this and can kind of take this back to your patients now. So last question that I ask everyone and it’s so knowing where you are now in your life and your career, what advice would you give to yourself as a new Grad?

Sarah Haag:                                          Ask more questions. To be honest on, I came out of school pretty much like, like the teachers know best and what I learned is right.

Sarah Haag:                  53:16                And then when you get into the real world, I ended up thinking I was not very good at my job for awhile because like you would do what you were taught to do but it wouldn’t work. And then, you know, some things happen and I got older and more comfortable and when you start asking questions you realize there isn’t one answer. So if you start asking those questions, you’re part of, you’re part of the solution. By kind of pushing those boundaries and not like, I wish I would’ve just asked more questions sooner. I’d be so much smarter than I am now.

Karen Litzy:                                           Where can people find you on social media if they want to get in touch with you?

Sarah Haag:                                          Sarah Haig, PT on Twitter, you can find me on my website, and um, I mean Facebook, Sarah Hague.

Sarah Haag:                  54:07                I don’t know what my picture looks like right now, but I’m friends with Karen, so if it says I’m friends with Karen, that’s probably me.

Karen Litzy:                                           Awesome. And just so that everyone knows a lot of this stuff that Sarah spoke about, we will have links to it. We’ll have links to the home health section. We’ll have links to the testing, the urogenic testing. Is that neurodynamic testing? You could just send me a link or something about it. So we’ll have it all in the show notes. Thanks everyone for watching the live. We appreciate it and everybody, thanks for listening. Have a great couple of days. Stay healthy, wealthy, and smart.

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Dec 16, 2019

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Steve Anderson on the show to discuss leadership coaching. Steve is an Executive Coach with Orange Dot Coaching and the host of the Podcast, Profiles in Leadership.  He is a former Board of Trustee for The Foundation for Physical Therapy and was the President of The Private Practice Section of APTA for 6 years between 2002-2008. 

In this episode, we discuss:

-Why you should invest in a coach

-The importance of outside perspective when you’re pursuing excellence

-How to be open-minded and gracefully accept constructive criticism

-Redefining your daily operations with purpose and vision

-And so much more!


Steve Anderson Twitter

Steve Anderson Facebook

Steve Anderson LinkedIn

Orange Dot Coaching Website

Episode 197: The Graham Sessions with Steve Anderson

Profiles in Leadership Podcast

Optima: A New Health