What Is Your Game Plan?

Creating a successful team in your private practice.

By Jean Darling, PT, LAT

Imagine The 1992 United States men’s Olympic basketball team, nicknamed the “Dream Team;” it was the first American Olympic team to feature active National Basketball Association (NBA) players. Described by American journalists as the greatest sports team ever assembled and called by the Naismith Memorial Basketball Hall of Fame “The greatest collection of basketball talent on the planet.” This team defeated its opponents by an average of almost 44 points en route to the gold medal. What if you could assemble your Dream Team, what would it look like? If you have your top picks when it comes to basketball players would LeBron James and Stephen Curry be in your starting line up? That sounds like a great start up plan but what if your team can only practice once a week, due to being spread out geographically?

This is a problem that mid- to large-sized physical therapy companies may be presented with, but having a stellar executive team is the key to success. What makes a winning team within a company? Certainly an all for one and one for all mentality comes into play, but we must consider the overall mission statement that a business has. If a business has the following three core qualities, it can assemble a winning team of its own.

1) Hard Workers
A business needs to employ people who realize that good things come to people who put out good effort. This is a trait that will become the backbone for your business and keep you afloat in the event of a crisis or even just a down period. Hard work must be given out willingly, too, without asking constantly, “What’s in it for me?” Consistent, strong effort rarely goes unnoticed, but someone who always wants a little something extra for themselves and is looking out for only “number one” might not be the best fit as a team player.

2) Bring in Your Unique You!
Now that you have a backbone established, you can begin rounding out the team and honing in on the particular strengths each member has to offer. Diversity is what makes a business strong—not everyone can or should be the same. Embrace that. Otherwise we would have 50 CEOs in the same corporation and that would be a real disaster. Celebrate what skill sets your team members have that made them stand out from the crowd when you decided to hire them, from great writing skills to stellar negotiation tactics and focus on assignment deadlines.

3) Problems? Communication Assemble!
You have the backbone and sharp characteristics of your team players established now but even with all of these strengths going into play, there is always a challenge to address or a crisis to be prepared for and face head-on. Do not do it alone or it will overwhelm you. Know how to communicate with your team members—all of them. Whether you communicate best via email, in person, or within an organized meeting, keep communication lines open and be available to new ideas and options suggested in the process.

Last, How do you reward these individuals within your management team?
An obvious answer is to get to know your new employee well! Are they motivated by cash, bonus, or stock options in accordance with how well the company does this year? It would be an excellent fit to find someone who enjoys a modest salary and is happy with a challenging job, and those individuals do exist. Some are happy with family time and a fun culture, while others may be attracted to being part of innovation or a world changing effort.

Do not forget, once the new members of your team are on board, it is time for the truly hard part: putting your trust in them. Your gut will fight you every step of the way. You will assume your instructions are clear and misunderstandings are their fault. You will assume when you disagree that you are right and they are wrong. But you will sometimes be wrong. The key to successful executive relationships is changing what your gut tells you. Remember how you interviewed for trust? That is important because once you hire an executive team, you must let them take their responsibilities and run with them. That means agreeing with them about what their roles are, what deliverables they are responsible for and on what timeframe.

Entrepreneurship and business creation is about going for the things that are much bigger than what you could do alone. Your job is not to reach the goal; it is to build a team that will reach the goal. If you really want to reach your goals, you will need to bring on others to help. Creating a good executive team means knowing what you need them to do, finding good candidates, promoting from within, and giving them what they need to do their jobs. If you choose well, they will be successful and make you successful as well. Now you can build your Dream Team of 2016!

Jean Darling, PT, LAT, is an Impact editorial board member and vice president of Advanced Physical Therapy & Sports Medicine. She can be reached at jean@advancedptsm.com.

Dip into the Pool

Guidelines to providing excellent aquatic care

By Kelly McFarland, PT, DPT

Risk. Thrill. Heartache. Sleepless nights. Profit.

Perhaps like many of you, I come from a family of entrepreneurs. My father started his own business. As did my mother, and my brother, and my sister, and myself. We are passionate about what we do. This makes for some interesting kitchen table discussions about customer service, leadership, return on investment (ROI), return on equity (ROE), and net operating income (NOI).

Business may run in my veins, but so does another substance.


I opened my physical therapy practice with the goal of helping people heal the best way—my way—with personalized plans and individual care. I knew going into private practice would be my best shot at accomplishing this. Because of personal experience and the positive outcomes that I have witnessed, I believe in aquatic therapy as an adjunct to a patient’s care. Water soothes, relaxes, promotes movement, compresses, and—when used correctly—heals. From the beginning, I wanted to make water my “niche.” I researched many options and eventually chose to invest in a therapy pool with an underwater treadmill, resistance jets, and underwater video monitoring system. With a pool and a place to put it, I was ready to roll.

Twelve years, three clinics, and 18 employees later, aquatic therapy remains a focal point of our practice. Its mere existence in our practice draws clients to us and its effectiveness brings them—and their friends—back. Water has helped brand us as a premier clinic; expanding into new markets, and serving people with diverse conditions. Along the way we have learned a few things about how to create and maintain a high-quality aquatics program.

One Patient at a Time

Treating multiple patients in the therapy pool at the same time is possible, but at Premier, we like to specialize in individualized care as a best practice. We found patients tend to feel apprehensive when they are being treated in the pool in a small group setting. Some are not comfortable exposing their bodies “publically” in a swimsuit. They want privacy. Others may be rehabbing from a joint replacement surgery and are unsure of their body’s functionality, while others are ready for speed training. They want personalized attention. When a therapist is juggling multiple patients it cuts down the quality of care, at least in the patient’s mind. With a single-patient policy and 45-minute sessions, the maximum capacity each day for our pools is 12 patients. We average 8-12 patients per day.

Invest in the Best Product on the Market

I heard a respected attorney once answer this question from a young, soon-to-be law student. “I’m choosing between two schools. One will pay my way but the other is in the top 10. Where should I go?” His answer: “Always choose the better school. It will pay off in spades.”

I opened my first clinic in 2003 with the crowning feature being a therapy pool with underwater treadmill, resistance jets, and video monitoring system. Since the day we opened, we have strived to provide premium service, special attention, and a more personalized approach, much like a “private school” version of physical therapy. People notice that we are different. Having water helps us “niche” our practice and stand out, but having the best water and using its tools creatively conveys to our patients our dedication to innovation and quality care. Many patients seek us out simply for our aquatic tools.

Create Personalized Programs

Our patients receive individual care created specifically for their situation. Some programming inevitably overlaps, but we progress patients based on their needs for each visit.


Judy suffered from scoliosis since she was a child, undergoing various amounts of pain medication and physical therapy through the years. As she progressed through middle age, the pain and neuropathy increased dramatically. She lost function. At age 55, Judy chose lumbar spinal fusion surgery, from T9 to sacrum, totaling nearly half of her back.

Judy was presented to our clinic two and a half months postsurgery. She was unable to sit during the initial evaluation due to her pain level and limited mobility. After an initial evaluation, we moved her immediately into the pool.

We instituted a Core/Lumbar Stabilization program where we were able to focus on muscle reeducation and establishing the proper firing patterns from the core stabilizers. We also incorporated functional movements such as squats, step ups, and walking.

Judy began the walking program without the use of the resistance jets, holding the handrails 100 percent of the time. She progressed quickly. Soon she was able to walk pain-free in the pool. We increased the treadmill speed, duration of the walk, and added resistance jets.

Judy now walks pain-free on land and has increased her stride length and range of motion. She also drives, sits for longer periods of time and walks—pain free—up stairs. She feels her “spirit has been lifted” as she has regained her functional mobility that she thought might be forever lost.

Educate Others about the Value of Water

Because of some therapists’ perceptions that patients are simply “floating around in the water,” aquatic therapy sometimes gets dismissed as a nonaggressive modality. With the underwater treadmill, resistance jets, and monitoring equipment, this is not true. Many research studies show its effectiveness for advanced recovery time, return to running, exercise advancements, weight loss, and rehabilitation.

Doctors W. Matthews Silvers and Dennis Dolny conducted several conclusive hydrotherapy research experiments at the University of Idaho. In the first study, it was found that training on an underwater treadmill can create a metabolic and cardiovascular environment as stressful as traditional land-based treadmills but with reduced joint stress. In follow-up studies, positive results were also verified with factors such as maximal oxygen consumption, heart rate, ventilation, blood lactate, leg stride rate and length, and perception of effort. Each study confirmed the effectiveness and equivalent responses with aquatic fitness vs. land-based treadmills.1

Offering a low-pain and less-feared method of exercise, physical therapy can greatly enhance patients’ quality of life. In the water, there is no fear of falling. Research from the University of Utah shows that older adults who consistently exercise on an underwater treadmill improve flexibility and even sleep patterns. 2 As we educate patients, caregivers, and practitioners about the benefits of aquatic exercise, we become the “facility of choice” in the region and a valuable asset to their overall health.

Business ownership may be many things, but it is always interesting. My goal in opening a physical therapy practice was to provide the highest standard of therapy with compassion to each patient, focusing on return to function, education, and wellness. Creating and maintaining an innovative aquatics program helped me accomplish this and in so doing, brand our practice as “creative,” “premier,” and “innovative.”

Run a quick check to see what is running through your veins. I bet you’ll find some platelets, plasma, and—if you’re lucky—a little water.

Kelly McFarland, PT, DPT, is a member of the American Physical therapy Association and serves as a guest lecturer for the Texas Physical Therapy Association, HydroWorx. She founded Premier Rehab Physical Therapy in 2003. She can be reached at premierrehab@sbcglobal.net.

Hope and Opportunity

By Stacy M. Menz, PT, DPT, PCS

As I read through Sturdy’s article this month, appropriately titled, “Hope and Opportunity,” I was struck by exactly that, the hope and opportunity that our profession has. The article discusses how when we contract with employers directly to provide services to their employees, we are not only getting their employees back to work, but also we are preventing lost time from work—creating a savings on the company’s bottom line. Through these actions, we are demonstrating our value as a profession.

What I found even more compelling was that therapists are contracting with companies in ways that are innovative. One therapist is working with the ballet, while another works with a tech company. If you are in pediatrics like me, you can contract with school systems (this is the kiddo version of work). The opportunities are there if we as a profession look for them and continue to promote our own value.

Even more exciting is how we have moved beyond just getting employees back to work, we are also preventing injuries and thereby preventing days missed. And as employers ourselves, who cannot get behind the idea of keeping our employees working! What are some of the innovative ideas you and your company have supported employers by keeping their staff healthy? I can only speak from a pediatric perspective, but I know that we have begun using motor groups in the pre-schools where we work, which has cut down on the number of referrals for physical therapy overall; it has also empowered the teachers and staff on how to support their kiddos. It would be great to hear your ideas on our discussion board www.ppsapta.org.

On a different topic, we are going to start running a new column occasionally called “What’s on my Desk?” I know as a business owner, and as a person, I am always looking for new and interesting ideas for things to listen to, read, and explore. So, I am sharing four of the things that I am into at the moment. I would love to hear from other members of the private practice section with regards to what’s on your desk (or iphone, or computer, or ipad). If you want to share, please write it up and send it into me, and we will include it in one of our issues.


Physical Therapy and the Subscription Economy


How the patient churn rate can erode your business’s bottom line.

By Scott Hebert, PT, DPT

If you have been watching your bank account recently, you may have noticed a lot more recurring transactions happening. I know I have. To put an eternity’s worth of new music on my iPhone, I fork over $9.99 a month for Spotify. For unlimited TV shows and movies, it is another $7.99 for Netflix. My gym membership, razor blades, and even certain groceries are all goods and services I purchase through a subscription. There is a good reason why this model is becoming more common: It is a business model that has proven to be an incredibly successful way to make money—that is, if you understand how to optimize it. Just like any other business, it comes with its own set of risks. Without the security of a long-term contract, subscription companies must keep customers happy and engaged or risk losing millions. The second they cannot, customers drop off—sometimes never to be seen again. This customer drop off is what has come to be known as “churn” and is measured with a simple metric known as the churn rate.

So what about your physical therapy business? When a patient walks in your door, are you selling them a series of one-time services? Or are you selling them a subscription path to recovery? While perhaps not as immediately obvious, your physical therapy practice already generates revenue via a subscription model, there is just a good chance that you are not framing it this way to yourself or to your staff. Nearly every patient who walks in your door will require multiple visits to reach their recovery goals; every new evaluation signs up for a physical therapy subscription. In a fee-for-service world, there are no long-term contracts; you only get paid if the patient shows up. Every time a patient comes back to your office they renew their physical therapy subscription, and it is up to you to make sure they keep coming back. If you fail to engage a patient in the process or are unable to sell them on their plan of care, not only will your patient’s outcomes suffer, but also your business’s bottom line will suffer.

Running a subscription business requires laser focus on key metrics such as the churn rate, which is simply how you measure the percentage of customers who leave a supplier over a specific time period. In physical therapy, patient churn is a bit trickier to calculate than in other business sectors but still just as important. This is because metrics like average visits per case and cancel/no show percentage, while easier to measure, can often misrepresent the true business problems. By thinking about your physical therapy business as you would a subscription business, you can borrow the best practices from a host of other industries to maximize both your patient’s outcomes and your business’ profitability.

Understanding the Subscription Model in Physical Therapy

In a subscription model, and in your physical therapy business, the basic unit economics are simple. Just take the product of the following three variables to estimate top line revenue.

  • Total Number of Subscribers (in your case, patients)
  • Average Length of Subscription (how many visits do they come for?)
  • Subscription Price (How much you make per visit)

While optimizing a subscription business requires monitoring a number of key metrics,1 churn rate is a critical place to start.

The Hidden Impact of Churn Rate On Your Bottom Line

In looking for a good benchmark for patient churn rate, we examined over 30,000 outpatient physical therapy episodes of care. The results were startling: Over 20 percent of all patients treated came in for 3 visits or less.2 While a certain percentage of patients experience quick recovery, I think we can all agree that one in five patients requiring less than three visits is unlikely. It is therefore safe to draw the conclusion that a large subset of patients are not seeing the value of physical therapy for one reason or another and are failing to complete their course of care all the way through. This fact is a textbook example of bad customer churn.

So Why Not Just Measure Average Visits per Case?

The quick answer: You should measure visits per case, but it will lie to you. While almost every practice owner that I talk to can rattle off an average visits per case number for their clinic, I find that very few are accurately measuring patient churn and the impact of patient dropouts on their practice. As it turns out, it is really easy to hide bad churn behind a good average visits per case number.

In the sample of 30,000 discussed before, even though 20 percent of all patients came for three visits or less, the average visits per case was still 10. Ten visits per case is typically just fine; in fact, it is a number for which most physical practices strive. The problem is, this number can clearly be misleading. To start, take a look at Graph A.

While the large majority of patients are coming in for 10 visits or less, there will always be outliers. These outliers have the ability to substantially alter your average visits per case number, as it has done with our sample. If you zoom in further on that same graph, the actual impact of bad patient churn is clear.

Your average visits per case figure can be drastically swayed by outliers, and because of this, average visits per case alone may not be the best metric to measure. As health care continues to evolve, and new forms of payment become more and more common, these outliers will become much less frequent. Being proactive about monitoring churn now will allow you to be ahead of coming reform, and help you focus on providing the highest quality care.

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Defining Churn Rate in Physical Therapy

Churn rate in physical therapy is simply the difference between expected visits and actual visits divided by expected visits. If the patient exceeds the expected visits, just calculate that churn rate as 0 percent (no need for negative churn here). The beauty of the churn rate calculation is that it takes into account the variability of care length. By taking the average churn rate for each patient, you start to get a much more accurate assessment of your clinic’s ability to keep patients engaged in their course of care, identify weak areas with regard to age and diagnosis, and target providers who are more engaging than others.

Measuring churn rate itself is not all that complicated, but it does take a plan. While actual visits are usually easy to pull from your practice management system, expected visits can be a bit more difficult to come by. Here are some of the strategies we have seen practices use to estimate expected visits.

Option 1: Take a Subjective Approach
After completing an evaluation, every therapist estimates how many visits a patient will need to reach their recovery goals. This number is being relayed to insurance companies, doctors, and other therapists—why not use it for your churn rate assessment? This is often a great estimation of expected visits per patient. The problem with this approach, however, is that it can be quite subjective and may vary by therapist experience level and skill. Still, it will get you started on your path to analyzing patient churn.

Option 2: Bucketing
If you feel like you have a good handle on the expected visits per case needed for a given patient type at your practice, it can sometimes work to bucket your patients by diagnosis, age, or a number of other factors. Specifically, if you feel that patients at your practice require only four visits for a meniscal repair, bucket all patients with a meniscal repair to use four visits per case as their expected visits. While this is sometimes hard to administer, Microsoft Excel can be your friend.

Option 3: Outcomes Tools
If you are using a standardized outcomes registry, you will often have access to an expected visits per case estimate. This is an excellent number to use and makes expected visits per case simple to track. It is also a bit less subjective as it takes into account your practice’s history, the patient’s diagnosis, and leverages a larger dataset to get a more accurate prediction when used correctly.

Once you have a handle on expected visits and actual visits, you are ready to start calculating. Be sure to calculate it on a patient-by-patient basis to get the most accurate numbers.

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Always Strive for Good Churn

So what happens if your patient comes less than the expected number of visits but meets their recovery goals? Is this still bad? The answer is a resounding No! In fact, you should strive for this with every patient you treat. Exceeding expectations is an excellent way to develop customer evangelists.

How do you measure good churn from bad? Simply make a note if the patient’s goals were met or not. If his or her physical therapy goals were met and his or her actual visits were less than their expected visits, do not sweat it. Simply mark that patient down as 0 percent in your churn rate calculation. This will give you the most accurate picture of bad churn, which is what you are trying to correct anyway.

While there are other key metrics like patient lifetime value (LTV), customer acquisition cost (CAC), and viral coefficient to keep in mind, churn rate is perhaps the most important metric with which to start. By understanding churn, you will be well on your way to running your practice like a more efficient subscription business.


1. Hebert, S. Physical therapy and the subscription economy. Strive Labs blog Web site. http://blog.strivelabs.com/2015/04/10/pt-and-the-subscription-economy. Updated April 10th 2015. Accessed May 5th 2015.

2. Hebert, S. 5 steps to improve patient outcomes & increase revenue in PT part 1: churn rate overview. Strive Labs Blog Web site. http://blog.strivelabs.com/2015/04/16/churn-rate-pt-and-the-subscription-economy. Updated April 16th, 2008.

Scott Hebert, PT, DPT, is a PPS member and chief executive officer of Strive Labs, Inc., a patient relationship management platform for physical therapists. He can be reached at scott@strivelabs.com.

Mixed Emotions

By Terry C. Brown, PT, DPT

It is the weekend after returning home from the American Physical Therapy Association (APTA) NEXT conference and the House of Delegates (HOD); I have mixed emotions as to what occurred. I am a veteran of the HOD after spending 13 years as a Kentucky delegate and six years as the Private Practice Section alternate delegate. I realize this may seem paramount to a prison sentence to some of you, but I have always found it to be a fascinating process that can elicit some profound discussion, or it can be an exercise in futility. This year’s HOD was a bit of both.

Looking at it from my water bottle being half full, let’s start with the positive.

  • An excellent discussion regarding the physical therapist’s role in prevention, wellness, fitness, health promotion, and management of disease and disability will help place the profession in its rightful place at the forefront of this important movement.
  • A most substantive discussion was had on the feasibility of obtaining primary care practitioner status. The pros and cons of this status were discussed openly and debated with intelligence. Issues regarding ordering imaging and prescribing meds were argued in ways so that I found myself being swayed in both directions. In the end, the decision was made that we are indeed an integral part of the primary care team and the experts in movement disorders, and this is where our efforts should focus.
  • Good discussion also occurred on the use of health information technology and electronic medical records, which will help move APTA forward in this important area.

These types of rich debates are what make the HOD a necessary and effective body for our profession.

Now, for the other side, with my water bottle “half empty,” I bemoan the things that we as the governing body of this profession cannot seem to get over. Again, we spent an entire morning discussing the vote, or no vote, or half a vote on the physical therapist assistant (PTA): if the PTA should or should not be a chapter delegate and if the PTA should be able to be elected to the APTA board of directors. Let me preface this report by saying that I have nothing against PTAs and employ two highly qualified and stellar PTAs who enhance our practice. This is more about who sets the professional standards and directs the future rules and regulations of our profession. This act should always remain in the hands of the physical therapist. However, we as the HOD cannot say enough, or discuss enough, or rehash enough, as this subject has come back every year for the majority of my 19 HOD years.

Finally, the HOD voted to continue to not allow the section’s delegates a vote. While we have a voice in the HOD by the right to submit a Reference Committee (RC) and to speak in debates of all RC, we are not given a vote in either the House itself or in the election of APTA leaders. The HOD soundly defeated an RC submitted by the Health Policy and Administration (HPA) section—the catalyst supported by all sections.

So there you have it, my bird’s-eye view from the back of the room on the 2015 House of Delegates.


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