The Right Stuff

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Providing the right level of health care.

By F. Mark Amundson, PT, DPT, DSc, MA, ATC, SCS, CSCS

Several expressions are used to describe aims of health care: “The right care, at the right time and place,” evidence-based practice (EBP), and “best practices” are examples of well-known aspirations. Physical therapists should be aware that these objectives correspond to a dramatic shift occurring in health care from being “provider centered” to “patient centered.” To date, the outcome from health care services has been determined primarily by providers. Going forward, patients will contribute more to determining if the health care they receive results in positive outcomes. The probability for achieving these crucial objectives can improve if each patient has received the right level of health care (RLOHC).5,13

“Working in silos” is a common description of health care providers who conduct themselves in a feudalistic system characterized by little if any interaction with other providers.7,8,12 However, the recent health care renaissance finds collaboration being the directive for the breakdown of old silos to achieve the right care at the right time and place; through the use of EBP, resulting in best practices that deliver the RLOHC. During this period of revitalization, physical therapists face a crossroads of either being a commodity or seizing opportunities to be leaders and indispensable members in contemporary health care systems.

Leadership may be secured through the use of a common functional capability-based language for classification of patients/clients along the health wellness continuum. Effective classification facilitates matching health care needs of patients/clients to the RLOHC. A functional capability-based classification system illustrates the valuable role physical therapists possess as health care leaders and providers along the entire length of the continuum.

The World Health Organization (WHO),36 and in turn the American Physical Therapy Association (APTA),15 has adopted a biopsychosocial model for health care. This model represents that health care of a person must incorporate the biological, psychological, and societal implications an injury or illness has on that person. Each component is on a continuum comparing a person’s functional capability level to the degree of difficulty of performing a particular activity. Take for example a female tennis player recovering from a knee injury that has resulted in the knee feeling unstable. The knee injury represents the biological component. Due to the feeling of instability, she is unable to participate in her tennis league. Being unable to play in her league has psychological and societal consequences. Her regular tennis matches allow her to feel good about herself. During and after each match she spends meaningful time socializing with teammates as well as competitors. Returning to her previous functional capability level certainly has biopsychosocial implications.6

What is meant by functional capability level? A level is defined as being “a relative rank on a scale.”32 One definition of scale is “a system of classification in which people or things are ranked according to a specific criterion.”32 In turn a scale is identified as a synonym for continuum. Continuum is defined as “a continuous sequence in which adjacent elements are not perceptibly different from each other, although the extremes are quite distinct.”32 A functional capability continuum ranges from unable to poor to fair to good and ultimately to complex levels. Here the extremes are very different but each successive level along the continuum may not be perceptibly different. By narrowing in on the current functional capability level of a patient/client, a physical therapist can determine the current biopsychosocial status of the individual. They can then level specific interventions—including the best providers for those interventions—and can work toward functional goals while avoiding harm by exceeding current capability, thus achieving the RLOHC. Matching movement capability with the physical stress demands of an activity increases the probability of positive outcomes.18,19,28,29

Movement is an actual change in position that occurs along a continuum of multiple interacting levels. That description forms the basis for the movement continuum theory (MCT)9 that describes levels of movement ranging from micro/molecular to body part to total person to the macro level of the person’s ability to move within society. The cumulative effect will determine the person’s ability to control movement at a preferred functional level. Movement fits into the biopsychosocial model as each level is influenced by physical, social, psychological, and environmental factors. According to MCT, each person has a maximum achievable movement potential (MAMP), current movement capability (CMC), and preferred movement capability (PMC).9 To maximize performance and decrease the risk of injury a person’s CMC needs to match the PMC degree of difficulty. Expectation of others can have an enormous impact on the level of movement attempted by an individual.9 Physical therapists when selecting interventions for a plan of care need to take into consideration that if the demands of the interventions are greater than the person’s CMC there is an increased probability of an injury or other poor outcome.

The movement ability measure (MAM)1,2 provides a standardized measurement to determine the effectiveness of an intervention in improving movement. MAM is a self-report of movement ability based on the MCT. Contained within 24 items, the MAM examines six dimensions of movement: flexibility, strength, accuracy, speed, adaptability, and endurance. Each dimension is measured along a continuum of six levels of ability. The MAM can help physical therapists learn of patients’/clients’ self-perception regarding their ability to move within each dimension along six specific levels for that dimension.1,2 One example of the continuum has at the low end being “unable to move” with “able to move as an athlete or star performer” on the high end. MAM establishes the person’s current and preferred movement capability in the same item.1,2 Knowing the patient’s/client’s movement capabilities aids in learning the RLOHC including the parameters of exercise to use to reach PMC.

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Changes in the relative level of physical stress causes a predictable adaptive response in all biological tissue is the basis of the physical stress theory.25 A fundamental principle of the theory is biological tissue has predictable responses to stress that are along a continuum of stress levels: death, atrophy, maintenance, hypertrophy, injury, and death.25 RLOHC exercise prescription utilizes stress levels at the patient/client’s current capability level. To improve capability physical stress needs to be at a maximum threshold level to prompt the body to adapt, increasing the body’s ability to function at a higher stress level. Stress higher or lower than the maximum threshold will result in a poor outcome. To achieve a positive outcome, exercise interventions are at the current and progressed to the preferred capability levels.33,34 RLOHC is dynamic—changing with functional capability.

Function includes all three biopsychosocial components that may be placed along a continuum. WHO developed The International Classification of Functioning, Disability, and Health (ICF),36 which is composed of these interacting components that range from, disability to function of overall health condition, and unable to participate to being able to participate in desired activities. ICF provides a common language for levels of disability to function based on the biopsychosocial model. Accordingly the continuum can be divided into functional levels along a scale from unable at one end to complex on the other end. In between are levels along the continuum that include requiring assistance in daily activities, followed by being able to move about the community without assistance, to the capability for taking part in usual and nonroutine activities.

Individuals have a current and preferred functional capability. A challenge in physical therapy is for current and preferred capabilities to be at the same level.3,4,10,11,14,20,21,22,23,26,27,31,35,37 RLOHC involves matching these capabilities to increase a person’s quality of life while decreasing the risk of injury.16,17,24,30,34 For instance, if current capability is at being able to move about the community, but the preferred capability is sports participation, there will be a high risk of injury if at this point in time the patient/client attempts to take part in sports at a physical stress level higher than current capability.

One component of a physical therapy best practice is physical therapists using EBP for determining the current RLOHC to provide the right care at the right time and place in achieving positive patient-centered functional outcomes. A classification system based on functional capability levels related to biopsychosocial demands of an activity can be used as a guide for physical therapists when determining RLOHC. Current functional capabilities help to ascertain the RLOHC that incorporates the present movement and physical stress levels.18,19,28,29 From this starting point physical therapists can then develop a plan that bridges the gap between current and preferred functional capability. RLOHC interventions are used to ultimately have the current and preferred functional capability at the same level.1,2 Physical therapists can use functional capability-based RLOHC to effectively and efficiently achieve positive patient-centered outcomes.

References

1. Allen D. Proposing 6 dimensions within construct of movement in the movement continuum theory. Phys Ther. 2007;87:888-898.

2. Allen D. Validity and reliability of the movement ability measure: a self-report instrument proposed for assessing movement across diagnosis and ability levels. Phys Ther. 2007;87:899-916.

3. Arden, CL, et.al. Return to preinjury level of competitive sport after ACL reconstruction surgery. Am J Sports Med. 2011;39:538-543.

4. Barber-Westin SD, Noyes FR. Factors used to determine return to unrestricted sports activities after ACL-R. Arthroscopy. 2011;27:1697-1705.

5. Bechtel C, Ness D. If you build it, will they come? Designing truly patient-centered health care. Health Affairs. 2010;29:914-920.

6. Bhagwant, S, et.al. Influence of fear-avoidance beliefs on functional status outcomes for people with musculoskeletal conditions of the shoulder. Phys Ther. 2012;92:992-1005.

7. Bircher J. Towards a dynamic definition of health and disease. Med Health Care and Philosophy. 2005;8:335-341.

8. Bircher J, Wehkamp K. Health care needs need to be focused on health. Health. 2011;3:378-382.

9. Cott C, Finch E, Gasner D, et al. The movement continuum theory of physical therapy. Physiotherapy Canada. Spring 1995;47:87-95.

10. Creighton DW, Shrier I, Shultz R, Meeuwisse WH, Matheson GO. Return-to-play in sport: a decision-based model. Clin J Sport Med. 2010;20(5):379-385.

11. Edwards PK, Ackland T, Ebert JR. Clinical rehabilitation guidelines for matrix-induced autologous chondrocyte implantation on tibiofemoral joint. J Orthop. Sports Phys Ther. 2014;44:102-119.

12. Engel G. The need for a new medical model: a challenge for biomedicine. Science. 1977 April;196:129-136.

13. Epstein RM, Fiscella K, Lesser CS, Stange KC. Why the nation needs a policy push on patient-centered health care. Health Affairs. 8;2010:1489-1495.

14. Grindem, H, et.al. Single-legged hop tests as predictors of self-reported knee function in nonoperatively treated individuals with ACL injury. Am J Sports Med. 2011;39:2347-2354.

15. Guide to Physical Therapist Practice 3.0. Alexandria, VA: American Physical Therapy Association; 2014. Available at: http://guidetoptpractice.apta.org. Accessed 12/14/14.

16. Hamilton GM, Meeuwisse WH, Emery CA, Shrier I. Subsequent injury definition, classification, and consequence. Clin J Sport Med. 2011;21(6):508-514.

17. Hamilton GM, Meeuwisse WH, Emery CA, et al. Past injury as a risk factor: an illustrative example where appearances are deceiving. Am J Epidemiol. 2011;173(8):941-948.

18. Harris-Hayes M, Sahrmann S, Van Dillen L. Relationship between the hip and low back pain in athletes who participate in rotation-related sports. J Sports Rehabil. 2009 February; 18(1): 60-75.

19. Harris-Hayes M, Van Dillen L. The inter-tester reliability of physical therapists classifying low back pain problems based on the movement system impairment classification system. PMR. 2009 February; 1(2): 117-126. doi:10.1016/j.pmrj.2008.08.001.

20. Hewett T, Di Stasis S, Meyer G. Current concepts in injury prevention in athletes after anterior curciate ligament reconstruction. Am J Sports Med. 2013. January; 41(1): 216-224. doi:10.1177/0363546512459638.

21. Hurd WJ, et.al. The effects of anthropometric scaling parameters on normalized muscle strength in uninjured baseball pitchers. J Sport Rehab. 2011;20:311-320.

22. Logerstedt DS, Snyder-Mackler L, Ritter RC, et al. Orthopedic section of the American Physical Therapy Association, knee stability and movement coordination impairments. J Ortho Sports Phys Ther. 2010 April;40(4):A1-A37.

23. Meuffels D, Poldervaart M, Diercks R, et al. Guidelines on anterior cruciate ligament injury: a multidisciplinary review by the Dutch Orthopedic Association. ACT Ortho 2012: 83(4):379-386. DOI10.3109/17453674.2012.704563.

24. Meyer GD, Schmitt LC, Brent JL, et al. Utilization of modified NFL combine testing to identify functional deficits in athletes following ACL reconstruction. J Ortho Sports Phys Ther. 2011;41(6):337-387.

25. Mueller M, Maluf K. Tissue adaptation to physical stress: proposed “physical stress theory” to guide physical therapist practice, education, and research. 2002;82:383-403.

26. Negrete RJ, Hanney WJ, Kolber MJ, et al. Reliability, minimal detectable change and normative values for tests of upper extremity function and power. J Strength Cond Res, 2101;24:3318-3325.

27. Reiman MP, Lorenz DS. The integration of strength and conditioning into a rehabilitation program. Inter J Sports Phys Ther. 2011; 6:241-254.

28. Sahrman S. Diagnosis and Treatment on Movement Impairment Syndrome. St Louis, MO: Mosby: 2002.

29. Sahrman S. Movement System Impairment Syndromes of the Extremities, Cervical, and Thoracic Spines. St Louis, MO: Mosby: 2010.

30. Schmitt L, Byrnes R, Cherny C, et al. Evidence-based clinical care guidelines for return to activity after lower extremity injury. www.cincinnatichildrens.org/suc/alpha/h/health-policy/otpt.htm. Guideline38, p1-13, 5/24/10.

31. Silbernagel KG. Does one size fit all when it comes to exercise treatment for Achilles tendinopathy? J Ortho Sports Phys Ther. 2014;44:42-44.

32. The Free Dictionary.com. Accessed 11/10/15.

33. Thein Brody L. Effective therapeutic exercise prescription: the right exercise at the right dose. J Hand Ther. 2012;25:220-232.

34. Toscano L, Carroll B. Preventing ACL injuries in females: what physical educators need to know. J Phys Ed Rec Dance. 2015 January;86:40-46.

35. Van der Wees PJ, Moore AP, Powers CM, et al. Development of clinical guidelines in physical therapy: perspective for international collaboration. Phys Ther. 2011; 91:1551-1563.

36. World Health Organization. How to use the ICF: a practical manual for using the International Classification of Functioning, Disability, and Health (ICF). Exposure draft for comment. October 2013. Geneva: WHO.

37. Yenchak AJ, Wilk KE, Arrigo CA. Criteria-based management of an acute multistructure knee injury in a professional football player: a case report. J Ortho Sports Phys Ther. 2011;41(9):675-686.

F. Mark Amundson, PT, DPT, DSc, MA, ATC, SCS, CSCS, is a PPS member, clinician, and Chief Clinical Officer for Twin Boro Physical Therapy in New Jersey. He may be reached at famundson@twinboro.com.

Blank Slate

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By Stacy M. Menz, PT, DPT, PCS

The start of a new year is like the first page of a brand-new notebook. The pages have not been written on yet and we get to create the story that fills the pages. It is a great time to sit down and strategically plan for the upcoming year. What were the goals you declared last year? Did you meet those goals? What are the goals that you want to achieve in the coming year? What do you want to change? What have you learned for the future of your practice?

The Private Practice Section Annual Conference each November is fortuitous in terms of timing. This event can be a catalyst to reflect on the past year; discuss ideas—as well as challenges—with colleagues; and attend presentations that may open your eyes to new systems, ideas, or perspectives that can benefit your practice. Discussing your past year with colleagues may help you to take a step back and reflect on the past year, and this reflection can help you look at things that happened a little differently.

Privacy Please

Revisiting data security in an evolving tech world.

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By Eric Cardin, PT, MS

This year heralds the 20th anniversary of Congress’ passage of the Health Insurance Portability and Accountability Act (HIPAA). Two decades later the protection of health information and privacy continues to be an important issue among private practitioners. As much as HIPAA has become a household name, a new or established practice can potentially overlook the necessary steps needed to protect their clients and limit their liability related to handling sensitive data. Over the course of its life, HIPAA has centered around the “privacy rule” and the “security rule.” It is important to check in with these regulations, their clarifications, and subsequent updates (see Health Information Technology for Economic and Clinical Health [HITECH] Act below) to ensure compliance and increase peace of mind when it comes to data security and privacy.

The “security rule” requires “appropriate administrative, physical, and technical safeguards to ensure the confidentiality, integrity, and security of electronic protected health information.”1 New private practice physical therapists are tasked with understanding and complying while established therapy practices should revisit their plans to ensure compliance. Compliance must be thought of as an ongoing and evolving process. After all, iPhones, iPads, “The Cloud,” Smartwatches and the ubiquitous “selfie” were yet to arrive when HIPAA went into effect. What will technology bring in two, three, or ten years from now?

Risk Assessment

First, the private practice physical therapist should conduct a risk assessment. It is important to consider how protected and private information is being handled and anticipate possible lapses in security. A thorough risk assessment helps identify possible ways protected information might be compromised. Basic documentation of an assessment demonstrates a reasonable effort to maintain and secure private health information. A risk assessment can be followed by a complete analysis of what is currently being done or could potentially be done to overcome the risk found during the risk assessment. This analysis of current security and the inherent risks found surrounding the protection of private information is the cornerstone of compliance.

Administrative, Physical, and Technical safeguards

Administrative safeguards: In general, these are the administrative functions that should be implemented to meet the security standards. These include assignment or delegation of security responsibility to an individual and security training requirements. Clear policies regarding reporting security incidents are a required part of these safeguards. Efforts should be made to train the entire team to understand and enforce the plans. Compliance plans should also address data backup, disaster recovery, and contingency plans.

Physical safeguards: In general, these are the mechanisms required to protect electronic systems, equipment, and the data they hold, from threats, environmental hazards, and unauthorized intrusion. They include restricting access to protected health information and retaining off-site computer backups. Cloud computing offers cheap and nearly limitless storage and backups. Understanding how information you handle is stored is a key part of selecting an electronic medical records (EMR) vendor. Simple physical safeguards include the computer or device to “lock” after a period of nonuse. However, compliance and enforcement require staff to buy-in and be educated by the management team.

Technical safeguards: In general, these are primarily the automated processes used to protect data and control access to data. They include using authentication controls to verify that the person signing onto a computer is authorized to access that protected information or encrypting and decrypting data as it is being stored and/or transmitted. Mandatory password changes, protected/private Wi-Fi networks, clear policies regarding “bring-your-own-device,” and education regarding secure home networks are all important parts of technical safeguards.

In 2009, the HITECH Act further defined requirements and strengthened enforcement and penalties for noncompliance. The government strengthened enforcement and penalties related to data security in this Act after a culture of lax compliance developed nationally regarding the protection of health and private information. The HITECH Act enables the government to impose large monetary penalties for those covered entities found to be in “willful neglect.” This can seem like an ambiguous term, but it presents an opportunity for a prepared provider to establish a basic plan for compliance. The Act also defined when patients and the government must be notified of a “breach” of protected information. This definition can be summarized into including basically any unprotected or compromised information that requires the patient to be notified and larger scale incidents that require the government to be notified.

The interaction of regulation, technology, and security can be a complex web of requirements. Regular review of policies, procedures, training together with documentation, and efforts to educate employees are an important part of compliance. Information to assist private practice physical therapists, summarized here, is available across multiple internet resources, including www.hhs.gov, www.healthIT.gov, and the American Physical Therapy Association (APTA) website. 

References

1. www.hhs.gov/ocr/privacy/hipaa/administrative/securityrule. Accessed Nov. 2015.

Eric Cardin, PT, MS, is the executive director of South County Physical Therapy, Inc. He can be reached at ecardin@sc-pt.com.

Meet the Press

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They are your untapped referral source

By Ben Montgomery

When you think of your referral sources, who comes to mind? Physicians, specialists, clinical providers—they all serve as trusted professional partners who view you as a credible source for rehabilitation and pain management services, and likely much more.

Yet these sources live on a distinct island. They are some of your greatest advocates, but beyond their own line of patients, their reach is limited. Traditional referral sources can guide clients in your direction, but you cannot rely on them alone to tell your story, the story of your clinic, or the story of the physical therapy profession.

To tell such stories, you need a much wider megaphone—a credible messenger with an eager audience made up of a bold cross section of your local market. Regardless of where you are or the size of your market, such a megaphone does exist: It is your local press.

Loosely defined, “the press” is any person, company, or organization that produces content reaching a wide audience of readers, viewers, listeners, subscribers, and/or members. The channels they use to connect with their audiences vary from print publications and online blogs to television and radio, yet they all have one thing in common: the need for compelling content.

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That is your cue.

As a private practice physical therapist, you have value to add to the public conversation. The press wants your news, stories, expertise, and perspective—they need it, in fact, because such things are valuable to their audience, and hence offer value to their products.

Few writers, journalists, and assignment editors are experts on issues of exercise, functional movement, or overall lifestyle enhancement, so they are always on the lookout for credible health care sources. The goal of a media strategy is to create relationships and establish your credibility with such gatekeepers of content so you can fill this valuable niche.

As a natural educator, you as a physical therapist should thrive in this role.

Media relations is your opportunity to educate your community about yourself, your clinic, and the role physical therapy plays (or can play) in improving people’s lives. It is also a way to enhance your credibility in the eyes of your community at large, propelling you and your brand above others simply due to your willingness to speak up and share a little of yourself.

Needless to say, a consistent media relations strategy should be a part of every private practice’s marketing effort. It is your time to grab that media megaphone.

Here are a few tips to get you started

Be a media consumer: Read newspapers, watch the news, pick up a magazine, scan your chamber of commerce newsletter, and subscribe to the local blog for active moms. As you get better acquainted with your local media landscape, pay particular attention to who covers health and lifestyle news, what topics they are covering, and how you as a physical therapist might enhance the conversation.

Develop a media list: Do not make a list of places, but of people who cover health, lifestyle, sports, and business within your local market. If you cannot find their contact information online or in local publications, call the media office(s) for names and email addresses. Most are happy to oblige.

Create and share content: Share an inspiring story about a patient. Provide a physical therapist’s perspective on a trending news topic. Offer seasonal and consumer-ready tips or advice about exercise, movement, or injury prevention. Whatever you choose, consistent content (generally shared via monthly press releases) is your “in” with the local media.

Be available: Always make it a priority to keep communication channels with the media open and free of delay. Writers, journalists, and editors often work under the pressure of tight deadlines, and returning messages promptly will show them you are an eager and reliable source, perhaps opening the door to future contact. Also, they will likely return the favor next time you reach out to them.

Be consistent and realistic: Media relations is a long play. Not every press release you distribute will find its way online or in the paper, but it all contributes to building relationships, establishing trust, and keeping you top-of-mind with people in the press. It is a process that takes time and consistency—but one that can pay big dividends for you, your clinic, and the profession as a whole.

Ben Montgomery, a former journalist, applies years of copywriting and message development experience toward serving physical therapist through BuildPT, the recently developed marketing services arm of Vantage Clinical Solutions helping private practice clinicians develop media relations, email marketing, and online engagement strategies. He can be reached at ben@buildpt.com.

The Life-Changing Magic of Tidying Up

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How to organize your stuff.

By Marie Kondo | Reviewed by Deb Gulbrandson, PT, DPT

The book, The Life-Changing Magic of Tidying Up, may seem like a strange choice to review in a physical therapy journal but many of us are perennially challenged by “stuff” in our lives. This can impact our efficiency and decision-making ability. As business owners it is becoming more challenging to run a successful private practice. The fewer distractions we have, the more we can focus on the important things. The author Marie Kondo takes a Zen-like approach to the art of “tidying up” or reducing clutter. Whether our office, home, or even car, we all work and feel better when there is open space. Putting our physical environment in order positively impacts other aspects of our lives. We start by discarding; then we organize our space. 

An interesting aspect is to keep only things that spark joy in our lives. We hold onto unused items because they are still serviceable or we might need them someday. Kondo’s rule is to sort by category, not location. We assume we should organize by room or area. Kondo’s explanation is that we all have too much stuff. We need to collect everything in one place. For example, at home, search all areas to find items in the same category. For clothes search the laundry room, storage closets, etc. By collecting one category (and if you have too many clothes, subgroup into tops, pants, etc.), we really see how much stuff we have. In many cases there are duplicates that we do not even realize. Handle each item and see if it sparks joy. Keep only those that do. 

Discard in the following order: 

  1. Clothes
  2. Books
  3. Papers
  4. Miscellaneous
  5. Mementos

This order runs from least emotional to most emotional. We want to create momentum by working quickly through the discard phase so that when we get to the really hard stuff, we have honed our skills for what makes us happy. Kondo says in her book, if you start with mementos, you are doomed to failure. It is just too hard. 

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This approach includes conversing with the item, thanking it for its service to you. Now that may seem a little weird to us Westerners, but I like that idea. It seems to make it easier to let it go; even those purchases that I regretted. They taught me that I should not do that again. Kondo reports that by handling each sentimental item and deciding what to discard, you process your past. If you store or hide things away, before you realize it, your past becomes a weight that holds you back and keeps you from living in the here and now. This technique can be applied to our office, our files, and our email. 

Once you have discarded as much as possible, only then do you decide where to put things. Everything should be in one place, rather than multiple sites such as screwdrivers in the garage, kitchen, and/or laundry room. It is easier to remember and retrieve.

By reducing the clutter in our environment, we can see where to focus our attention. This allows us to put energy into making our businesses and lives as successful as possible.

Ben Montgomery, a former journalist, applies years of copywriting and message development experience toward serving physical therapist through BuildPT, the recently developed marketing services arm of Vantage Clinical Solutions helping private practice clinicians develop media relations, email marketing, and online engagement strategies. He can be reached at ben@buildpt.com.

Copyright © 2018, Private Practice Section of the American Physical Therapy Association. All Rights Reserved.