Social media marketing and advertising may be new for many physical therapists, but amidst the COVID-19 crisis, it is a marketing avenue that physical therapy owners need to consider. Joining Nathan Shields today is Edric Zheng of Medical Patient Referrals. Edric provides some of the basics about the why, how, and what is best to do when it comes to marketing on Facebook. Stick to the end for useful strategies in making irresistible offers, generating good content, broadening your audience, building a database and many more.
My guest is Edric Zheng out of New York. He is with Medical Patient Referrals and he is an expert on social media marketing. I thought it'd be appropriate to bring him on, as owners have the time to consider their digital presence, the marketing that they do digitally, especially as we've been forced in that direction with the Coronavirus pandemic. First of all, Edric, thanks for coming on.Marketing is only as powerful as your sales process. Click To Tweet
Thank you, Nathan, for having me. I appreciate it.
Tell us a little bit about you, Edric and what you do for physical therapy owners, but also a little bit about your backstory and what got you to the point where you are now.
What I do is I set up a direct access patient generation system using Facebook ads to help them acquire new patients with social media and to take advantage of all this traffic they have available to them. My background is I've spent a few years in digital marketing, learning copywriting, running ads, and creating profitable campaigns. Also, spending a ton of my own money trying to figure things out for my eCommerce products as an affiliate in my previous life for other health companies and nutraceutical products. That's how I got good at Facebook ads. I’m using those skills and taking it to help physical therapy owners with their patient acquisition systems and processes.
You've been spending a lot of time trying this, trying that, and refining content when it comes to Facebook ads. Why specifically do you focus on Facebook ads? Why are Facebook ads beneficial for physical therapists?
The reason why I focus on Facebook ads in the past was there’s so much opportunity there. Almost everyone that I know is on Facebook. Probably the same for yourself as well.
It's probably two billion Facebook users or something like that on my side of the country?
People spend 30 minutes to two hours a day every single day on social media and the biggest growing demographics on Facebook are older people, over the age of 45. People are getting on so they could spend more time connecting with their family and look at photos of their children and things like that.
How did you utilize Facebook to drive direct access and patient generation?
What do for a client specifically or for my own company?
We want to be more PT specific. What do you do specifically for physical therapists to help them get direct access and patient generation? To some extent, we already have some direct access capabilities with physical therapy.
It all started with creating an irresistible offer for someone to want to come in and start a conversation with you. For example, it could start with maybe like a free consultation offer if you want to be super basic or free discovery visit, a second type of offer. It could be a workshop if you haven't experienced hosting those types of things. It could be something super unique that you do and that no one else has ever seen before, like a free laser therapy session or something like that. It all started with coming up with an irresistible offer and then putting that on Facebook.
Physical therapy only needs to be specific or at least have a niche in which they can offer or somehow be able to share some of their knowledge base in order to gain that traffic and that interest.
When it comes to paid advertising, all you need is an ad text and an offer and you can start promoting that to almost whoever you want. You can start showing your offers and what you have to offer, the value that you can provide. You can start showing that to thousands of people if you have a couple of bucks to spend on Facebook.With the number of people on social media, especially Facebook, during the COVID-19 crisis, it's an opportunity to gain a bigger audience. Click To Tweet
When I consider Facebook and talking to some of the marketing specialists, you want to get that patient in front of that patient as much as possible so that they click and buy or sign up for whatever offer you're providing. There's added value in simply gaining an email address and that’s building your list so you can send them future offers.
Getting an email address means that this person is interested in what you have to offer. It means that this person has back pain, knee pain or maybe has been involved in a motor vehicle accident or just has gotten out of surgery. They’re looking for related content. They're looking around and they're trying to find out who they can trust. If they're on your email list, that means you have a line of communication with them where you can continuously provide value, educate them, and build that trust until they're ready to come in and start a conversation with you or get the help that they need.
How does someone go about creating a successful marketing campaign on Facebook? What process do you recommend they go through?
If you wanted to, physical therapy owners can look at the different clinics in their city. Go on their Facebook pages and look at their ads that they're currently running because that's all public information that Facebook has made available to all advertisers to promote transparency. Being able to reverse engineer what's already out there and what's been running for a long time is probably the best way to start to do what's already working.
How long do you recommend someone keep a Facebook ad up before they determine if it's successful or not? Do you give it 2 or 3 days or do you give it 2 or 3 weeks before you look back and assess what the statistics are?
Since we have a lot of data already on Facebook ads, a KPI that physical therapy owners should look out for is the cost per lead metric. If they're seeing their cost per lead go above $20, pause that ad and then to try again. Try a different offer, image, video, and angle. You want to try and get your cost per lead to around $10 because that's where we know that you can have a lot of success if you can get there.
You're saying $20 is the point at which you want to reconsider what you're offering and what that looks like in the design and whatnot. When you say $20 per lead, that's not necessarily a converted lead. That's just simply $20 per lead.
That $20 is just someone who's seen your ad, who's given you their name, email, phone number, and is interested in whatever you have to offer on Facebook, be it a free consultation or a $21 evaluation or something like that.
You want to keep that number then below $10, is what you're saying?
Yes, if you can keep it around $10, that is ideal because you're not going to convert every single lead. That's why you want to have a good amount of leads coming in at a solid price.
What are some of the most successful things someone can do as they're setting up this strategy? What are some of the components of having a successful Facebook strategy?
For us, it always boils down to four things. Number one is your offer. What do you have to offer to get someone to want to come in or give you their information? That's probably the most important thing. Number two is your creativity, which could be your image, a video or a testimonial that you're attaching to that Facebook ad. That's the second thing that people pay attention to. The third thing is your headline. Does it stop people from scrolling on social media? Does it get them to pay attention to what you have to say? The fourth thing is your body text. It’s whatever else you want to put into the Facebook ad and things that you want to say to keep them reading in on your Facebook ad. Whatever you write in your ad, it has to be whatever the conversation that the person is already having in their head. If you can answer that conversation and you can put that in the text format, you're going to have a lot of success.
Do you find more success with video-based advertisements versus those that are simply text?
For sure. Video allows you to build a lot more rapport and a lot more trust that you can't do with photos or with text.
How long should a video like that be? Do you have any recommendations?
If you're going after an audience that doesn't know who you are yet and people around your city, it’s maybe around 3 to 5 minutes providing value and educating people so they know that they can trust you and they can use what you have to say.
It's an obvious answer but I'm sure in the body of the text, you're wanting to refer them over to the landing page and a YouTube channel that you might have generated or other social media as well?
If you take them to a landing page, you can sell them some more, you can provide some more testimonials, and you can tell them more about your product, whatever you have to offer. It gives you another chance to sell them again and to qualify someone before they come into your funnel.Effective advertising starts with an irresistible offer for someone to want to come in and start a conversation with you. Click To Tweet
For me, creating content is my biggest fear. I can do it and I'd do it, but for someone who isn't into developing that content, how would you guide them to make an irresistible offer that gets that client or that potential lead to reach out?
You have to put yourself in the perspective of your end client or your end customer and think about what is it that they want and what they find valuable. Put yourself in their shoes and think about whatever it is they would find useful. I would test that as an offer or a content to give away.
One of the books that I refer to is called Building a StoryBrand by Donald Miller. Interestingly, he recommends the same thing. When you're advertising to somebody, you don't want to come across as the hero in their story. If you're advertising to somebody, they want to be the hero of their own story and you want to be essentially the guide like the Obi-Wan Kenobi that takes this person who doesn't know their strengths and what they're capable of and develops them. That way, they can become the true hero. That's good advice. What you're saying is that you want to talk to them as if you are the guide, but not the hero to their story. We have to remember as physical therapists that we can't use our jargon, our vocabulary, especially the specifics. You want to get down to their level and talk about, “Do you have back pain that's keeping you up at night?” Without getting into the technicalities of it, per se. “We have the four things that you need to do to sleep better.” Something like that. By saying that, do you find that content that has a list of the 4 or 5 things or how to blank that kind of thing? Is that helpful?
Yes. Those types of content always do well. A good way to know if your video content is doing well is there's a metric you can look at on Facebook ads. It's called Cost per ThruPlay, and that's how much it cost you to get a fifteen-second video view of your ad. If that's under $0.06, that piece of content is good because that's another good metric to look at in your Facebook ad.
These are all metrics that you manage via Medical Patient Referrals but it's something that people can also look at themselves if they are admins on their page?
Exactly. These are numbers that we've found over time to establish a good baseline for success.
When someone's considering Facebook ads, buying ads and putting them out there, should they have more than one going at a time or just stick with one and see how it goes? What kind of mindset should they have as they're considering purchasing Facebook ads?
They should definitely have more than one ad running at a time because this way, you can see what ad is performing better and why it's performing better. Let's say you run two ads at the same time. With one ad, you're using a picture of a knee and the second ad is you're talking about the back. Maybe the cost per lead with the back is half the price of the knee. You're getting more bang for your buck, then you’re going to focus more on the back end and do as much as you can with that.
Do you find that some of your clients are having more success with Facebook ads during the slowdown, COVID-19 because people are more engaged in social media and Facebook itself?
The cost of advertising is definitely cheaper because a lot of people have quit and dropped out of the race. That leaves room for people who are still willing to try, adapt, and do new things. It gives them more breathing space since everything is cheaper. We're still generating increases in new leads. We just have to change up the angle a little bit. Instead of advertising in-person consultation, what we're doing is we're advertising a free discovery call or a free phone conversation, which leads to a virtual evaluation, which leads to a virtual rehabilitation program.
What would be your tip or advice for people to get those leads to convert? Is there some secret or magic that you like to consider when it comes to converting those people?
Number one is the quality of your campaign. Having yourself on video, getting the patient testimonials on video and putting that into the ad. Also, calling out who it is you're looking for. The pain that they're having, putting down into the text, and stepping into their head and into the conversation that they're having will not get you that qualified increase. Number two is when you do generate that inquiry, you can't wait three days later to call them. You have to try and get to that inquiry right away. Setting up notifications when you generate that lead and having someone in charge of that process and calling them right away when they're still hot, still super interested in what you have to offer, and that conversation is still going on in their head.
The cool thing about you is we talked a lot about getting patient referrals and leads. Sometimes, those leads take multiple touchpoints. It's not common that you're successful with just one touchpoint and the patient converts. That's why it's cool that you recommend more than one going out at a time. You can get your Facebook ads down to a certain locale, community, and demographic. Once you develop that community, then you can hone in on the issues that are arising in that community. Your content and your output can be specific. That's when it seems like it's more powerful in the capabilities of converting the increase, would you say?If you’re advertising to somebody, they want to be the hero of their own story and you want to be the guide. Click To Tweet
Have you also used any of this for recruiting purposes? Because I see the capability of physical therapy owners using Facebook ads to recruit for other physical therapists, especially when a lot of physical therapists are out of work to recruit physical therapists via Facebook ads. Have you done that in the past or do you see the possibility there?
I've done a little bit in the past as a small test but that didn't work out too well because we're just targeting like a small population. The cool thing with Facebook is you can target by what they put in their Facebook profile. If they put physical therapist, you can target specifically only physical therapists that live in this specific city within 30 to 40 years old, if that's the age range you're looking for.
Can you also advertise to a certain locale or can you advertise the multiple states in your region?
Yes, you can choose exactly where you want the ads to show and who you want to see the ads.
I bring that up because I see that as a potentiality, even though you haven't done a lot of it yourself. It's an easy crossover to say, “I can use this to not only get patients, at least leads and subsequent conversions, but I also could use Facebook ads for recruiting purposes and that would be cool to try out.”
You have to keep in mind that the person that does have that job title, physical therapist, is probably already with another company. You have to create an angle and an offer that would attract someone who's already working for someone else, and go from there.
You've shared with us a ton of stuff about Facebook ads specifically. Is there anything you want to add or anything that we didn't cover that you would recommend people consider when they're putting out Facebook ads?
Something that people can consider is number one, for $1,000 in marketing budget, they can generate about 100 phone numbers of people within five miles from their clinic who have things like back pain, neck pain or any or any type of chronic pain. They can get them interested in a consultation with one of the doctors at the clinic. The next time maybe someone thinks about buying coffee or buying a sandwich at a store, that $5 to $10 could be spent or invested into Facebook ads and could generate you a patient that's worth $1,500 or $2,000 and get you 2 or 3 more referrals. Keep that in the back of your mind. That's the power and the potential of what a Facebook ads has to offer for clinic owners.
In Medical Patient Referrals, you don't just focus on Facebook ads, but you also have some back-end stuff, whether that's an email marketing campaign for every lead that comes through and also text messaging campaigns to past patients as well.
Marketing is only as powerful as your sales process. If your sales are weak and you're generating all these leads, but you have no idea what time these leads are coming in, not recording any of the calls, not getting back to them quick enough, and not following up, it's so much potential being wasted. What we've done is we've built out a solution where as soon as the lead is generated, it gets populated in your dashboard and your whole team gets notified. They get added into this email and text sequence where for the next 2 or 3 weeks, they're getting testimonials, content, and value sent out automatically.
If someone does schedule someone from Facebook for that evaluation in the office, then my system will know and then it'll send them reminders leading up to that evaluation. It helps with the no shows as well. After someone comes out of that evaluation, the system is going to know and it's going to send them follow up emails, asking them about their experience, how their visit went, and when they want to come back for a second visit. If they already got treatment, want to leave feedback, and leave a review. It's all automated. It makes things so much easier for the clinic.
It's great that you have that because you don't want to get their information and just leave them hanging, especially for three days at a time before you respond back to them. If you can push them into an email marketing funnel and have automatically generated emails that send out testimonials and whatnot, that's when the power comes through. It reminds them that they had some interest, to begin with, and hit those multiple touchpoints that are needed to eventually get them to convert. That's great that you guys automatically provide that. If people wanted to reach out to you and find out a little bit more about you and what you're able to provide, how are they able to do that?As physical therapists, we can’t use our jargon in advertising. Click To Tweet
They can go to my website, MedicalPatientReferrals.com. Hit the live chat button and start a conversation with me. Get on a call. I can see what’s going on with their clinic and then I can show them the stuff that we have built out. Our campaigns, ads, and the success our clients have seen. If that's something they're interested in, we can work together.
I appreciate your time. Thanks so much for coming on, Edric.
Thank you so much, Nathan, for having me. I appreciate it.
Dropped out of school to start pursuing online marketing. Went from 0-15k a month in my first 3 months of online business, which was publishing books on amazon. Transitioned into affiliate marketing and selling pharmaceutical products (Skin creams, diet pills, muscle pills). Where I learned how to create profitable AD campaigns on Facebook & Google and spend over 2 million dollars in advertising profitably. Which later morphed into taking my ad buying skills and starting a marketing agency in the medical industry helping private practice owners create a profitable patient generation system on Facebook.
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The way physical therapists market has been affected and will be changed forever because of the COVID-19 pandemic; it's forced to go digital in the way we treat and connect. In today's episode of the Physical Therapy Owners Club, Nathan Shields talks to Tracy Repchuk, a multi-awarded pioneer in digital marketing who has worked with social media, branding, and websites for over 25 years. They discuss the ways physical therapists can market for the better and learn from this slowdown. It's time to turn our attention to digital.
I'm excited to bring on Tracy Repchuk. She is a marketing expert and I've met her a couple of times and I've seen the work that she's done, especially at this time during the Coronavirus crisis. It's important to recognize the importance of the marketing that we're doing to sustain our clientele and stay in communication with them. I thought it'd be important to bring her on. Tracy, thanks for coming on. I appreciate it.
Thank you, Nathan, for having me. I'm excited to be sharing what's happening out there.
If you could let us know a little bit about you, what you've been doing here and also what you're doing nowadays to help private practice owners with their marketing efforts?
I started a software company at the age of nineteen in 1985. I've been in technology and in marketing my entire life. In 1994 before it was even the internet, that's when I was doing development for banks, JC Penney, Walmart, the Lottery Corporation and large corporations because they didn't know what this was. I knew when I saw it that it was a future, that everything was becoming this. I was an extremely early adopter. In 2006, I went all-in on internet marketing and exploded. I moved from Toronto, Canada to California because I knew this is where the market was at that time. It had not been accepted yet in Canada. It's interesting though because this is an example, what we're going through, in a way was going to happen. The virus accelerated it, is what ended up happening. We were all going to be online in some bigger way. It rushed it by 5 or 10 years. It's turned into a disrupter. Uber and Lyft was a disrupter for taxis, Redbox and Netflix blew away Blockbuster. By the time 2000 came around, those that did not adapt to the new technologies, clung to the Yellow Pages, they perished. They're gone.
Normally, this type of thing has been localized or niche-specific. In this quite case, it's global. It's a planetary reboot. The world will be new. You're going to need to adapt rapidly. That's my excitement quite frankly because everything I've been trained for is happening and what I can do for companies, restaurants, retail, physical therapists, chiropractors, yoga, Pilates. Anyone with a physical location, it's time to take a look at where to go. I've been talking about what you do and where you go for years now. We're right and ready to move into this new era.
It's interesting because this shouldn't necessarily be a pause for a lot of the business owners out there, but rather a reset and consider what you've done and what you need to do differently in the future. If your business is the same coming out of this as it was going into it, then you've not taken advantage of the opportunity. I don't know how well you'll survive going forward. It's a great message to share like you're talking about for physical therapy owners to consider how they can take advantage of telehealth services. How can they sell their services on digital platforms and social media platforms? There's a lot of effort that should be looked into putting our businesses more digital and not rely on the brick and mortar. That's hard because as physical therapists, we want to be manually engaged. We have to recognize that there is a market out there for the other things and we can take advantage of it, frankly.
What's interesting is one of my specialties is to systemize, streamline and scale. When you only have a brick and mortar environment, scaling often involves high costs and expense as well and you're carrying huge debt loads. The beautiful part I'll say about what is occurring is we can add all of the technologies that exist for us to leverage. We can build a more systemized and streamlined infrastructure online. That's going to help you scale and make more money without necessarily adding buildings or offices unless you want to. It's great when that is a choice and not the only route so that you can figure out what you want to do. How do you want to make money going forward and how do you expand?
To me, I know it's an extremely exciting time because it's making companies think out of the box. What I love about physical therapists is you are built for health. You want to help people. You want to make sure that they understand how they can repair an injury or how they can get more mobility, especially without drugs. It's the savior of the planet from what's happening now. Two things the online environment can give us, and one is exposure. Instead of us having that localized message office by office, when the entire PT industry or people start to shout it from the rooftops what you do. It's an ambiguous think quite frankly, and people think it's specialized that it's not for them.
I came into the physical therapy world when my mom had a huge incident that resulted in her entire back crumbling. She had the entire thing repaired with pins and rods and through numerous surgeries and then ended up in the hospital for seven months doing physical therapy, during which time I stayed and assisted her. Hence, the beautiful part that I had an online business and could do that has that gift of time. The other part was what respect I built for what you did. That's where my passion became, I need to get out the message about what you do. That's where I entered into the physical therapy arena and started to help physical therapists to move online. This is what we'd be doing, but now it's game over. Get on now.
I like the points that you brought up and that is number one that spreading your message or at least relying on the office space to grow your business can be much more expensive and time-consuming and energy-consuming. Whereas, if you expand more digitally, it doesn't cost as much to expand and grow. Number two, we can market directly to the consumer if we take advantage of it the right way and not rely so much on physician referrals but rather go directly to the consumer because all 50 states have direct access in some form or another at this time. We can bypass the physician referrals and go directly to the consumer and say, "If you have an acute injury to your back, because you're a weekend warrior, come and see us.” For some reason, chiropractors are able to get that message out, but physical therapy hasn't been able to do that. If we work together as a group during and after this crisis, we can get that message out via social media, through digital marketing, what you have it, and help people understand that you don't have to go to see a doctor to see us. You don't have to have gone through surgery to see us. We can see you right now. That's a message that you can get out even for those people who aren't affected by the virus and then sustained as we ramp back up.We were all going to be online in some bigger way. The virus just accelerated the process. Click To Tweet
To me, this is part and parcel of a combination of how do you get people no longer addicted to opioids by spreading the message that there is an alternative. You can get natural-based therapies that most people are not aware of. This is the reason that prescription drug abuse, in particular, happens because people don't know. "If I get adjustments or if I do this or get a correction on an injury, I don't need to be in that pain." The biggest problem is when they choose that the alternative route is they don't want to end up out of pain. All they end up is masking it and it never gets repaired. It's important. Honestly, this is the greatest catalyst you’ve got for the PT industry and my other passion is nutrition response testing. Anything that deals with making the world a better place and helping a person to get healthier without any introduction of alternative elements other than your own body telling you how to heal.
I like how you brought that up because it made me think of two things. I thought this is going to be good for our profession in that it's going to force our hand into telehealth services. Our profession is going to be changed forever because of that. We've been forced into some telehealth services to a greater extent than we were before. Number two, this is going to force us to get our message out digitally that physical therapy owners, in general, are behind the curve when it comes to modern technology use and social media use. Some people have done it well, but I would go out on a limb and I think it's a big limb and that I don't think we've used it to our capabilities to push the message that we can see you directly, that your acute issues can come to us directly. We can see you without a doctor's referral that is forcing our hand in direct to consumer marketing. I don't think I realized that before talking to you. I did regarding the telehealth, but it's going to force out the physical therapy owner's hand to be more aware of their direct to consumer/digital approach. As you're working with somebody, where do you start? Do you start with the website? Do you start with their Facebook accounts or their Instagram or all of the above? Where do you start initially?
I’ll tell you where I normally start and then I’ll tell you the COVID-19 start. It's an important piece and I'd be talking about that again for years. It’s with the landing page and the list building. We need to focus on accumulating the database because that is going to be your greatest asset. It's also the reason that it's important is as you're now going to expand through social media, we don't want to expand through social media unless we have somewhere to send them. It has to be the landing page. We have to be list building so that we can do email marketing. Why is that important? It still has the highest return on investment. It is the way that I'm advising clients now is to get emails out to your database and triple your communication to them so they feel heard and taken care of. They're in worry as well, especially if they do have injuries. They know that they should be doing something and they feel like they can't.
It's one of the original technologies that have to become stable and should have been years ago. The other reason I love landing page technology, especially for PT's, is how we can create what we call the lead magnet. This gift, which I've been creating for many physical therapists now, is an educational tool and that's what they need. The five ways to whatever to get off of opioids or the five best strategies for pain reduction of your back, your knee. We pick the target market, we create an asset to give. The beautiful part about where we have gone is all of that marketing at that time was kept local.
You can grow at a certain rate. There are only so many people that might need you. Now with the introduction of this global pandemic and the fact that we should be out in a bigger way, it doesn't have to be local. It's great when it's local. I do a lot of the strategies to focus on that, but the bigger picture is the more people that have this gift or guide and content in their hand, the more people will understand what physical therapy as a whole is. This is how we elevate the entire industry at the same time as you're moving into a position of leadership and authority because you're the one delivering this information. We add fuel, which is social media. We start on Instagram and then we start on Facebook.
We create a community on Facebook. What I love about Facebook is it is the platform for community building. You can become a leader, not only in your community, which is wonderful, but overall for maybe a specific thing you deal with. I have physical therapists, some focus on sports injuries, some focus on back injuries. If you have specific needs then you can build an entire platform around that and attract all people. There are two billion people on Facebook. There's your entire market. You have many people to draw from. This is how we're going to educate.
I say, "Let's get the landing page and list building in place." What I'm saying to people now is we need to get the Zoom technology in. We need to get you in front of it and have you doing Facebook Live and we need to start talking telehealth. Both of these pieces have to get in rapidly so cashflow continues and you become the stable datum in your marketplace as that person of authority that says, "Welcome, everybody. I understand." Originally you're talking to people that are in your community, but as you grow and as you start to do more Facebook Lives, you can say, "We're going to be talking about how to remove or eliminate a back pain that you have from sitting too much."
You can start joking with things. "We're going to help you with your Netflix knee." I don't care what you're talking about. Don't be afraid to connect it to what most people are ending up doing and start to outflow. The beautiful part is if we do this in conjunction with the landing page, we're database list building at the same time. I have even, not just for my clients but for myself, quadrupled my outflow. I've been doing a Facebook Live almost every single day since we were put into lockdown and quarantined and my numbers have exploded. That's what can happen for every business that turns around and does it.We are experiencing a planetary reboot. We need to adapt rapidly as the world changes. Click To Tweet
I've been pushing my clients and my readers to make sure that their promotion and marketing don't suffer and decrease. That's the last expense line you want to rid of. I like how you're saying at this point where you would typically have them go through a landing page process and develop that all out. It's time to move fast and quick. The best way to do that is to get onto social media, develop your community. When you say list building, you mean collecting email addresses essentially. Probably the quickest way to do that is to create that Facebook page or the community. You should have a list of past patients that you can invite to it. You can maybe boost the page or something like that if you want to, but develop that immediately with your past patient email list, that database to begin with. Then build on that by inviting more people and get them to create more data or more content if you will and start developing more and more lists. That's a way that you can immediately start building up that list of subscribers.
Here's the cool part. As you do a Facebook Live, especially if it's content-driven, you're going to talk about the knee, the back, the shoulder, whatever. Now you have content. The average Facebook Live, let's say it's 20 and 30 minutes, you can break that apart into over 200 pieces of content. Even if we only do one thing and that one thing is to take the whole video and move it into YouTube. If you move it into YouTube and you do the necessary keyword optimization, here's the reality of YouTube. All of the deals in the world aren't going to be found if you do not search engine optimize with keywords. It's a critical and key part. It's exactly what I've been doing with my client. All we're doing is taking their content to YouTube and we're keywording it.
In general, I'm getting on page one of YouTube for searches in the top four spots when it's properly keyworded right off the bat. There is no loss in that content. Let's say you did a Facebook Live and you're like, "Nobody was there." No worries. One is going to replay on Facebook. Facebook Lives, it's going to continue to replay it for you and then we're going to take it and now build an asset from that. That content, we can pare it down even smaller. You can start thinking membership site. You can start thinking added-value for clients. That's what we're doing with one of my clients, which is a Pilates studio.
When we were shut down in California and she was shut down, she was like, "How on earth do I pay my rent, pay my mortgage?" She had eight staff. The rent on her studio was enormous. For some of the PT's, you're in the same boat, you have the equipment, you have studios and you have staff. We went into crisis management at that point and that is, how can we get money in this studio? The immediate answer was getting a Zoom camera in front of her and build out the website so that she could take money for classes immediately. We were recording those classes by Zoom.
They were going out there and then we were taking that same class, putting it into a replay page as an added bonus for purchasers and then we were taking that class and putting it into a membership site. Now, as people go through, they can buy a week's class, they can buy a one month class and/or they can buy access to the membership, which means they get access to every replay on Pilates in this situation. It has exploded. She went from, "How am I going to live?" to one week later, she had 65 people going through her classes, which was more than the physical studio because of the volume you can deliver to in that situation. It's great when you, one, know that you have the technology to help somebody in that situation, but two, you can see somebody who was extremely distraught. I'm sure there are many people out there like that. This technology will work for you, we just have to think out of the box on how.
How does that cross over to physical therapists? What could they do? What content do you recommend that they come up with that kind of growth if you will or accelerate maybe their digital presence or their online content?
We have physical therapists that are leveraging Zoom for telehealth. They're leveraging Zoom for Facebook Live. At first, your Facebook Lives are targeted at your current database and they're like, "This is what we're doing. This is what the office looks like." After that, you want to start taking a look at what is a niche you can talk about. Generally, to make money, you need to go nine miles deep and an inch wide. You'll come out as a physical therapist and let's say you specialize in athletic rehab. Let's say you specialize in back, sports, shoulder or golf, whatever it is. If you have that particular niche, I will start to talk about that. That's how you're going to attract not just your PT client-base, which you've already moved into there, but now you're going to attract those people that are interested in that particular topic. How you do that is not just through Facebook Live. You'll set up events because events on Facebook get promoted. Somebody sees, "Here's an event coming up on Facebook and it's on the three tips to increase your running speed." "Great, I want to know that." The PT can talk about that.
In the beginning, that is a lot of outflow without monetary income except for telehealth, but what I like about that is the power of positioning and the power of educating on what physical therapy is. Plus now, as the people start to follow you and you get 40, 60, 100, 200 followers on Facebook in your community, all you have to do at that point, and I always pilot everything before we build it and say, "What if I opened up out a community, a membership and you paid $47 a month and I would continue to do education and assessments, whatever you want to put in there? Who is interested?" If you get ten people that say, "I would like that. That's great." I always do it based on ten. You get ten people that say, "Yes," then you start to build and honestly the build starts simple. You don't have to fill it with 52 months of content. You're going to be building the content as they're in it. They're going to pay you to build the content. This is where social media starts to come into play. Before, more social media, more followers, we couldn't capitalize on monetization at that point yet, but we sure can when we have a membership site built. Now, we can funnel them in through that and start to build up a community of people that want our results that are running, better golf, health, out of pain, whatever it is that their goal is. This is what your membership community will start to focus on.Digital marketing will work for you. You just have to think outside the box on how. Click To Tweet
The alternative to that is building a course. You want to build a five-module course on that. Whatever route you choose, the beauty is it's scalable, salable and evergreen, which means Facebook Ads, Instagram Ads. More content to drive to this marketing media that you're building is the ability to create six figures without any extra cost to whether it be your office infrastructure or more staff. It's what I call a plan B. Plan B means if you were pulled out of the workplace, if you had to take care of your parents, like what happened to me, or if you had to take care of a family member, whatever. If you had to stop, would it be sustainable? With that infrastructure of the digital environment in place, the answer is yes. If we build this and rapidly and something like this occurs again. It's occurred how many times now? At least seven. I was in Toronto during the SARS. It was similar to this only it wasn't a global pandemic. It was in Toronto. We were the ones that were shut down and into lockdown. My business already went through a year of what we're going through right now. I knew and I did at the same time make these assessments and that's why I have so much experience on how the heck do you go digital because I needed plan B way back then and that's when I started talking about it. It's time to get plan B in place. I love to help people do those.
My biggest issue has always been creating content. I'm not one that can spin out content. Is that something that we would expect out of you or any marketing specialists that we hire on at this time?
You don't need us to create the content. You need us to take that video, SEO it on YouTube, and then build a membership site, put the video in the membership site, maintain the infrastructure, the communications, and email marketing. You have the PT knowledge that already your marketplace is waiting for. All you do is seven bullet points before you start talking and you already know what you're going to say and there is the training that you're giving them within the membership site. There is no need to get nervous about the content you're going to give or whether you know what you're doing. You know what you're doing. You can demonstrate things on a doll, whatever it is you’ve got to do to show somebody how to do something that can help them with whatever outcome that they're looking for. The knowledge is all in you. The marketing and technology are not and that is a piece we handle.
It seems like it goes without saying that you're pushing video over written, a blog or anything like that.
It is 2020 and beyond blowout. More video is consumed and uploaded than in the last 30 years of all three major networks. All search is coming through the video line. People are even bypassing Google now because they don't want to read. They want to watch a video because five billion people are watching on their phone and consuming content and reading is a pain in the butt on the phone. We are media watching junkies, Netflix, Hulu, Amazon Prime. That's what's happening. Media is key and the good video combined with what Google is looking for and what the YouTube search engine is looking for, which is keywords, is your secret sauce. That's where you're going to punch to the top for everything someone's looking for. That's it. Once you've done that, you can start to embed selling in your videos that are on YouTube by saying things like, "Go to my landing page, go to my channel, go here,” everything. There's this circular way of optimizing every piece of content you produce, driving them ultimately to a membership or a course.
Not to get too much into the details in regards to video, but is there a certain amount of time that is optimal, as a 15-minute versus a 30-minute video? Backgrounds like this, does that matter too much? I'm wondering about any details that you recommend if someone is to post a video on social media?
It depends on which social media platform. On Facebook, they like the longer the better. That's how you can get more people watching because you're constantly going to be fed through the news feed while you're still on. If you're a blip on the news feed and you're off, that was it. That was your shot. The longer is better on Facebook. Why? Let's say you're doing a training video on YouTube because we're going to take that content. Thirty minutes is fine on YouTube. The average person is consuming 40 minutes at a time on the YouTube platform. This is only going to go up during this time. That was before.
We know on average we can do 40 minutes. My videos are 40 minutes. YouTube wants over ten minutes. If you have a quick key tip, then that's 3 to 5 minutes, something fast. Let's say somebody had a headache and you're like, "How to get rid of your headache in two minutes?" That could be a video. You touch here and you do this and you put whatever. I only know how to translate it so someone pays for it. It all depends on what you're doing. To me, most of mine are longer and highly consumed from that perspective. You've got content. What do we do? Now we take that video and we embed it in the blog post, we're hitting another platform, then we do have Instagram on it. We do a LinkedIn on it, and then we do a Facebook promo on it.
It's a constant circle of leveraging content that you've already created and making sure that it can get consumed wherever your person might be. It’s because LinkedIn is B2B, it doesn't mean there are a lot of people incorporate suffering from physical therapy needs. It's interesting. It’s the same with Instagram. Even though that's the younger platform doesn't mean that a Millennial who's been jogging or playing tennis doesn't need a physical therapist. That's the beauty of what you do. Cross-platform promotion needs to happen so we can find the sweet spot. Once we know it, that's where the fuel pours in that area.
That's why I'm glad there are people like you out there because doing all of that blows my mind. I don't want to touch it. I don't want to put in all the keywords. I want to do my thing and then give it to someone to work with. Either that person is on your staff or you hire it out to someone like you who's a specialist at it. I'm sure the dollar put into you will go a lot further than having someone in the house through it unless they are super expert.This is not a time to shrink and go into survival mode. You need to market and promote more than you ever have to rise to the top. Click To Tweet
There's the other thing. Let's say you had a social media person on staff. We can work with people like that because what they're often missing is strategy. They're like, "I'll do this or this is a cute post." We're watching too. We have to know what all the trending keywords are, what all the trending hashtags are and we need to make sure that all posts optimize five different sets of hashtags for everything that's going on. They may not know that, but when they're talking about that, then there's like, "I understand what I need to do." That helps the office as well. For those of you who do have staff, but perhaps they need a little more guidance, that's where we often come in. We teach them specifically on what they're doing to help you and then we move either to another part of the company or you don't need this anymore, whichever happens.
A lot of times you lean on that social media person to be your strategist when maybe they're saying, "Here's a cute video. I'll post that. Here's a recipe that our audience might like,” and post that. It's what anything that we put out there is okay mentality instead of being strategic and focused on the content that they produce.
That goes to part and parcel of increasing your conversions, increasing your brand and your elevation of authority and influence comes strictly from the strategy that goes behind the post.
If people wanted to get in touch with you and see what you provide and how you can help them, how would they do that?
There are two ways. You can check me out at TracyRepchuk.com. You can check any social media platform with /TracyRepchuk or you can take a look at the funnel, what I want you to have. My landing page, which is FastActionResults.com and you'll see the process. I bring people in, I give you a gift. At that point, if you need to schedule a strategy call so I can take a look at what you've got, where you're bleeding and how we can help repair it, then that can happen immediately. You click and schedule.
Thank you for your time. Is there anything else you want to share with the audience?
The thing I would share as a final note is you need to market and promote more than you ever have. You said it at the beginning, Nathan, and that this is not a time to shrink. This is not a time to go into survival mode or hunkered down. You have to do the opposite of what everyone else is doing so that you're the one that rises to the top and becomes the cream. The only way to do it is to get out there bigger than you ever thought you would.
Maybe a lot of market owners have time now if they have slowed down and/or shutdown. If you've got time, now is the time to consider maybe your digital presence and that strategy a lot more. Thank you for your time, Tracy. I appreciate it.
Thank you, Nathan. It's been great.
Tracy Repchuk leads and empowers you to develop a freedom-based business by systemizing, streamlining and scaling to success
> 7 Time #1International Bestselling Author including 31 Days to Millionaire Marketing Miracles from Wiley Publishing
> World-renowned speaker in over 37 countries including China, Dubai, Brazil, Africa, Australia, Singapore, UK and more
> Award winning entrepreneur, writer and speaker since 1985 when at the age of 19 she started her software company
> Over 20 awards including from Senate, Assembly, the White House and President Obama
> Pioneer on the internet developing brands, websites, SEO and now social media since 1994 and currently serving on the Forbes Coaching Council, Amazon Influencer, and Linkedin Advisor programs
> Featured expert in over 22 National and Local TV as a trusted resource for technology, internet and social media including ABC, NBC, CBS, FOX and featured in 3 motivational movies
> Runs her own 501c3 foundation to help underprivileged women to gain life and business skills so they can be independent and run a business from anywhere with confidence
> Global leader in strategic thinking for increased market reach serving thousands of clients around the world to help you reach millions with your message.
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Andy Sabatier, PT, DPT is doing tremendous work with patients in the ICU setting - helping them get back to function by focusing on breathing properly. And since Andy is one of the few PTs in this setting that is doing front-line work with COVID-19 patients I figured it would be important to talk to him about how PT's can help those who are dealing with the symptoms of COVID-19 to help them overcome and recover faster by teaching proper breathing techniques and exercises. The message is timely and not typical of the PTOClub topics, but hopefully of great value to the listeners.
I'm bringing on the primary PT for a 24-bed ICU in Central Oregon. Andy Sabatier, who I met under odd circumstances, but we'll get to that. He's also the Founder of Academy West Breathing & Performance in Central Oregon. I wanted to bring Andy on because he has a unique perspective. As a physical therapist in ICU, he has seen the whole course of COVID-19 coronavirus pandemic in patients that have come through the hospital and they've seen the patients. They're also gearing up for more. First of all, Andy, thanks for coming on and joining me.
I’m happy to be here. Thanks for having me, Nathan.
You've seen it all, from what I can tell so far, as far as the course of the coronavirus in the patients that you're dealing with in the ICU. If you could share with us from your PT perspective and dealing with some of these patients, what does that course look like? I think there's a lot of unknowing out there what this looks like, what patients are feeling, what they're going through, what that course looks like. Could you share with us from your perspective what people are dealing with in the ICUs?
The word you used, unknown, is accurate. Every day we're dealing with a new reality. We have been from a rehab standpoint trying to understand where physical therapy enters that patient's care, whether they're critically ill or mildly ill or somewhere in between on that spectrum of the disease process. Every day is a little bit different. To say that I’ve seen a whole course, I’ve seen how the course of the disease goes with the sickest people. We have only a little bit of knowledge to go off of. I'm trying to consume as much data as I can from the CDC and the WHO websites and trying to read up on the data that's now coming out of China, Italy and Australia even. There seems to be a theme where things move fast. People's incubation is anywhere between 2 and 14 days. Most people, it's about 4 or 5 days. Once that disease has progressed to the point that they have to come to the hospital because of increased oxygen needs, low SpO2 values, we see a rapid progression.
What are the symptoms in those cases? What would the laymen feel in that situation?
The most common symptoms of COVID-19 appear to be fever, cough. Shortness of breath with some patients. Most are experiencing myalgia, but the two main symptoms that people are having are dry cough and a fever.
Is the myalgia simply the body ache?
It's a body ache and there's also an element of fatigue, where people are far more tired than they're used to being in. It lasts day after day. There are also some people that that's the whole disease and then they get better. Those are the people that are at home waiting this out, hoping that everything's okay, but if it does progress and there is a respiratory element, you’ll know fast because all of a sudden it's getting harder to breathe. As people need increasing amounts of oxygen, the speed at which the disease moves is fast. We've had a couple of people that come down to the ICU and are quickly intubated and things progress fast from there. Normal course, if we're talking about the most critical patients, those patients are going to be intubated working on a mechanical ventilator.
Depending on the amount of support they need, their bodies may be working hard, which is counteracting how much they're trying to get air in because they're working too hard and it's wearing them out. When somebody is working so hard that they're wearing themselves out and they're anxious, there are lots of drugs that are used to slow the body down and even to the point that they're paralyzed. If somebody is paralyzed, they’re medically paralyzed to give their body a rest. The position of the body has a lot to do with how they want the lungs to drain or how they want the lungs to get rid of all the fluid, mucus, and consolidations that are built up.If you can't breathe, you can't function. Click To Tweet
Those people that are progressing quickly, do they usually have other underlying medical conditions? Are they a certain age group or are you seeing healthy people regress that quickly?
Mostly it's people with cardiac conditions, diabetes, chronic lung issues, liver conditions, kidney issues. All of those chronic problems get exacerbated. One of the things that are not necessarily being torn out there quite as much with COVID-19 is that there is a cardiac element to it. There appears to be COVID-19 cardiomyopathy that happens where all of a sudden their ejection fraction is poor. Somebody who's got a functioning heart or at least a fairly well functioning heart will all of a sudden their heart will not be working nearly as well.
These are people who have cardiac conditions before?
Some yes, some no, mostly yes. When all those body systems start shutting down at the same time, it's a matter of, “Let's get everything to calm down. Let's save this person's life. Let's make sure that all those systems recover before we start doing anything else.” At least so far, we've had a lot of patients that we positioned prone. We'll have the person lying in bed and then we'll flip them over so that they're facing downward and their lungs are then allowed to drain a little more easily. The worst position the human body can be in to breathe is lying flat on your back. There's something that I often say to my patients when I'm going in and meeting them and introducing why a physical therapist comes in to see you in the ICU on the worst day you've ever had. It's basically because there are only three things you do lying down. We sleep, we have sex and we die. We're here to do none of those things. It's time to get you out of bed. That usually gets a laugh on hopefully what's one of the worst days they've ever had.
Is it a good idea if someone's may be recovering at home or maybe they are in the ICU wing of the hospital, to get up and sit up for quite a bit of time and walk around a little bit?
In general, in life, the bed is the enemy. There is nothing good that's going to come from inactivity. Even if you are in some disease process, unless you're so far advanced that you can't maintain your breathing without help, you should be moving. I’m not saying you should be out running laps when you're sick, but standing up, marching in place, walking around your house, making sure that you're continuing to move is going to allow your body to get some of those secretions out. It's going to allow you to move that venous blood back into the center of your body, move all that lymph system. Everything should be moving along with your body. When we sit, still, only bad things happen.
Even if people are recovering from home, they should at least get out of the bed, sit up, move around, walk, get some fresh air, I'm assuming as well you’re recommending. You might be able to do that with some of the people in the ICU, but when it gets to the point where they need ventilation, that's because what's happening at that point that they need ventilation. Are they not getting enough oxygen into their body?
I don't want to tread too far into somebody else's area because I will do a worse job of explaining medically why things are shutting down than their intensivist or their pulmonologist. The way that I try to explain it to patients before this COVID crisis, when we did have family members that were in the room and they're wondering why things are going so badly, there are a lot of muscles that have to work in conjunction to accomplish normal breathing. When your lung tissue is suboptimal, when it's stiffer or when it's clogged with mucus and consolidations and fluid, any number of reasons that can cause you to have respiratory failure, it's a matter of trying to support the body through that. Most people don't have an understanding of what muscles they're using when they breathe because they breathe without thinking. Oftentimes, they are working hard to breathe but not necessarily working smartly, if that makes sense.
This is the reason why I wanted to bring you on because you essentially teach breathing every day. That's part of your job. You're teaching all kinds of patients how to breathe properly. Doing some strengthening for the breathing musculature, we know it's the diaphragm, but doing exercises for your breathing can improve your ability to overcome and recover from this flu epidemic. You see that as part of the process in the ICU.
I’ll only slightly correct you and then I'm sure we'll come back to it. You're right. The diaphragm is the primary muscle of breathing, but the muscles that accomplish your breathing, it's a concert of muscles. Everything from starting with your mouth, orbicularis oris, glottal folds into the intercostal muscles down through the diaphragm, TA across the front. Quadratus lumborum in the back, the pelvic floor on the bottom. PTs talk about core muscles. Those are your core muscles. What's more core activity than breathing? Usually what we're trying to do is to train a little bit of every one of those, maybe not the pelvic floor in the ICU setting, but we're teaching people how to use their mouth effectively. We're teaching people how to use their glottal folds effectively for coughing versus huffing. We're teaching people how to expand their chest. We're teaching people how to recruit their diaphragm. The diaphragm is definitely the most important thing because if that diaphragm isn't working efficiently and effectively, there is little chance of being able to take the breath that you need to take in order to recover and clear your lungs.
What does poor breathing look like compared to good breathing?
When we're assessing breathing, we have to look at two things. We've got to look at their sequence in their pattern. The number one pattern that I see with most people, the poor breathers, is anybody that's using that accessory muscle. All you have to do is ask somebody, “Please take a deep breath,” and you'll know right away. You'll see what they do. You'll see what muscles move the most. Our traps are one of those muscles that take over. It's a big bully group, a big massive muscle directly innervated into the brain through cranial nerves, not a spinal nerve at all. It's one of the first muscles that form in our neural tube when we're in development. If you let it take over, it will take over anything, whether that's some physical movement like that you'd see in an outpatient orthopedic setting or somebody who's relying on it for breathing. It's a muscle that's designed to keep you alive. It's fight or flight. If you hear a bear behind you, your shoulders come up and you're running away from them. If you hurt yourself, you stub your toe on the corner of the bed, you go, “That hurt.” Your shoulders come up.
The second you get anxious or worried, your shoulders start coming up. Anything that's painful, it’s coming up. It's one of these muscles that all those things that wreck your breathing are linked to your traps. Everything we're trying to do when it comes to patients with difficulty breathing is getting them to calm down the accessory muscles, recruit the diaphragm because it's the complete opposite of the traps. Traps are designed to move your head. They're not designed to move 20,000 times a day, which is about how many times you breathe. Somewhere between 17,000 and 30,000 times a day. Your diaphragm, on the other hand, is designed to do exactly that. It's a slow-twitch muscle. It moves in big, slow arcs up and down, and if you can train it, it will support your breathing without you even trying. It’s the most efficient and effective muscle in our bodies. It's the second most important muscle in anybody's body, but we don't talk about it at all. That's one of those easy things. You walk in and you say, “We fixed your heart. Now let's talk about the second most important muscle you've got.” It's right here and they don't even know where it is.
What does a good diaphragmatic breath look like?
I'm going to slightly tilt you down because I'm a hand talker. When you're assessing somebody breathing, you should be able to see SCM scalene traps, intercostals right down here. You're going to want to follow their sternum down. Find that spot right with the xiphoid processes, that soft spot. That's where your diaphragm is, and then tell them to sniff in. If you sniff with a quick little sniff, you should feel a quick impulse of that diaphragm. If you're not getting that right away, you've already identified somebody who probably is sequencing. They are going to go up. All that results in is ineffective breathing, so coaching them through that, helping them understand this is where your diaphragm is. Feel it, understand it, touch it, because you have one. You have to learn how to use it.
From there, smooth, natural diaphragm contractions are going to pull. We're going to have expansion in the lower fields. There's a little subtle expansion forward. Lateral expansion of the lower ribs. Mid-thoracic, a little bit of expansion, slight expansion upward, but I'm tilting my hands because that's the action of the ribs. They're like bucket handles. They tilt up. As you inhale, the diaphragm comes out and then tilt up and never at any point am I raising my shoulders or using any of these neck muscles. If you get somebody to inhale maximally, it can be anybody, whether it's an athlete or the layperson, the biggest breath you can take is at the end, going to recruit some of these muscles. These aren't accomplishing any of that expansion of the thoracic cage. They're finishing the job.
When you're talking about sequencing, that's the last part of the sequence, I’d assume.
Normal sequencing goes diaphragm, lateral expansion, upper chest expansion and nothing else. Nothing above where my hands are here. If you're getting any movement above the shoulders, that's more accessory muscle recruitment than you want during even normal quiet breathing or exerted breathing.The incubation period of the coronavirus is between two and fourteen days. Click To Tweet
You're training this on every patient if they've got a respiratory issue and you're hospitalized.
I’m training this on every patient. When I started going down this wormhole years ago, initially I was going, “Am I going to be able to do this with any of my patients besides these hearts or someone's got pneumonia?” The more you see it, every single person breathes. Not every person breathes well. Strokes definitely have breathing problems. Kidney patients, there are tons of breathing problems. There are breathing problems on anybody with any neurologic compromise. TBIs, there are breathing problems. You name it. The more I started doing it, the more I realized if you can optimize anybody's breathing right before they move, you're going to get more function out of them.
It's almost like giving somebody a supplement before they work out like, “Have this shake and it's going to allow you to work out a little bit harder and get a little bit better, lift in and get more results.” It's the same exact thing. If you can breathe better, you're going to be able to walk farther. You're going to be able to do more tasks, you're going to be able to accomplish more. My mentor has a famous phrase. Mary Massery says, “If you can't breathe, you can't function.” She is 100% right. All the things that fall in their function, you’ve got to be able to breathe.
What are some of the exercises that you're giving some of your patients or anyone who's reading, saying, “Are there some exercises that you'd share with us that you'd take people through if they're feeling some of these issues?” Even if they want to breathe better in general, what are some basic exercises that they can do?
Basic exercises for anybody to be able to do. That one we talked about where you identify your diaphragm, the first thing you’ve got to be able to do is to find it. Once you find where your diaphragm is and feel like you can breathe using it every time, training yourself on it in the nose, out of the mouth breathe where you feel a big expansion and getting comfortable with that. I usually will try to pair that with some other visual input. One of the reasons why we don't breathe or we don't understand the way we breathe is because we don't see it. I know how my arm moves because I can see it. I understand the elbow. I understand my wrist. If my fingers aren't moving right, I can tell because I can see them.
I have no idea what's going on here and ignorance is bliss. I go about my life. If you can get yourself in a situation where you can see yourself breathe, that's going to help. I tell all my patients, “Tonight when you go home and brush your teeth, I want you to stand at the sink for one minute with your shirt off and breathe.” That throws some people off, but it's your anatomy and you have to understand how to use it. Nobody's there watching you. Spend a minute watching yourself breathe, understand what moves and understand what doesn't move. Given the knowledge that we went through. We talked about this should move, this should move and you want motion here and you want motion here. You don't have to get into all the anatomy. You have to show them where things are.
Once you have that, that starts to change how you think. Most of what changes breathing is thinking about it. I’m not saying you should be walking around all the time thinking about how you breathe, but it's going to be hard not to think about it if you're understanding more of it and you know how to be more efficient. Here's a way for you to walk and save your energy. I’ll buy into that. All it is, control your breathing. Have a breathing strategy. Be purposeful about what you're doing. When you've got somebody walking out in the hallways in the hospital or somebody out training for a run or somebody that's trying to motivate themselves to have lower stress levels at work. All of that can be accomplished by having a breathing strategy ready to go that's based on knowledge. It’s understanding how to use your tool.
What I'm gathering from you is if I was at work or if I got sick, I'm going to start thinking about sitting up upright and thinking about in through the nose, out through the mouth, but also maybe feeling my stomach or looking in the mirror. I'm feeling my stomach expand and contract, feeling my ribs flail out and in or up in front and down. I’m concentrating on that. Would you have someone do that a certain number of repetitions if you were essentially in a therapy setting?
In a therapy setting, it's like you're under my control. I'm going to be working with you and I'm going to tell you what to do. There are lots of cues and I'm going to look for those little things. I'm going to use my hands to try to get you to understand where I want you to move things. For homework, it can boil down to being as simple as devote 60 breaths every day to getting better. You take 20,000, you can probably find 60 breaths to make yourself a little stronger and a little better. Thirty breaths while you're lying in bed, trying to focus on how much your diaphragm moves. Maybe that's 30 breaths when you're out walking around, taking them slowly in through the nose, out through the mouth, relax the shoulders and slowing it down.
Doing it while you're active and understanding that I can deep breathe when I'm out taking a walk, I can deep breathe while I'm sitting there typing away. There is literally not a time when you're not breathing, unless you're here and we've got a whole other circumstance, then you're definitely not working with me. It's changing your perspective on things. If we're talking about this specific exercise to strengthen the diaphragm, it's like any other muscle. It wants resistance. There are lots of respiratory trainers out there that you can put in your mouth and you can breathe in and breathe out and we'll give you a little resistance. The best respiratory trainer you have is right here. Orbicularis oris is one of the strongest muscles we've got.
What I tell my patients is, “I want you to purse your lips tightly, like we were doing when you were blowing out, like you're blowing out candles. Except this time what I want you to do is have that hand down on your diaphragm and you're going to inhale through that same tightly pursed-lip mouth.” If I'm here, I'm going to tilt this down slightly. I’ve got my fingers on my diaphragm. You can see my mouth and I'm going to go. It’s the opposite of personal breathing. It's personal inhalation rather than personal exhalation. What I was able to do, because I was breathing slowly and I had a little bit of resistance, feel the diaphragm completely expand and then gradually moving there up into the chest and feeling, “This is where it stops. This is as much as I can fit in before I start pulling my shoulders. It's time to let it out and then open mouth and let it out, relax.”
You see some incredible results with your COVID patients, I'm assuming.
I’ve had the patients that I’ve worked with, my COVID patients are the ones that I like to say where is physical therapy entering into their continuum of care? Some people, it's like they're coming into the hospital and they're feeling sick and they’re up on the medical floors and we're helping to keep them moving and keep them doing things. The patients that I'm encountering are the ones that crash. The ones that come down that go into multisystem organ failure, go into respiratory failure, are intubated and then often prone, and paralyzed. After 4 or 5 days, when their lung function starts to recover, then we start weaning them from sedation.
I'm the first person you see when you can move. You see your nurse in and out of the room, but the first time you sit up at the edge of the bed is with me. What I'm doing with those patients is first we work on your breathing mechanics. We try to make sure that you've got all those things we talked about. Once I feel like things are moving in the right direction with somebody behind you and somebody in front of you, we help you sit up on the edge of the bed. Now you're sitting up on the edge of the bed for the first couple of minutes, maybe 10, 15 minutes on the edge of the bed. That might be your whole PT session.
Through those fifteen minutes, we're going to be working on trying to focus on deep breathing, getting your mechanics to be sound, and making sure your breathing is moving in the right direction. Everything is about nudging the system. Our bodies are designed to breathe well. It's why none of us have to think about breathing. When you can't breathe well, we've got to try to do something to nudge your system the other way. COVID-19 is what wrecked your breathing or it was all these other complications and comorbidities that you had prior to admission. Now we need something to push the other direction. By getting a little bit of a nudge towards sound mechanics, we see people start to improve. Once those improvements happened, now it's time to do something with it.
For me, I'm thinking of two things. Your breathing is improving. Now we want to add a functional task and we want to change your position. By giving somebody a functional task, let's say it's reaching or balancing on the edge of the bed or standing up or walking or any of that, making sure their breathing is solid first and then giving them a functional task and do at the same time. You’ve got to be able to walk and chew gum at the same time. With those patients, their first PT session, the next day you come in, you're seeing significant changes. They're more alert, they're more awake, their mechanics are better, their oxygen requirements are lower and their activity tolerance is much better. As fast as the disease can come on, it can be as fast as the disease process can accelerate, the recovery process can have equally impressive leaps. At least that's what I see so far.
It can be spurred along as long as they're breathing better, as they're getting deeper breaths and strengthening up the diaphragm and becoming more functional, getting out of the prone and supine positions and sitting at the edge of the bed and walking. It starts coming back quickly.
The bed is the enemy. Anybody's going to get worse in bed. It's the one thing we know. We know that no matter why you're here, this bed is the thing that's ultimately going to take you down. It's not going to guarantee that you get better, but the whole point of the ICU is to increase the percent chance that you survive. We increase the percent chance that you survive when you move, when you get out of bed, when you start doing functional tasks. Along with the physical aspect of it comes the cognitive aspect. People that have been down in the ICU for days, they lose track of day and night. They lose track of life in general because no cues are coming to them, saying, “You're awake. It's daytime, it's nighttime, it's time to sleep.”Breathing is the point wherein the physical and mental aspects of your body collide. Click To Tweet
It's all one bizarre reality. Like the bizarre reality we're living in now as a society, we have a way of resetting that. They don't. The PTs and the OTs, we are the ones that are trying to restore function. We're trying to restore something normal. That normal thing is you got out of bed, you took deep breaths, you coughed, you moved, and you did all that but you also stood up. You also sat on a toilet, looked in the mirror and brushed your teeth. Those little things help to cue the brain that, “We need to start moving along. This is important that we recover and we play a role in this.”
It sounds like you provide hope like, “I'm getting back to normal function,” and so you're showing the light at the end of the tunnel.
We hope so. One of the things I ask all my patients and I have a lot of one-way conversations because I have a lot of patients that are on ventilators or can't talk. It becomes like a stand-up comedy. One of the things I say to them is, “Do you feel like you accomplished something?” By and large, they say yes. I say, “Remember that because this place is going to play tricks on you. Your job is to keep it together for the next 23 hours because the next time I see you, I want you to be still progressing.” There are many things that we do for you at the hospital.
We can do everything for you. We can keep you alive without your brain even functioning. The one thing that I tell patients is, “Your job is to breathe. I can't do that for you. I can help you. I can show you and I can help nudge your system along, but these are the exercises that I want you to do. This is your incentive spirometer. This is your acapella. This is diaphragmatic breathing. This is personal breathing. This is how to cough. This is how to huff. This is how to whatever. This is your job. We've got jobs and you've got a job too. Your job is to breathe.”
Tell us how someone should cough if they are having some of those issues?
Everybody's a little bit different. Some people when they cough, they get into coughing fits and then they can't take a deep breath in. I would say five mini coughs are not effective. In fact, coughs are a high-risk maneuver if we're talking about pulmonary clearance. Sticky secretions get stuck in the lungs and cough is a high-pressure move. Closure of the glottis, developing all that pressure using all those muscles we talked about and then a big cough out. Sometimes that cough can be so much that that high pressure reaches a choke point and it pushes the secretions back down. Sometimes it's preparing yourself to cough. Making sure that you've done all the techniques you can to try to loosen all that gunk up before you cough. One of the simple things we teach people is cycles of breathing. That's one of those things we learned in PT school.
I remember hearing that term, active cycles of breathing. It does work to try to get people taking big, slow, deep breaths and then moving some of those secretions along with a maneuver called a huff. A huff and a cough differ whether or not the glottis is closed. A cough, the glottal folds close and the pressure’s built up in you, but a huff, you keep the glottis open and you try to move things along. You can have a smaller huff, a medium huff, a big huff, depending on the airways you're trying to clear. That's the thing that's guided by somebody who is around you or written down on a piece of paper. You can say, “I want you to follow this step-by-step thing, so that every time you're going to get a big old cough because it takes a lot of energy, I want you to try and get as much ready as you can so that you're coughing effectively.”
Some deep breaths followed by some huffs and a full-blown cough?
An active cycle of breathing is 3 to 5 deep breaths all the way in, 2 or 3-second hold, casually relax, let it out. It's not like blowing out. It'd be hold for 2, 3, all the way out. Repeat that 4 or 5 times. You're going to start doing huffs where you have little huffs, medium huffs, big huffs. Finally, once you feel like you've got things going, now you cough. You tell them, “Take that big cough, build up pressure, and then out it comes.” I naturally do that thing where I'm a sternotomy patient. I'm holding my cardiac pillow, but it works for me. A cough can be a double-edged sword because a cough can send you to a coughing spell. Everybody's been there where they're coughing and they can't take a big breath in without agitating our airways.
It's more about, “If you're in a coughing fit, we want you to slow things down. We want you to breathe in the nose, we want you to breathe out the mouth and slow it all down.” How you cue people as a therapist is important like the timbre of your voice. If you want somebody to inhale, you can use big, exciting cues. “Inhale.” If you're trying to get somebody to exhale calmly, you've got to slow it down. You want their diaphragm involved. That's a slow-moving muscle and it's a calm muscle. Calm language and using your tone of voice to try to get people to do what you want them to do. Your job as an educator turns into something different than you're used to.
I love what you shared with us so far because it's about breathing and not only breathing, but the anatomy behind it. The proper breathing cycle and the huffing and coughing for those people who would get to that point where they might have some productivity in their lungs. How much it can help people to overcome and recover from some of these flu-like symptoms that they have. It's imperative, especially considering this as mostly a respiratory issue, that a lot of this information gets out.
I'm glad we're talking about all the pulmonary clearance stuff and the mechanical stuff that has to do with breathing. Breathing is the point where your physical body and your mental body, for lack of a better term, collide. For somebody who is anxious breathes differently than somebody who's not, we know that for sure. We also know that you can use your breathing to slow your heart rate down, to lower your cortisol levels, to get your body's sympathetic nervous system to calm down and your parasympathetic nervous system to turn on and bring some of that balance that our body is supposed to have. Owning your breathing means owning all those different aspects. Owning your own role in your anxiety. Everybody's been anxious and this is an anxious time. We all know that panicking doesn't do anything. Panicking, buying all the toilet paper in the world doesn't prepare you for this. Being calm and taking 30 deep breaths, you will feel better than you did before that. Did you solve everything? No. You had a positive effect and you're halfway to those 60 breaths that you're supposed to use to make your body better every day.
I love the information that you shared, Andy. If people wanted to get in touch with you, ask you more questions from the PT side, from the general public, how can they do that? How can they get in touch with you?
You can email me at Andy@AcademyWestPerformance.com. Things are crazy and we're shut down on an outpatient basis, but I'm here full-time at the hospital and working as hard as I can to try to get us ready. The nurses that are here and the docs that are here and the respiratory therapists, because what I'm doing is a little bit different than what most PTs are doing. All those people, whether it's doc, PT, nurse, RT, none of those people own breathing. I think it's important that educating everybody around you, if you have some understanding about how to breathe a little bit better, share it. That's why I'm talking to you.
This is an important thing for everybody to understand that we've all got the same tool and we all could use a little bit better breathing. Can you find one person that says, “No, I don't want to breathe any better.” If you start looking at it and start thinking about it, you will start understanding this. It's a matter of saying, “I'm going to start looking, I'm going to start thinking about breathing, period.” You probably have it. If there's a curiosity and you want to learn more, the courses by Mary Massery will change how you look at the body. I would recommend any PT or OT or speech therapist to sign up for those with Mary Massery.
I'm looking forward because I know you're going to be eventually having your own clinic and focusing on Academy West Breathing & Performance. I'm excited to see what you do in the future, but what you're doing now, I have to thank you. You're on the front lines. You're doing so much for those people in Central Oregon. Hopefully, people can recognize that the work that you're doing is something that saves days of people in ICU and the recovery time is faster. They're able to overcome quicker and get back to functional activity. You're improving people's lives faster, quicker. You're saving hospitals millions of dollars. Your work is amazing. I hope it gets more promotion, more publicity going forward.
I appreciate that. I think you're right in that it's important work that we're doing down here. People ask me why I work in the ICU. I work here because this is where the best team is. There is a blurring of lines the more critical the patients get. The PTs, OTs, respiratory therapists, nurses, and doctors job, they all blend together and there are tons of communication. There are tons of collaboration. I'm trying to be the best advocate I can for that team and for my patients and trying to do my part.
My part is I want everybody in this community and everybody in this hospital to breathe better and to maximize how much potential they have physically and beyond. That starts with how you breathe. It's not what I expected to be doing when I went to PT school. I could take you down the road of how I ended up here. I think it's a good story, but suffice to say, I love my job. I'm happy to be here doing this even though it's such a messed up time to be working in an ICU and seeing things you haven't seen before in the volume that you haven't seen before. We're going to get through this as we get through everything else.
I wish you luck. Good luck with everything. There might be more coming around the corner here soon. I wish you the best. Stay on top of things. I wish you the best in Central Oregon and in your work. Stay safe and stay alive and good luck with everything. I appreciate you working in your time.
I appreciate you, Nathan. I think we're probably going to hear in about May. We're settled in for the long haul. I’ll leave you with this. This struck me. The military has a term called VUCA. It stands for Volatility, Uncertainty, Complexity and Ambiguity. We are without a doubt in a time of VUCA. With every period of volatility, there's always opportunity. I think that this period of volatility has opened an opportunity for physical therapists and rehab specifically to have an impact on our patients through improving their breathing and doing that on a grand scale. There's going to be a ton of PTs that need to go back to work when all this settles down. There's going to be a ton of people with respiratory issues that have no idea how to breathe and no idea how to use their bodies. Nobody out there is better at explaining your anatomy, your biomechanics, how you use your body and how to perform better than a physical therapist. It’s time for us to shine.
Let's incorporate all of that back into everyday function and high-level performance. Run the gamut. Thank you for your time, Andy. I appreciate it.
It’s my pleasure, Nathan. Thank you very much.
Andy Sabatier, PT, DPT is doing tremendous work with patients in the ICU setting - helping them get back to function by focusing on breathing properly. And since Andy is one of the few PTs in this setting that is doing front-line work with COVID-19 patients I figured it would be important to talk to him about how PT's can help those who are dealing with the symptoms of COVID-19 to help them overcome and recover faster by teaching proper breathing techniques and exercises. The message is timely and not typical of the PTOClub topics, but hopefully of great value to the listeners.
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The Coronavirus pandemic has become a great test for the healthcare systems we have in place. Facing it head on, the time is here for Telehealth in Physical Therapy. In this episode, Nathan Shields speaks with Daniel Seidler, PT of TelePT Solutions about the benefits of the remote provision of healthcare through technology, especially in this time of the outbreak. A relative expert when it comes to providing TelePT services, Daniel has the answers about what you can do to adapt your PT services online. This is a great episode worth listening for any PT owner, to take advantage of the services you can provide, helping those in need in this most pressing time.
This interview is scheduled with Daniel Seidler of TelePT Solutions to talk about Telehealth PT services and how we can use it during this Coronavirus outbreak. There's plenty of information to help you get started at least in providing telehealth PT services. Daniel provides those services through his company, TelePT Solutions. I wanted to rush this episode out considering the current nature of what we're dealing with on this outbreak. Let's get to the interview.
I have Daniel Seidler, Founder, and Owner of TelePT Solutions, a consulting firm to provide telehealth services for physical therapists. He also is a telehealth Physical Therapist himself. He's got a great story that I want to share with everybody. The topic that we're going to cover is rather timely. First off, Daniel, thanks for coming on. I appreciate it.
Thank you, Nathan. I appreciate you having me. We talked and realized that we should record this podcast as soon as possible. You made it happen, so thanks for that.
Thanks for coming on. We want to talk about telehealth services in regards to PT, especially as it's going to affect our services here by the Coronavirus and what's happening. It’s considered a pandemic. Before we get into that a little bit for the benefit of the readers, if you can share a little bit of your professional story and what got you to where you're at this point.
I've been a PT since 1996. I owned a practice in the Bronx in New York for fifteen years. We were acquired by a larger group and I worked for them for three years, MOTION Physical Therapy and helped develop their telehealth practice, the division of telehealth at MOTION. I decided to go out and start my telehealth practice and help other groups to get telehealth off the ground. I never imagined this scenario would arise but either way, the time is here for telehealth for medicine and physical therapy.
I'm sure you couldn't have predicted that a flu pandemic like this would break out and soon after, the need for your services would be almost immediate. It was great to hear that you've gotten established quickly for people who want to get to your website ASAP. What is the website and how can they get in contact with you?
It's TelePTSolutions.com. That's the best way to reach us. All the other information is on there.
Thanks for sharing your story. Tell us a little bit about Telehealth PT services. Let's start answering some of the general questions that you get from PT owners and providers on a regular basis.
The first question I usually get is, “Can I do this on my phone? Can I FaceTime or Skype?” The answer to that is no, you need a secure platform. There are plenty of platforms out there that look a lot like Zoom or FaceTime but they secure the communication on both ends to and from the practitioner and the patient. The audio and video can't be stolen and intercepted. It's secure in both directions.
Do providers need to find something that's going to be shown to be HIPAA-compliant?
HIPAA-compliant and the platform will require a BAA, which is a Business Associate Agreement.
Between the PT company and the software provider as well, that's pretty easy to get that at Zoom?
There are a bunch of software programs. The ones that are most adapted to PT are Doxy.me, BlueJay and Physitrack, and some of them have exercises built-in. A couple of them were built as home exercise programs. Some of the home exercise programs are adding telehealth to their platforms as well making it easy for PTs to do telehealth.
Do you have to have the patient sign anything different or can you use your typical intake paperwork for this?
It’s very similar. You would have them do your typical intake. Any information that you can get in advance is easiest. The answer to a lot of questions about telehealth is different from every state. Different states have different rules about consent. Consent can be verbal, digital or on a sign on paper, and every state is a little bit different. New York State requires only verbal consent. I'm not sure about Alaska and other States but that information is out there.
Do you get patient consent to do telehealth services?
If people wanted to find out those regulations as it pertains to their state, is there a website that has accumulated that information into one website or do you simply have to go through your own state by-laws.
That's always the best idea to go to your State Practice Act and most States at this point have some verbiage about telehealth. One central resource is CCHPCA, which is the Center for Connected Health Policy. They're based in California. They've done the research and plenty of documentation about the changing telehealth laws and they keep it up-to-date.Telehealth is an opportunity to spread practitioners’ geographic reach so they can treat patients in other counties and states. Click To Tweet
Are there some states that simply don't allow telehealth services?
In some capacity, every state allows it, not necessarily for PT though. It's CCHPCA.org.
You find the software program that you're going to use, you sign the BAA, you have the patient's consent to do telehealth services. Your treatment is like any other except you can't touch them.
That's the simplest form. If you're an independent PT and let's say you treat a patient in their home or at the gym on a regular basis and you have an ongoing relationship with them as a patient-client relationship but they can't make it to one of their visits. It's as simple as that. You have communication. Say, "I'm going to send you a ping. You click on this link, it will take us both to this conference to this BlueJay page and we'll do a telehealth session." That type of session is going to be you much like when you start most PT visits, "How are you? What's going on in your life? What's happened since the last time I saw you? What feels good and what doesn't?"
The subjective stuff, the conversational, comfortable things that you're going to talk about with a patient. That guides your visit like any other visit. If they need to, they can do a warm-up on their own. Someone who you're seeing on a regular basis via telehealth, may heat up a heating pad and sit with it for fifteen minutes before your telehealth session so that they're ready for you going in. Warm-up depending on if they have some exercise equipment at home, they might ride a bike or do whatever warm-up they might do at the beginning of the session. You can guide them through that or have them prepare to do that before you get on the phone with them or visit them.
What are some of your limitations outside of the manual when you can't get yours on them? What do you find is the most difficult thing in treating patients over the phone or through the software?
It depends on the patient and their set-up. I've found that most patients are doing their sessions with a phone. They have to have a good place to put that phone. When you're in front of somebody, you can see their whole body like three feet away from you. With a phone, it's a little bit different. Different accommodations work. You can use speakerphone with some patients in some situations. I always find that wireless earbuds are the best thing for the patient to be wearing so that they can move without a wire. They can hear you, you can hear them.
AirPods are ideal or something similar to that. That one challenge is having a visual and see the patient. The patient might think, "You have to see my arm move." You want to see their whole torso move. You might want to see how the trunk is moving well or even if they're bending their knees as they try to reach overhead or whatever it may be. That can be a challenge. Technology is always a challenge. It seems, for us, as the practitioner who's become used to using the software and it's very simple for me. On the other side, it takes some understanding from the patient.
Especially for those who are not technologically competent, I'm sure that's got to be difficult sometimes.
You've been on the phone with somebody who can't quite figure out how to use their phone. A phone conversation sometimes can be tough.
Do you usually share some of these things with them ahead of time like, “Here’s what is going to make our telehealth visits most successful? Make sure you have wireless earbuds, have your phone set up at a distance where I can see your whole body or you have a telephone stand if you're using one.” Do you list some of those things out for them?
I have a checklist for the patient and practitioners. The other complication or challenge can always be the Wi-Fi or the connection. That depends, sometimes it's perfect. Other times, it's all over the place. You do have to have a contingency plan. You have to have a backup, “If we get disconnected, we're going to reconnect like this, I'll call you, I'll ping you back,” or whatever is going to work for that situation.
You treat as much as you can over the software program. Do you bill as if you had seen them in person with the same CPT codes and time services and all that kind of stuff?
That’s right. Typically, Medicare does not pay for telehealth services for PT.
We can't expect to get anything from our Medicare patients, unfortunately. These are the people that might be home down more than the others during this outbreak.
I have reached out to people I know who were in Washington who might have the ear of the government to get some accommodations on that. At this point, we all know someone in their 60s, 70s or 80s who is reluctant to go outside and probably is not attending PT right now even if they need it. It's important that those services get covered.
There are lobbyists out there that are pushing for it. If there was a way for physical therapists to do some footwork at the grassroots level to push a little bit, is there any way they can do that?
I wish I had a solid answer. The best thing to do is to speak with the APTA and to your local representatives, whether it's local reps or federal government. It's the federal government because it's Medicare. I don't know if it's on their radar right now or not but I would think it has to be.
If some of these PT owners could flood the APTA who have lobbyists set already too, "We need to push Medicare somehow to continue to provide these services to the patients that are home-bound during the pandemic." That would be huge, I would imagine.
You would ask about billing and coding.
The billing and coding and then to follow up, since we're talking about Medicare, after you're talking about CPT codes and what insurances do pay for and who can we focus on?
It's different by state. I have found in New York that most of the commercial payers are paying, most Medicaid does cover all teleservices and managed Medicaid. I'm not sure that every state has the same arrangement but administrators of Medicaid.
It’s a matter of the owners simply need to sit down and start calling.
Speak with your payers and make sure you speak with the right person. Sometimes that first rep that you get on the call has no idea what telehealth is. They don't know. They don't see it right in front of them and they're not sure. A supervisor is your best bet.
With your consulting firm, have you made some of those calls on the behalf of some of your clients in different States or do you have some of that footwork already prepared?
I've only covered New York as far as that goes with the clients, but I've gotten some feedback from people in some other states that are telling me mixed things. Some payers are paying, some are not.
It's up to the individual PT owners to get someone to start making those calls.
As you alluded to, that is part of what we do. If someone does need assistance for that, we're definitely on board. I can be very helpful. I assisted in a lot of calls in New York so I know the conversation.
It’s good to hear that people can reach out to you. It's the person that you talked to, the verbiage that you use, don't take the first answer as the truth as these people are making the call and looking through your contracts and getting that figured out. In terms of billing and coding then, it's the same CPT codes, but there's a modifier.
Most are asking for the modified GT for telehealth and many require that you change the place of service to 02. For outpatient PT or outpatient services, typically is eleven. It's one of those things that's defaulted in most CMRs. Most practitioners have no idea that it even goes in. When you submit a claim, the number eleven goes to the payer. That field needs to be filled with a 02 to indicate that it’s telehealth.
As you've done some of the billing, are you getting denials initially and there have to appeals or are they easy and good about paying considering the modifier and the place of service?
I haven't seen any denials. I and my clients haven't taken too many chances yet. We've gone for the ones that we know will pay. I'm at that point right now where there's more and more demand. Patients want services and we’re going to give you a shot with other payers.
What do you find as you're doing some of this consulting? What are some of the hurdles that you have to prepare the owners for and those coming up against that you have to address?
Part of it is practitioner buy-in. For some PTs, it's completely something new. People don't love change but this environment changes that a little bit. It changes people's mindset a little bit. People are in survival mode and realize that they want to work, they want to reach out to their patients, that patients need the care. They're not going to get it otherwise. It's been a challenge but I suspect that might change. If a PT is sitting around with no patients, they would want to make contact with that patient.
They’ll get some buy-in pretty quick then.
It’s similar on the other side where some patients are very eager to do telehealth because it's so convenient. It's easy but others are not. I always say it's not for every patient, not for every visit but situations change things.
Can PTAs do these in calls?
It depends on the state. In New York, the best answer I've gotten is no. I'm unsure, to be honest with you. I'm hedging a little bit, but we're going with no in New York right now.
That would be up to the owners to call the insurance companies and ask that specific question, I'm assuming.
It's based on the contract. Its two different things. You do have to follow the state law and your State Practice Act and you do have to follow the reimbursement rules or laws from your insurance company if you expect to get paid. We do have clients who do all cash so they only have to follow the state law that they're in. There is no concern for what the payors at. We haven't talked about it yet but another thing to follow is a lot of practitioners now in telehealth recognize it. It's an opportunity to spread their geographic reach so they can treat patients in other counties and states. You do have to be licensed in the state that the patient lives in order to treat there.
You could live in Washington and do a telehealth call to Alaska if you have an Alaska PT license. You can't do a telehealth call to Alaska if you only have a Washington license.
To add to that, there is what's called the PT Compact. The compact is an agreement with, I believe it's eighteen states at this point where if you're licensed in one of those eighteen states, you can get the right to treat in one of the other compact states. Without getting a full-blown license, you can still treat those other states.
Do you have to go through a process in order to get that right?
Each state in the compact has its own process, whether it pays a fee or pass the jurisprudence tests or get approval from your state. Every state is different.
How can we find out about the PT compact from the states involved?
Is that PT compact only for telehealth services?
I don't think so. I believe it's the right to treat in any state in the compact.
If you live near the border, you could cross state lines and do a home health visit in another state?
I'm sure that's how it started and telehealth got the ball rolling in further.
To back up a little bit, if someone's billing for some of these services, it's the CPT code and the GT modifier on top of the other modifiers that they're using. Whether you go 1st, 2nd or 3rd, it doesn’t matter.
I haven't heard that it matters. You're going to be billing and my experience thus far has been billing for an evaluation, if you do one or re-evaluation, it’s 97161. If you are billing for therapeutic exercise, that's 97110. Neuromuscular re-ed, it’s 97112. Therapeutic activity, that's in 97530. It's limited to that. You could get into 97535 or 97537, I believe it is. It's a functional activity like home activities. Reorient the community, that's community reorientation.
What are some of the difficulties than from the patient side? What are some of their complaints as they're going through this? Is it either they like it or they don't or do you hear some of the same concerns?
I don't know if they can't stand the sound of my voice in their ears. They don't like how they look on camera. That is one. Some people are very uncomfortable doing video calls which I get it. You get past that quickly. The biggest thing is you're not getting that physical touch. I encourage people to use foam rollers, physio balls, get some of their own home equipment because as we know as PTs, they should be doing home exercises anyway. They should be managing their chronic pain. This is a great way to get them off on the right foot.
How is compliance? Do you have a cancel rate or a no-show rate?
I'm pretty persistent. My patient's schedule is not that packed. I'll find a time for most patients to get in on that day. That is a good thing, meaning flexibility. If someone can't do their 10:00, you don't want to make an open schedule then you'll have that. If someone can’t make their 10:00, they can see you at 2:00 and make that work because you're there and it's at their convenience. I try to make it that way.
Your documentation is no different than when you see them in-house?
That's true. You want to document that you're doing a visit by telehealth secure remote video call.
Where do you put that? Somewhere in the objective?
It doesn't matter, as long as it's on there.
You use the same EMR system. You use this software program with a BAA and it’s HIPAA-compliant. You do the same therapy that you would without the manual. Your billing is the same CPT codes with an additional modifier and a place of service is changed. Make sure you're dealing with the right insurance companies.
I like to take advantage of the fact that we work in the patient's home or at their office. There's the opportunity to do an ergonomic assessment of their desk. There's an opportunity to have them put some plates into a cabinet, do some functional activities, how difficult to open a door or go to a window or something like that. I haven't done any of these treatments of patients with vestibular issues, but I had a very long conversation with someone who does. She makes sure that the patient is in a very safe environment. For her vestibular patients, she does their sessions with them standing in a corner. Nothing else around. They put the phone on a nice platform where it can video them while they're doing their program while they're standing in the corner so that they have something to grab onto at all times.Back pain heals because patients understand what's going on with them better. Click To Tweet
How does marketing go? Are the doctors receptive to some of this especially now, I'd assume they are more receptive? What is your response from the physicians?
The real answer is everybody's first response is how you can do physical therapy if you can't touch the person. I've always believed that that's a perception of what PT is a problem. Many people still think it's massage and hamstring stretching. That's a problem within our profession. I've addressed that forever and I continue to address it. This is another opportunity for us to speak for our profession and say we do so much more about education. Back pain heals because patients understand what's going on with them better. That's how people get better. That's a lot of it. Once that conversation happens in the right tone and manner, most people tend to be a lot more receptive.
You get referrals directly from physicians to specifically provide telehealth PT services.
I have not marketed it in that way. I haven't pushed it hard in that way but I suspect that it will start happening very soon and not just for me but across the board.
Have you marketed directly to a consumer and gotten patients? How do you get most of your patients this time? You have direct access in marketing your telehealth services directly to the consumer and they're calling you up and starting the therapy.
They either hit on the website or calling. I have some other online referral sources that refer directly to me. I have not made a big push on social media yet. There are regulations.
Advertising for pain relief and that kind of stuff.
Particularly in New York is tough about that. My methodology has always been when I had a brick and mortar practice was we'd put information out there. It's about being a source of information showing you professional knowledge, people respect that and want to learn more from you.
What is your website? How can people reach out to you?
What I'm getting from this is number one, it's not as hard as people might expect it to be. The ins and outs and intricacies are a place where someone like you could help out quite a bit as a consultant and getting this branch or this section of their PT practice off the ground. I'm thinking, not for this pandemic but also snow days. Like here in Alaska, I'm thinking it would be great if you could offer this service to people who live out in the bush that simply don't want to live near other people and don't want to drive two hours for PT three times a week. There are opportunities there for sure, for people to provide those services. It's time that you established your business to help people out like this.
Thank you and I'm looking at this. This is an impetus to get telehealth into the mainstream. I don't think it's a fad or it's something that's going to go away when this pandemic is gone. It might be the thing that makes people comfortable with it. Look at where demographics are going and how people are working now. A lot more people are working from home and recognizing that they can access stores and food via the internet right from the comfort of their homes. It's not every patient or visit, but if you have a total knee replacement and you're expected to go to physical therapy three times a week, maybe you’d go into the office twice a week and the third visit, you do via telehealth. It's convenient.
Even more simply, what about the mother or father that has a child sick at home and they can't leave? Instead of canceling that visit to the out-patient facility, they do their services over the internet. It can be so great. If a patient cancels, no shows or if there's a drop in a provider's schedule, they can make some of those calls to people who couldn't make it and say, “Let's do it right now if you've got time.” There's an opportunity.
Different groups are looking to do exactly what you said in different ways. Some will have the same PT treat that patient later in the day. If that patient doesn't have so much flexibility in their schedule, they might have someone who only does telehealth visits. They might even outsource to a particular group or PT that never comes into their office and just does their coverage work for those next visits. There are plenty of opportunities out there and plenty of ways for us to reach out to patients and our patients to reach us. That's what this is about.
At this point, the important thing is to make sure providers recognize that this is an option, that there are people like you out there that can help them. Lastly, they need to push at the federal level to make sure these telehealth services are covered. Is there anything else you want to share, Daniel?
Be safe out there. It's crazy times. We'll all get through this. Telehealth and other services like this are ways for us to be smart and handle a challenging situation. Going forward, it will be something a lot more fun for us to do.Telehealth and other services like this are ways for us to be smart and handle a challenging situation. Click To Tweet
Out of every challenge comes an opportunity. Thanks for your time, Daniel. I appreciate you reaching out.
Thank you, Nathan.
It was timely that you did so. I'm glad that we're putting this out.
I appreciate it. I'll be in touch again soon.
Daniel Seidler, PT, MS
Daniel is an experienced Physical Therapist, healthcare innovator, entrepreneur and executive. He grew his practice in the Bronx, NY to three successful locations before being acquired by a regional multi-site group. Daniel developed and launched the company's telehealth program in early 2019.
Daniel's passion for PT and desire to dramatically improve care delivery models inspired him to formalize his telehealth PT education programs and offer them through TelePT Solutions.
Daniel now treats remotely, coaches PTs to be telehealth specialists and consults owners on building successful telehealth practices.
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