Becoming the front door to MSK care: How primary care PT works in practice

Marla: [00:00:00] Welcome everyone, and thank you so much for joining today's webinar, Becoming the Front Door to Musculoskeletal Care: How Primary Care PT Works in Practice. And I'm Marla Ranieri. I'm the head of clinical innovation and clinical strategy at Prompt Health, and I'm here with

Mike: Mike Dwyer. I'm one of the co-founders at Prompt Health.

Thank you all for being here

Marla: And we'll be moderating today's conversation. Um, we are particularly excited about today's topic because we believe primary care PT represents one of the biggest opportunities for the future of the profession. Uh, for years we've talked about the need to rethink the traditional physical therapy model.

As a profession, we have an incredible opportunity right now to become that first point of contact for musculoskeletal care, to improve patient access, to practice at the top of our education and licenses, and to establish ourselves as the providers patients think of first when they experience pain or a movement-related issue.

But that comes with some challenges. It's not that easy just to go and change your whole model. Um, and it's one thing to talk about primary care PT as a concept, it's another thing to figure it out, how to operationalize it, get it reimbursed, and make it work with an existing practice. So that's really what we're here to talk about today.

We're bridging together two clinic leaders who are actually putting these ideas into practice, and they're doing them a little differently. Um, they have different approaches. So we've got one centered around the urgent care [00:01:30] model. We have another focused on ongoing wellness and proactive care, and both are finding ways to deliver primary care PT with insurance-based practices.

So we're gonna go beyond the philosophy to exploring what it actually takes to make these models work, and how the business, the reimbursing, the staffing, workflows, all of the above, to be able to say, "How do we make sure this is successful?" So before we get started, wanna do a couple housekeeping. Um, there is a chat.

Please feel free, we want this to be interactive. You can start introducing yourselves to each other. Tell us where you're from. Tell us your name, your, your clinic, um, so that way everybody could really get to know each other in the chat. But if you have a question, we want you to use the Q&A feature button at the bottom of your screen, that way all those questions will be tracked.

We can answer them at the end when we go through the Q&A section, or we can email you afterwards if we didn't get to your question. So please feel free to use that button for questions. And then finally, this session's gonna be recorded, so you will be able to see this afterwards. You can share with your colleagues and your friends, and we'll send that out, um, in a day or so afterwards.

And so now like we said, we wanna hear from you guys, so we're gonna do an opening poll. You'll see it pop up on your screen, and this is just to find out where everybody is when they hear primary care PT right now. Where are you? Where's your practice at? Are you doing [00:03:00] some version of it? Are you actively exploring it?

Interested but you don't know where to start, or you're just still trying to understand what primary care PT is? So go ahead, let's have everybody fill that out, and we will see some answers in a second

Great. Great. All right, and hopefully those answers will pop up on the screen. So we've got a lot of people actively exploring it, and we also have some people who still don't really understand, know what primary care PT means. So that's great. Um, a wealth of different experiences here on this call. So hopefully everybody can learn some really great concrete ideas and approaches for your own practice after leaving this session.

So now I'll get into our amazing leaders who have joined us today and who are here to share their knowledge with everybody else. First, we have Sam Schmidt.

Sam: Hi. Thank you for having me.

Marla: Such a pleasure to have you, and Sam is a physical therapist and a co-owner of Alpine Physical Therapy, which actually operates six primary care and urgent care locations in Montana.

She's also the APTA Montana Legislative Chair, and also co-chairs the APTA Primary Care PT Special Interest Group. So thank you so much for being here.

Lauren: Thank you.

Marla: And, and next we have Rick Lybbert. Rick, so such a pleasure to have you as well.

Rick: Thank you. It's great to be here. Thanks Marla, and thanks Mike for having us.

Marla: And Rick is the CEO of Mountain [00:04:30] Land Physical Therapy. He started as a rehab tech way back in the day in 1992 at Mountain Land Physical Therapy, and has grown it to more than 80 locations across Utah, Idaho, and Montana, and he's been thoughtfully introducing primary care PT in his model as we speak.

Great. Well, let's start by jumping in, and Mike, I really want to bring you into this conversation first. Um, I know primary care PT is something you're incredibly passionate about, but before we get into the models, can you share why primary care PT matters so much to you?

Mike: Yeah. So I, when I started Prompt, I was a patient for five years, and it can be frustrating being a patient, navigating, you know, what do I need, like, to get back and to, to be normal?

And I, I was fortunate to have some excellent therapists who, you know, didn't only just help me with my immediate need, but I see them every three to four months to make sure I'm on the right track and, you know, I'm staying healthy. And, um, every year unfortunately, I've been very good at getting hurt and, uh, I've been using a few individuals quite a bit.

But, um, yeah, for me it's we're in a position in the market right now where it's like 90% of people don't receive the MSK care they need, and I think PT can truly be the leader in being the first [00:06:00] touchpoint for a patient's journey as it relates to MSK. And as you said earlier, like, there's different ways to skin the cat, but at Prompt, like, we're very excited to provide solutions that help make this process of transitioning to primary care providers easier.

Um, Sam and Rick, I... You guys are actively doing this, you know, in your clinic today. Can you talk a little bit about what primary care means to you?

Rick: Go ahead, Sam.

Sam: Um, to me it's just that when the, the patient or the person has a pain or movement, they, they think PT. They think immediately like, "I gotta call Alpine today," and, um, "I need to follow up with my PT."

And there's an ongoing relationship, there's trust, there's trust in accessing in, in a timely way, um, and getting a standard of care, um, that kind of crosses lifespan, crosses what I call souvenirs from the fun weekends or adventures like you were explaining you have, Mike. But just having that person that you can, you can contact and they know your whole person, your lifestyle, y- what you're doing, and it, it just makes it a better experience to, to, for that individual

Rick: You know, uh, the[00:07:30]

Marla: I think we lost Rick.

Sam: Oh, there he is.

Mike: We got him.

Rick: Am I back?

Mike: You're

Rick: back. Well, I'm in my office. We'll see, we'll see how this works. That normally we have a very stable connection here, but, um, okay. So primary care physical therapy for, for Mountain Land, we define it as being the first trusted, uh, point of contact for the patient.

Uh, and we've added something new to it just recently. It's the first trusted point of contact for the patient and a lifelong partner for musculoskeletal movement health. And, and so we're figuring that out. You know, to be first, you have to be available, and Sam's gonna talk more about this, but I think she's got a really good model to make sure that they're available.

And then there's this other side. We've got to be a lifelong partner in a, in a business where we've traditionally discharged everybody. And so that's another problem that we're solving, but we'll, we'll talk a little bit more about that. But that's, that's what it is for us, is to make sure that we're available so that we can be that first trusted point of contact, and then have a long lifelong relationship with the patient, so we're, we can help them navigate musculoskeletal movement issues throughout their life.

Marla: And that's perfect. [00:09:00] Transitions us right into, okay, so what does that model look like? How does that work? And Sam, I'm gonna start with you. Looking at that urgent care model, can you explain really what that model is, how you got it started, and what it looks like today for a patient?

Sam: Yeah, um, I think it's been a- about 10 years that we've been kind of building this, but to bring you to speed today, um, we have already kind of been practicing up top of education for a long time in Montana, um, sometimes because of, uh, just the pure landscape, rural aspect, but also our practice act.

But it was more of an access issue, um, and not, when I say that, not direct access, we've had that since 1987, but people trying to get into PT and understanding like, "Oh, I don't know if I can wait two weeks," and, and then, you know, they... PT becomes the last stop. When we started to really think about pain science and the over-medicalization, sometimes we see the catastrophizing, the shuffling, the delays, and it was like, what if people could see us first, immediately, or as soon as possible, and we could kind of address their questions, get them information, and, and help them navigate that with, with good concrete science around how the pain system works.

So truly, it kind of came from that. And then, um, as of today, like, someone calls one of our two [00:10:30] walk-in, or they can book online, or they can walk in, and we get 'em in. We get 'em in either at those walk-in clinics, or we have, um, four other clinics that we know, based on our metrics with Prompt and everything else, that w- we will have white space somewhere, where we can get that person care, and it comes back to, like, serving our community, being compassionate about somebody that's in pain and, and has a lot of questions and may have a lot of things that are tr- they're trying to navigate, and just helping that person through that, um, pain experience.

And so, um, they will either come directly into the walk-in, we get 'em registered right there or online, and we do... We, we reserve an hour to see that person, sometimes it's a half hour, and that person is either going to be, um, kind of a treatment that is, is one and come back into the walk-in model as you need, or that is gonna be like, boy, this looks like it might be a, a bigger issue, let's try to get you into a traditional, you know, c- consistent PT model.

Um, or, boy, this is, this is outside of the scope, and we need to manage this with some pharmaceutical intervention, for example, like shingles or something like that. So it's really a bit of triage, um, but you're, you're definitely taking in the whole patient, understanding what they need. Sometimes we see patients that haven't seen a doctor in 30 years, so...

But then there's sometimes it's quick and it's an ankle for a, a youth athlete, and we're just trying to get them some questions whether they can play the game [00:12:00] this weekend, or somebody that has a trip to Hawaii, and they want to know if they should go, and how they should do it. So just helping people navigate life, um, around a pain experience quickly.

Marla: And one of the things I think is really exciting about that model, like you said, you sort of just are waiting for what comes in that day. It's, it's open, it's urgent care, and you have that around your regular clinical model so you can filter people to those afterwards for ongoing care if they need it, but you also filter it to other clinics, right?

Um-

Sam: Absolutely.

Mike: Sam, something I was thinking about when you were saying that is, like, a lot of PT offices, you know, they're getting a lot of referrals from outside parties, but sending it back maybe, you know, less frequent. It sounds like, you know, yes, if I can treat them, let's do that, but it's also a muscle you've likely built, like, with referral sources of being able to send people back.

Are you able to just briefly touch on the implications of that?

Sam: Yeah. It's created just a really beautiful r- like, network of providers from imaging, um, partners to primary care urgent care facilities, um, when we talk about somebody maybe with shingles, for example. Or even, um, mental health, behavioral health.

Just trying to kind of circle in and, um, build our network of kind of that expanding the lateral primary care team within our community. And I also ask, um, "Who's your primary PT that you [00:13:30] see in our community?" We have... Uh, Missoula is just, like, a hub of curated awesome PT clinics. Um, Alpine House happens to be one of them.

But if someone comes in and says, "I usually see so-and-so," I'm like, "Okay. Well, we'll get you started and I'm gonna send this over to her so she can get you in on her schedule as soon as possible." And I think that's really important, like, putting the patient first, um, because oftentimes in the healthcare system they're not.

Marla: And I know this is a difficult model to stand up, so in general... Or when you first did it, 'cause you're sort of one of the, one of the first. Um, so in general, what are some of the operational standpoints or biggest challenges that you had to make to support this model, and how would you say that you've gotten about those challenges?

Sam: Um, you know, there's been several. I kind of tell people I've been building the plane or we all have been building the plane here as we're flying it, and sometimes it's like, "Whoa, we don't have a wing over there." So it can be bumpy, but I think we've really gotten it smoothed out with technology as, um, we've seen the development of Scribe.

I can now do, you know, five to six evals and I don't have all that information in my head. I'm not trying to get it out and onto the keyboard. That's been a game changer. I think just, um, the online booking, so many things have advanced to really help support that, that, um, those barriers are, are very little there.

I think it's best, it, like the biggest thing is messaging. Like, how do you tell the consumer what you're offering and how they can access it? And then also, like [00:15:00] making sure in-house within our company, people understand that what the purpose is of it and how we navigate patients to the walk-in or maybe how, who goes where.

And those are kind of just more making sure people are having that paradigm shift a bit because we're changing a system. And I would also say that, you know, as I talk to a lot of different practice act- or practice owners, a lot of people are doing this. "Oh, well, we do that sort of. We, we, we squeeze in people on the lunch hour if someone's really hurt," or, "We will, if someone's a frequent flyer and they've been to our clinic a lot, you know, we'll get them in at the end of the day."

I'm like, "Well, then call it walk-in." Because until we all call it the same thing, the consumer is not gonna know where to find us. Everybody knows what a Kleenex is, even though it's actually a tissue, right? So we need as an industry to like call it what it is if it, and however you offer it. You can have walk-in hours, but the consumer needs to know like, "Oh, I can get to PT and get some answers, and then I might not be able to see that person for two weeks, but at least I can get started with some things and have some, some things that I can do."

And we know when we give someone agency, that helps with their pain and it helps reducing costs and it just creates a better customer for long-term, so they come back to you, right Rick?

Marla: Yeah, and I think you've done such a good job at promoting that in the industry, in the, in your area so that people know they can go directly [00:16:30] to you, whether any kind of ache or pain, and that's something that is bigger than us that we wanna keep doing.

Um, and that you are able to get them in, see them, and appropriately do their plan of care. And not everyone is three, you know, two to three times a week for six weeks. It's really by what they exactly need in that urgent care model.

Sam: Yeah.

Marla: So Rick, you've got a little different model. Um, and now you're enterprise as well, so you're, you're a lot bigger.

You've got these 80 clinics. How do you guys do urgent care? Not urgent care. How do you do primary care where you are, and what are the different pieces that you've added to be able to, to start and pilot this and expand it and scale it?

Rick: Well, great question. Um, we're still figuring it out. You know, the survey that you put up at the beginning, uh, right now today, I think I relate with all of those answers in, in certain areas.

Certainly we're doing things, and then, y- and we're discovering. I mean, every, every day is like Christmas morning, you know? Where it's like, "Oh, this is a great surprise," you know? And there's, there's great resources. Sam, for example, I've- she's been a huge influence in how we, uh, in our model of, uh, uh, primary care physical therapy.

Uh, she just mentioned, you know, we may not have a, an urgent, you know, or a, a walk-in clinic, but we squeeze people in. And Sam says, "Stop saying squeeze them in. Just say you have walk-in services." [00:18:00] Great point. You know, um, Katie Albright has been a huge influence. Uh, recently read an article by Jeremy Vandervender.

Uh, it was a w- white paper called The, The Doctors We Never Became, uh, where he's talking about a PT, a PT pod model that we're piloting. So it's, it's a moving target, Marla. Um, it started in twen- uh, 2024, the summer of 2024, when we had decided we had achieved our, our then vision statement had become a reality and we were, "Oh, what's our next vision gonna be?"

And I remember right before we published our, our vision statement, it said, "A family physical therapist," and somebody went "Should we make it primary care?" I mean, that's how, like, organic this has be- And I went, "I kinda like how family fit, I, the F, F sound, family fit. But, you know, primary care is probably more inclusive."

And we changed it, you know? And so there's been a lot of luck in this. So it's our, our vision statement is a... And I think this is important, you know, w- whether you've got one clinic or, you know, 300, uh, messaging is a big deal, uh, messaging to your, your, uh, your team, your, your employees. So our vision statement is a, a primary care physical therapist for everyone to advance healthcare and empower movement for life.

And I [00:19:30] probably say that I don't know, half dozen times a day, and have for the last, you know, couple of years as we've been, uh, we've been figuring this out. So it's a, it's a, you know, I, I would say it starts, you know, our model starts with having, you know, clear messaging, you know, what our vision is, and then you get everybody involved on, okay, you know, what, what does that really mean?

What does primary care physical therapy really mean? And then that definition has evolved. I, I mentioned to you that, you know, for, uh, shoot, uh, at least a year it's been, uh, fir- first trusted point of contact for a patient. Recently we went and, oh yeah, there's this longitudinal thing. You know, we, we need to have a lifelong relationship with them.

Okay, how are we gonna solve for that? So we're doing things to, to try and make, you know, meet that definition, uh, within our company, and it's, you know, there's pockets. Some people are all in, others are still watching.

Marla: Yeah. I think we ... Oh, go ahead, Mike.

Mike: Yeah, that's gonna be my question, is the change management of communication that, you know, deliver that message to patients.

Like, how have you approached that process internally to, you know, ensure that it's landing the right way?

Rick: Right. And I think it's just, it, this is the same with any leadership. You have to have [00:21:00] a really clear, simple, concise message, and then you actually have to do something, right? I mean, if it's just all talk, pretty soon they go, "Uh, this is just the flavor of the month."

And, and the fun thing about this is we don't really know, so we're going, "Let's give this a shot." And we go all in and we do it, and, and sometimes it works, and sometimes it doesn't. One of the things that we leaned into really hard for the last couple of years is we've trained about, I think just shy of 50 physical therapists on doing diagnostic musculoskeletal ultrasound.

Huge lift. You know, it's, uh, uh, bigger than we ever expected it would be, but that's been very helpful for, you know, and, and obviously attached it to this primary care vision, you know, being, and, uh, it's put us, you know, at least in our own minds as the, I mean, clear best choice for that first point of contact, uh, against any other choice.

And, and so that's really helped with kind of our own team's mentality towards we're really going after this. And then to the patient, we pair that, you know, offering of, of that diagnostic mu- musculoskeletal ultrasound as b- you know, with primary care PT, and I think it's resonated with patients as well.

Marla: And you also mentioned earlier that you're [00:22:30] focusing on the continuity of care throughout their lifespan and life cycle. What are some changes you've made in order to do that and, quote-unquote, "maybe not discharge them and change that perception"?

Rick: Yeah. Yeah. So, you know, we can talk about it all we want, but if, you know, Medicare requires us to do a discharge note and, you know, it, it, the, the momentum is certainly towards discharge.

Um, recently, you know, we've put together, uh, what we're calling an, an annual wellness movement assessment. It's cash pay at this point. Uh, there isn't a code to ch- charge for it, so we're just doing cash pay, and we're piloting that in a number of our clinics where, you know, at the... And we start talking about it earlier in the, you know, in the course of care.

But at discharge, we schedule patients a year out, you know, we want to be able to see you in a, in a year and, and check in with you, and this is the, the movement analysis that we'll be doing with you, and this is going to help you continue to maintain movement health throughout your life. And, um, you know, this is the, that, that's an example of one thing we're doing to try and create that, that longitudinal care.

And then the trick is, and this is all new, so we don't have any data on it yet, but we're going to be measuring, you know, what percentage of our patients do we see on an annual basis. And, um, hopefully we'll see that [00:24:00] percentage increase, and that would suggest to us that we have more of a, a lifelong partnership with our patients.

Marla: That's great. That's great. And Sam, you had said that you started cash-based and then moved into insurance-based. If you can tell us a little bit about, as well, how, how did you end up being able to make this urgent care model or primary care model work in the insurance-based system too?

Sam: Yeah, I mean, it was interesting.

The people that were using the cash were people that had had really positive experience with PT and knew it, and they often had insurance. So we were like, "Well..." And then it was, it was great to bring it under our traditional, um, clinic, Alpine, because at that point, we just had more of that, um, infrastructure to send out referrals, and we had, obviously, Prompt, um, to just coordinate care across, even if I saw somebody that needed pelvic health, um, or our vestibular.

Like, we could then send people in-house underneath the same EMR if we needed that. So that just helped build the infrastructure a little bit more. Um, and I think, um, overall it's, you know, again, it's the technology that really we're seeing that is really, uh, allowing us to step more and more fluidly into this space.

Um, you know, a- another piece of this, right, is, [00:25:30] "Oh, well, we don't have time to check their benefits and how much they owe, and the, the... How do we do that?" And, you know, when someone's in pain, y- they could have the best insurance in the world, they're... I, I've seen it. They're just like, "Here, just take my credit card.

I'll pay cash. Can we just get started?" Like, and- They can do that, right? Like, they don't have to show me their insurance. If they wanna pay me cash, I will take cash. So i- it is, like, trying to just be a little bit flexible, meet the patient where they are, but also, um, get our, our ducks in a row so if someone does have insurance, how does that get, um, cleared beforehand.

If we haven't had the opportunity to ve- to vet their benefits and explain them to them, then we, we have a very candid conversation that says, you know, "This is what our cash rate is. You are responsible for this visit. You will pay before re- you know, upon services received. Are you okay with that?" And, you know, people are like, "Yes."

Especially, especially when you help somebody from not being able to stand up, and within an hour they, they are moving, they can stand, they can sit, they're willing to, like, give you, you know, their first child. So they are so appreciative of the time and what PTs offer. And this is where I'm like, I don't know that PTs understand, like, the power that we have, especially at an acute stage, of impacting someone's pain and their function.

It is, it is awesome. It makes you feel like such a [00:27:00] good PT, for one, and two, it's just like the patient is so grateful. It's that gratitude that you get immediately. So it's, it's kind of this awesome place to work and operate. Um, and you, you have to get your ducks in a row, but also you have to understand, like, if people wanna pay cash, let them.

Like, it's okay, and they're willing to pay your, the value of what you're giving them, so.

Marla: That's great. That's perfect. And, and Rick, I know you explained that you started making changes and you have a little bit more of this cash-based wellness visit, but you're also doing things differently in the clinic.

How does that work at an enterprise for financial, uh, forecasting and all those different changes in terms of the, the financial metrics of this model? How do you feel that you can explain to the group how that's worked for you?

Rick: Well, I mean, just putting it bluntly, primary care PT is good business. I mean, it's, it, there's, we...

It's, it's not a cost. It, it actually is revenue generating and, uh, more efficient than just this episodic care than, you know, that we've done in the past. Um, you know, as I mentioned, uh, being the first trusted point of contact for a patient means we need to be first. We actually need to be available. We need to be quick.

That's not something that y- historically we've really put a lot of emphasis on. Uh, uh, I [00:28:30] mean, maybe even the opposite. There's, I

Mike: think- The wait list isn't a bragging point in your offices.

Rick: What's that? That's what I was just gonna say. I was just gonna say that, you know, historically, I think there was maybe a badge of honor in saying, "Oh, I've got a two-week waiting list."

And now we're saying, "No, that's bad care. You know, that's, that's poor quality of care." You know? So, um, you know, we've leaned in a lot to trying to increase that speed to schedule, and surprisingly, I guess not surprisingly, it shouldn't be surprisingly, but for 10 years we've tried to improve our, uh, lead conversion without much, you know, improvement.

And that speed to schedule has, um, has moved the needle, like, four points. And for us to increase, you know, that lead conversion by 4% in the, in these pilot clinics that we're, we're, we've got a model where we're pairing clinics that are more busy with clinics that maybe have some openings, and then we give, uh, um, patients an option where they could cons- maybe schedule more quickly or be seen more quickly, and it's improved our lead conversion in a, in a very meaningful way

Marla: And I, I would say to getting more evals in the door and treating those patients, Sam, this was a great example for you as well.

You know, you say not all of them need an extended care. Sometimes because they're so early they only need one or two visits. It actually [00:30:00] is a little bit more financially viable to see those evals in those clinics and, and be able to get them first and not extend the care out, 'cause as we know reimbursement actually works a little bit better for that.

The primary- Yeah ... eval.

Sam: Y- yeah, I think that, um... And again, we have landed on walk-in, uh, urgent care, both of those terms, but we do see a high use of people that did their Spartan race and they're- they wanna come in and get some dry needling. They have- they've traveled and their neck is tight. And the- or people that are nurses and firefighters, their schedules are all over.

They can't schedule on a normal PT clinic. They come in as they need. And so it, it is not just somebody that is in acute pain, but it can be, and it's also somebody that is like maybe has persistent pain that has been a longtime Alpine patient but has a flare-up and can't get into their normal. And we can manage that, get them kind of back on track before they go to the ER or before they go back to their primary care and, and, and get sent through the medical system with delays.

So, um, I think it- a- and then not everybody, again, needs to have a, a standalone ur- ur- walk-in urgent care like we do. We have the two, but it has helped with, um, people understanding where to go and, and having those funnels. But y- you know, it's scary for business owners to see like all this [00:31:30] blank schedule, but it- it's amazing.

It does fill up, right? As you go up, you know, sometimes the night before I'm like, "Oh, I only have four patients tomorrow." And all of a sudden I have a full schedule. Um, but we're seeing a lot higher codes because we're seeing, you know, six evals in a, a seven-hour shift. So those visits are being paid at a higher rate than some of the other codes that we might see across other clinics.

So there's, you know, there's ways. And I would say that, you know, again, back to Rick's point, like you treat somebody when they're in pain or they're in need or you give them the flexibility to get in, they're gonna be so grateful and they're loyal customers. They're gonna come back, you know? And that's good business and good care.

Marla: Yeah. And Rick, you mentioned a little bit that you guys are doing the PT, PTA pod, is that correct?

Rick: You know, we've got a, uh, we've got a few clinics that are doing that, and it's something that we're interested in, uh, in exploring further. Y- um, you know, theoretically, if you've got a PT that's supervising, the Practice Act allows for su- supervising, you know, a, a few extenders, PT assistants Um, per- perhaps techs.

You know, I know, Sam, that- that's off limits in Montana. Um- The techs, yeah ... Idaho and Utah, you know, we can use techs. Uh, and the PT really plays a leadership role. That doesn't mean they're doing evals all day long, but, you know, they're d- they're doing [00:33:00] evals. They're also training their, their, uh, assistants and their techs, and they're, they're overseeing the overall model.

I, I think there's a lot of potential there to be able to actually care for more patients at a higher level of care. Um, you know, at, at the end of the day, we've got a primary care shortage, and we need to come up with ways where we can serve more people at a, the highest quality of care possible and, and, um, you know, help solve that problem.

Marla: That's great. And what are the metrics or outcomes or anything that you're looking to see that this is successful, that it's working for you, that, you know, you're, you're getting the patients in quicker, faster? And Sam or Rick, please feel free to take this, but what are you tracking to say, "Yes, this is working, and, and we're making a difference here for the patients and, and providers"?

Rick: The, for, for me, the, the two that we're trying to look at are speed to schedule, because that really makes a difference on being able, you know, that, that first point of contact, and then the, you know, what percentage of our patients are seen annually. And, uh, that will satisfy that other half of the definition of being a lifelong partner.

Sam: Yeah, and I think similar, like in our walk-in clinics looking at like a good eyeball from week to week is just like how many, [00:34:30] um, evals per, per shift are we seeing or, you know, per week in those clinics. Um, somet- we're looking at conversion, um, of how many do tend to, you know, what are we getting out of the, the walk-in on average?

Is it two follow-up visits or is it four? You know, depending and looking at that cycle there. Um, and then do they stay in basically Alpine once they've been in the walk-in? Do they come back and find us when they need us for, for post-op or, or whatever they might be, so. Great

Mike: As you both are speaking, um, curious, is there an application for telehealth here in this model?

Like, telehealth in 2020 was, like, skyrocketed. Now in Prompt, I, I mean, it has to be sub a quarter of a percent. But I keep hearing success stories-

Rick: Yeah, Sam, go ahead. I've, I've got some thoughts as well, but go ahead.

Sam: Yeah, I just think it's another point of access, you know? And I think that we have to be more accessible.

We have to really sh- question our old ways. I feel like we have for 20 years been billing the exact same way, treating the exact same way, and everything around us, including payment, has really shifted. And, um, you know, y- the, the doctors are no longer doing vitals or taking blood. They have ... They, they have the right person [00:36:00] doing the, the right job for the person in front, for that patient, right?

And that's where to, to, to Rick's point is, you know, is there a more appropriate patient for that person to see if it's a simple ankle versus a complex spine? Um, and making sure that we're matching our providers with the patient's needs and the patient's kinda level of, of complexity. Um, I don't ... I think I got d- off track of your question, Mike.

Sorry. Okay.

Mike: Good information.

Rick: No, I, I totally agree. I think tech can play a, a very important role in primary care PT. Um, whether it's telehealth or whether it's, you know, some other type of a digital care application, I think there's a place for that. If what we're talking about is being first and having a, a lifelong relationship, you know, um, at scale, y- I think you need to lean into tech to really help the patient, and there's so many amazing things happening with AI.

Um, just yesterday, um, my, my CFO and, uh, COO shared with me some, some things that they're ... You know, we've got essentially a ChatGPT overlaid over all of our data, and it's, it's a, like, mind-blowing the kind of stuff that can be done now. And being able to follow up with patients using, you [00:37:30] know, AI and, uh, I think there's, I think there's a real role for that moving forward.

Sam: And to that point too, in primary care medical, um, physicians get paid more if there is a complex patient. So if there are comorbidity, um, ICD-10 codes, then they're getting paid more. And it would be interesting if, if PT could step into that role and when someone comes in, um, and we track their other ICD-10 codes, it's very visible that that's a complex patient.

And maybe if we start to manage some of the data, um, instead of having the insurance companies have all the data, then we have more of a, a, a force to go and, and get paid what we are, are deserved. Um, and I think, like, when I, I presented to the Montana Medical Association Physicians of Montana, and they were just like, "Where can we find PTs?

We don't want to see pain and movement. We wish they could just go to you first." And I have these people, and I only have eight minutes to do a neuro screen. I would love to just make sure that that person gets to a PT right away before they spend, you know, $3,000 on an MRI. And I was like, you got to make network.

You got to make connections. But maybe in the future there will be an opportunity for, um, tech to connect us with our primary care cohorts, um, to create a better landscape on that, at that front too. Um, I also think eventually if we can even have [00:39:00] referrals that go straight to the patient that's not just for, um, an- back to the, to their MD or onto, to imaging, but what if we also sent them a referral to, you know, I want you to go to this Pilates studio and it has Alpine PT on there, then we're just creating a better marketing with a, a huge group of movement, um, specialists within our community.

And like, I know you want to do Pilates, but I think maybe this particular class would be better. Why don't you go to this place? You know, where we can kind of help direct nutritionists. Um, and then, you know, those people in the community are seeing referrals from PT, and I think that helps brand us too as, as an entry point and the person on the primary care that's managing and quarterbacking all of, uh, the movement pain, h- uh, health around our patients in our community.

Marla: And Mike, I want to punt it over to you because I know we've done so much technology-wise to really help with this movement, um, from RTM to authorizations to just making access easier. So would love to hear your perspective on that as well

Mike: Yeah. I mean, we're trying to make it easier for patients obviously to do business, but for clinics to do business with other parties.

Um, and a lot of that has to do with interoperability, like API access. Um, yeah, we have, we have a lot rolling out [00:40:30] there to make our system more connected to the broader ecosystem, not just having people in ours.

Marla: Yep. Yep. And the outcomes that we've fully embedded in and the auth- AI bots for authorization, I think that's gonna make it a lot easier, Sam, something that you, uh, absolutely like you said, those people that come in.

Um, but Rick and Sam, I wanna put it back to you two. What piece of technology do you feel like has really helped make this model or is valuable in keeping this going and extending it?

Rick: I, you know, I, I think probably the m- the, and this isn't even directly related, but it's created bandwidth, is just the ambient listening.

Uh, y- you know, our, our therapists can do their documentation so much easier now. Uh, I remember, uh, it was a, a therapist about a, a couple years younger than me, an old guy. Uh, one, uh, about a month after we, uh, started with Prompt, he sent me a screenshot of his timer on his phone, and it was like four minutes and change.

And he says, "This is how long it took me to do an evaluation." And that's huge. Before, there's no way we could have been able to roll this out because our therapists just didn't have the bandwidth to think about one more thing. But because you've unloaded them with the, with, you know, the, the ease [00:42:00] and accuracy of the software, the documentation, they've got capacity, and they're interested, and they're not burnt out.

And, you know, they're, they're, they're excited about blazing new trails. I think that's been the biggest thing, honestly.

Sam: I, I absolutely agree. Like, um, there was no way I could do six evals and, and still, like... I mean, I did them, of course, but it was exhausting. And, uh, that was when I was working five days a week in the, in the walk-in.

And, you know, once we got scribed, my kids are like, "Are you not seeing patients anymore?" Like, it was very- ... 'cause I wasn't home, like, doing the charts and all the things. And it is, it's been a game changer. And I- it is interesting, we asked at our Montana summit a, a couple weeks ago, like, how many people, uh, you know, feel like three evals in one eight-hour shift is too many, and, and about half the room raised their hand, and we need to shift that.

Like, we need to, like, as a doctorate of PT, our education is, is to evaluate, to, to use the full breadth of amazing knowledge that we've, we've been given to help our patients really navigate the, the care they need. And then from there, you know, lean in on a team. And if you don't have a team, like, build that team and, and, and make sure that they fit right next to you, like somebody that you would trust with your rope, you know?

And, um, in Montana, [00:43:30] yes, we do- do not have any licensed techs or aides, and that has been pretty good when we go and talk to insurance companies. We say y- you're only gonna get a licensed, you know, healthcare professional. But we have a huge deficit in PTAs, um, uh, when you look at the workforce. So, you know, there is, uh, there's some challenges out there being able to, to do the evals and then also provide the care.

Marla: And I know there's a lot of questions coming in, um, some of them around legislative, some of them around, you know, advocacy and so forth. And Sam, you have just really done a ton with, uh, being able to advocate and make some wins and gains. Can you share some of those and what you recommend other people doing as well?

Sam: Yeah, absolutely. Um, in Montana, we are recognized by the work comp as treating physicians, which is great. Um, and so anybody that gets injured at work can come directly to PT now. Um, and through that process, just really educating legislators of what we do, what does our education of, um, prepare us to do, and, and just talking to them.

Most people have gone, most legislators and lawmakers have gone to PT, and they've had positive experiences, and it's really hard to argue. There's, like, not side effects. There's not addictions with PT. It's, it, we're a great group to educate and, and make friends and, and let people know where we fit on the [00:45:00] healthcare spectrum and how we can help their, their cons- constituents.

So it's a lot of education and just boiling it down to simple. Like, you know, I, I think a lot of people have seen this. I got it from Mike Hornsfield. But, like, if you're, if you're an MD, if you're sick, you go to the MD. If you hurt, you go to the PT. Like, you know, and that's pretty simplified, but just really trying to, to create good messaging to lawmakers and to payers and to, um, other healthcare providers of where we fit in and what our specialty is.

So yeah, just I always say this. Patient, uh, advocacy is the best top-level, um, patient care you can do, so.

Mike: Sam, when you're with a legislative person, how do you describe PT to them? Like

Sam: Um, I, I describe them that I, I'm, I'm the person that people come and see, and I hear what's going on with them based on their story and their presentations.

I look at their movement, and ultimately really try to find out what is giving them their, their symptoms, educate them, give them agency, give them active exercises to do, give them some input, whether that's through needling or manual therapy, and then I s- I get them on a plan. And, and that plan may be, like, consistent or maybe it's, maybe it's referring if it's, it's sinister or something else.

But I'm giving them a plan and expectations and helping them reduce their total cost care, um, and kinda just talk them through. Like, I'm the quarterback of someone that is [00:46:30] not able to move and is, is experiencing pain or questions, and that lands pretty, pretty heavily to anybody that has experienced the healthcare system.

We all have been there. Like, "Do I really wanna go get that test? It sounds expensive. I have to wait three weeks." Like, it's great to have somebody to answer, help answer those questions

Marla: Well, like I said, we've got a ton of questions coming in. Okay. Oh my goodness, 30. So I'm gonna go through some of these.

Before we do that, I've also seen a lot of people in the chat ask about Sam's info, Rick's info. So we are gonna put a quick poll up, and it's gonna say if you're interested in learning more about Prompt, about, um, Sidekick, about Sam and Alpine, about Rick and Mountainland, and then we will give your information over to those different resources so that they can reach out to you if you're interested in learning more.

Um, so with that, I'm gonna go into a bunch of questions. Uh, they're all across the board, and I'll start with, um, so da, da, da, da. R- Rick, how do you marry cash-based practice and insurance-based practice in the same practice?

Rick: Most of our practice is, is insurance. I mean, far and above it's insurance. So, um, as far as the cash-based practice is concerned, that's, uh, we, we just inform the patient that this [00:48:00] is m- this is a service that's not covered by your insurance. We charge X amount for it, and it's available to you and you just pay at the time of service.

Marla: And like you said, you're generally scheduling them for that wellness visit after they've had this amazing experience and they've completed their plan of care so they're actually, you're communicating to that upon that

Rick: time. Uh, yeah, absolutely. And when you put it in the context of, you know, this is once a year, it's not very much.

Marla: Great. Um, and Sam, for you, can you tell us how you've marketed this to patients and the community?

Sam: I mean, a lot of it is just word of mouth hon- honestly. Like, it's so crazy when, again, you help someone acutely, they're gonna tell everybody about the model. Um, but we have had some strategic placements of just, like, messaging to urgent cares, 'cause they're often staffed with PAs, and just, you know, asking them like, "Do you wanna treat pain?"

And they're like, "I don't know. Like, people come in. I, I w- love to send them right over." So making relationships with those urgent care clinics, um, where people might still traditionally be going to the medical urgent care. Um, and then, you know, just again being like a voice in the community, and we are very involved with, you know, um, different pr- like educational outreaches and sport [00:49:30] outreaches and just promoting that, that people can have access to us quickly so that when they think, "Who can I get into quick?"

They think Alpine.

Marla: Great. And then, uh, we've got a couple questions about staffing, that being understaffed is a real issue. How do you address staffing? And I'd love to know, I mean, this to me is almost talking about why clinicians love these models, um, and if you can answer on that in terms of staffing and how you're able to get people to love doing this type of a model.

Rick: Go ahead, Sam

Sam: Um, we rotate. Um, we- some of our more experienced PTs and/or ones that we have mentored specifically in the walk-in, they love it. It's, it's can be busy, and sometimes it can be slow, but it, it's, it's stimulating. Um, you get a little bit more, um, mentorship around that. Um, and then, you know, it has been a great place to also, if we do have some- a PT that calls in sick and those patients still need to get in, we have a little bit of some- a buffer to put those folks over on the walk-in schedule.

And then if I have a new PT maybe that is having a complex patient, we co-treat through the walk-in. So I might say, "Well, send that person over on my schedule. I'll see them for a visit and see what I see, and then I can, you know, help that new grad, like, understand from my perspective what I- I'm seeing with that complex patient."

So I think our, our, our staff is appreciative of [00:51:00] it. And again, I think PTs really wanna help people. Bottom line, we all went into this profession to help people, and so I think it is, like, there's no better way to say, like, "I can... I'm here when you're, when you're most time and most need." That is pretty powerful help, so I think it's, it's an easy fit for ours.

Marla: Great.

Rick: Yeah.

Marla: And then... Oh, go ahead.

Rick: I was just gonna say, staffing is challenging everywhere, you know? Montana's not the easiest place to recruit to. Uh, and you know, I've, uh, downtown Salt Lake City these days is, is challenging with the cost of living, so it's, it's a challenge. And this is really where it comes down to...

A- and to Sam's point, I think, I mean, we all wanna help as many patients as possible, but we wanna make sure we're actually helping them. We, we don't want it to ever cross over to a spot where it's that mill. That would, that's terrible. That's, you know, that, uh, that would be futile. Um, so it's, it's a matter of trying to find efficiencies.

I think Prompt has done a great job in helping with that. Uh, I think there's probably more efficiencies to be found in, in the, the way you structure it. I, you know, I m- we discussed briefly about the PT pod model. That might help with being able to serve more. Um, but it's, yeah, it's finding efficiencies so that our therapists are able to do what they really want to do, which is care for [00:52:30] patients

Marla: I think you n- hit the nail on the head with that is that sometimes PTs get bogged down in just the, the cycle of just doing the same thing every day and not treating at the top of their education and license and doing a lot of that follow-up.

Right. Where this truly allows them to be that doctor, use all their skills in all the different areas, um, and not just be on, on the wheel, the cog, right?

Rick: Yeah. I mean, burnout happens when you feel like your efforts are futile. You know, if, i- heck, I can work day and night if I feel like I'm really making a difference.

Yes, and that's, I think that's really where we need to focus our energy is making sure that our- Yeah ... what we're doing is truly making a difference for the patient that's in front of us and for the health, the broader healthcare system

Marla: And we are gonna put that survey out one more time, 'cause a lot of people said they couldn't click more than one thing, and it- I bet they wanna put multiple people on here.

So go ahead, you can now click multiple options for those that put that in the chat. Um, and as you're doing that, I'll keep going with questions. So another great question is just about what education or what programs have you been using for your clinicians to help train them up to this type of care and this type of primary care PT?

Sam: I'll let you lead out

Rick: again, Sam.

Sam: You're great at that Well, I think we've done two different models, so it'll be good. I, [00:54:00] we have done an in-house mentorship program, um, especially around the walk-in. Um, we also have just an onboarding walk-in mentorship or a overall mentorship program. But I will share, I think, at the end of this for show notes, um, there is a self-identifier that the primary care, um, PT SIG has put out that really will help your team understand where the gaps in their knowledge is, or just even their experience where they haven't, like, really practiced a lot.

And I would encourage folks to download that and take themselves through that because it will really help you understand what you're doing, um, as defined by primary care, and where you can seek out some more, um, educational opportunities to upskill in those areas. 'Cause we're all doing a certain level of this, and I think it's really important to understand where you, you can invest to make it, um, a full circle of what you're truly doing as primary care.

Correct.

Rick: So I, I'm gonna just throw a quick endorsement on, on those self i- uh, uh, uh, identifiers that Sam's talking about. She shared those with me. I think it's great. I mean, it... And again, we're building this plane as it flies in the air, and, you know, what is primary care? Uh, y- you know, are we prepared to do primary care when we graduate from school?

I think to some extent, y- yeah, we, we receive an education in school that qualifies us to be a primary care physical [00:55:30] therapist. Now, are we done learning? Of course not. You know, I mentioned that we've, you know, leaned into the diagnostic ultrasound. A number of our therapists have attended Katie Albright's, uh, courses.

Um, but it's, it's really kind of wrapping our head around what does it mean to be a primary care PT, and then where are the gaps? And, and then just focusing in on maybe where those gaps are, and that can be, you know, across the entire organization or it can be individual.

Marla: And I believe, I know we've got Katie Albright in the chat here, so if you wanna put some resources in there, we'd love that, 'cause really has done a lot of work to help educate clinicians, clinic owners, and all of the above on primary care PT.

And if we get more educated, the mentors are also what help the new grads coming out, is if you're practicing that way and your clinic's doing it, that's, that's the best training you get. So definitely the more people we can train up, the more it's gonna end up going down the system Uh, all right, let's see.

We've got a couple more. Rick, you mentioned the ultrasound diagnostic. Um, does this mean you're looking at images, and have you heard of Butterfly? I think some people don't know exactly what that is, so it'd be great to hear more about that.

Rick: I don't know what Butterfly is, but i- if that's common, you know, p- the fact that I don't know shouldn't reflect on Mountain Land.

I, um, but, uh, yeah. Yeah, I mean, our therapists, uh, it's a, it's a [00:57:00] really extensive training. The, the first 150 studies that they do get read by a certified, uh, you know, an individual that's certified in diagnostic ultrasound. It's, um, it is much heavier, like, like I mentioned, much heavier lift than I thought it was gonna be, and the same as with the therapist.

The... I haven't talked to a single therapist that's done this that has said, "Oh yeah, it's easy." They all say it's a lot. But yeah, they read images. They're, they're, uh, trained just like any physician.

Marla: Perfect. And then Sam, this one I'll punt to you. Are you advertising this model to MDs, PAs, NPs in town to educate them on this quick access to care, or just the general community?

Sam: All of it, yes. And, um, again, my roots are pain science. I love... Like, this is why I like complex spine, so I've been a pain science educator. And interestingly enough, I have presented to the Montana Physician Assistance Association, to the Montana Medical Association Physicians, and then also to the State Fund Workers' Compensation Medical Systems.

And, like, to promote PT, obviously, and PT first, but through that and through education, I have gotten a lot of, um, interest and referrals and wanting to partner and those kind of things because of the access point. Especially with work comp and we just positioning ourselves as that first contact with the work comp system.

[00:58:30] But I would just encourage people, we educate all day long, like, go out and talk about what we do to, like, local groups. It's really powerful. And, and mentioning, talking about this new model in that aspect of how it plays a role in pain science is something that feels a little bit more within our wheelhouse and not so market-y.

Um, and so I would, I would layer that in as well.

Marla: Great. And then we got a question about how well does AI in prompt prescribing notes work in a room full of other people if you have the open concept gym?

Rick: It's great

Sam: Yeah. I haven't had any problems with it. Um- You

Mike: guys use lapels?

Sam: No

Rick: Uh, I don't think so

Mike: No, just a computer.

Sam: Mm-hmm. At times, I will- have used either an iPhone or a, um, laptop to... or a iPad.

Mike: It works quite well with sometimes having the phone and/or, um, you can buy, like, these $20 on Amazon microphones-

Marla: Mm-hmm ...

Mike: and it, it can help cut through some of the background.

Marla: Awesome. Well, we've had so many more questions. We will try to get through these later through emails.

Thank you, guys, for all of your engagement. Um, Sam and Rick, I just wanna s- give my sincere thanks for both of you joining us today and for sharing what you're doing and helping move our profession forward. Um, and Mike, absolutely, if you have any closing thoughts and messages as well, I wanna give the floor to you.

Mike: I have one more question, actually. Um- [01:00:00] Okay ... sitting on this, I, like, I get the benefit to the patient. I get the benefit to the community. I'm curious your guys' thoughts on the downstream implications of PTs being, being more in that primary care lens, whether it's with payers, you know, legislatively. Just curious.

Rick: I, I think it's pretty clear. I mean, it's, it's defined that if you get a P- a patient enters the musculoskeletal maze through a PT, it saves money. I mean, that's the, that's the bottom line. We actually, i- in a, in a recent negotiation with a payer, they said it. They, they said... You know, they... We looked at our data, and it's clear that when our, our members start with a physical therapist, it saves us money on, uh, on downstream musculoskeletal costs, and this was a major payer.

Sam: I, I also say, like, it's really important if you guys are thinking to go to your state chapters and get designated as a primary care provider in your statutes because then you won't have the co-pays of a specialist. A specialist is a rheumatologist. A specialist is, like, a dermatologist. It is not a PT where the patient then has to pay $75 a co-pay twice a week or something.

That's ridiculous. We need to be primary care providers, and that co-pay then is $10. And that is also improving access. Um, also, if you look at the [01:01:30] ACA, we state lev- uh, federally will never be able to do anything preventatively when we look at the federal payers until we're recognized as a primary care provider.

Those are who can do prevention. So when we wanna get the end game in 10 years where we are at, we're following Rick's lead here and having payers, including Medicaid and Medicare, pay for PT preventatively for annual visits, we have to get the states rolling to move that primary care status forward.

That's where we're gonna really change the system and be recognized as part of that primary care landscape

Marla: Yeah, you're, you're so right, and we really have an opportunity to change the perception of the community right now and become that front door. And if we all start communicating our values and services differently, then we will benefit each other, and most of all, we'll benefit our patients.

So thank you, guys. I really appreciate this. It's been fantastic. Um, again, we will share the recording. We'll follow up with resources afterwards, and hopefully everybody walks away just thinking a little differently and communicating their services a little differently as well. Thank you.

Sam: Thank you. Thank you.

Mike: Appreciate you guys. Bye.

‍