“Mental/behavioral health seems to have been deemed “selective” rather than a “necessary” service. Part of this is probably due to the fact that we didn’t really have much knowledge about mental health until the past couple of decades. I mean, they didn’t really know what PTSD was until around the Vietnam war in the 60s. As such, we’re just now beginning to truly understand the interplay between the mind and healthcare”
As a part of my interview series with leaders in healthcare, I had the pleasure to interview Rafael Salazar, Founder of Rehab U Practice Solutions. A licensed Occupational Therapist practicing in the State of Georgia, Rafael is a graduate of the Augusta University (formerly MCG) Department of Occupational Therapy class of 2012. Rafael has worked in a variety of settings focusing on the adult population to include skilled nursing, long term care, subacute rehabilitation, acute care, and outpatient specialty care.
Rafael has served on the Georgia State Board of Occupational Therapy as a Licensed board member and has taught as an adjunct faculty instructor at Augusta University in the Graduate OT Program. Rafael previously served at his local VA Hospital in the outpatient specialty clinic as clinic lead and treated patients from specialty services such as orthopedics, plastic surgery, neurology, rheumatology, emergency care, and primary care. He also coordinated clinical education for his OT department. After leaving the VA, he embarked on a journey as a clinical consultant, assisting Georgia Department of Behavioral health & Developmental Disabilities (DBHDD) in transitioning individuals from state-run institutions into community residences.
In that time, he also founded Rehab U Practice Solutions, a training and advisory firm that helps clinics and healthcare organizations improve patient engagement and experience. He has been active and involved as a leader in the profession, being asked to volunteer as a subject matter expert with the National Board for Certification in Occupational Therapy (NBCOT) for item development and enhancement for the national certification examination, as well as being appointed to the Clinical Simulation Committee for NBCOT. In August of 2018, Rafael was elected to the Board of Directors for NBCOT.
Thank you so much for doing this with us! Can you tell us a story about what brought you to this specific career path?
Sure. My story begins the summer before my senior year in high school, when an accident landed me in emergency surgery and then in an outpatient hand-therapy clinic 2 days a week for 3 months. In that time, I was exposed to the world of OT/PT and physical rehabilitation. After that experience, I set my sights on a career in Occupational Therapy, to one day work in a hand clinic. Graduating from graduate school with a degree in Occupational Therapy, I started out on my journey as a rehab practitioner.
After several years as lead clinician in an outpatient specialty clinic, I left the VA to begin consulting with the State of Georgia, assisting in transitioning individuals from State-run institutions to community residences; a position that allowed me to leverage my clinical knowledge & expertise as well as an ability to effectively communicate, educate, and train people in order to ensure that the individuals transitioning from these institutions received the highest quality care and support possible.
Through all of these experiences, I became aware of one glaring issue: the healthcare system in the US is broken. Regulations abound. The way therapists provide services and do business is broken. Therapists are getting burned out, trying to hit productivity numbers and pumping patients through their clinics like a factory assembly line. Patients feel that the services they receive are cookie-cutter and sub-par at best. Neither therapists nor patients are achieving the outcomes they desire. I knew something had to change, and that’s why I started Rehab U Practice Solutions.
Can you share the most interesting story that happened to you since you began leading your company?
I think one of the first clients I worked with was the most interesting and eye-opening so far. I was working with a private therapy practice that had gone from two locations to one, had experienced some highs and lows. They were in a position where they were desperate for growth and for new business. This led them to make some poor positioning decisions that really didn’t do much to bring in new referrals, but watered down their perceived specialization in the local market. The owner had been in business for many years — decades really. Working with them to refocus their positioning and develop a new strategy for growing their clinic in the areas they wanted to grow, while shedding business and patients they didn’t want to work with was a great learning process for both the clinic and myself.
Can you share a story about the funniest mistake you made when you were first starting? Can you tell us what lesson you learned from that?
Well, It may not be funny to some, but when I was first starting — building my website and developing resources and content — I put together a soft “launch” campaign. I paid for some facebook ads and developed a few free resources to give out to prospective clients. Well, a day or two goes by and I get an email from what I think is a potential client. I eagerly open up the email and read “I just want you to know, you misspelled ‘solutions’ on your website header”. You want to talk about taking the air out of your bubble, I was disappointed to say the least. Let’s just say, I learned to proofread and show things to other people before making anything go live.
What do you think makes your company stand out? Can you share a story?
I think Rehab U Practice Solutions stands out because we’re not just a run-of-the-mill physical therapy “marketing” agency. Those seem to have sprung up like weeds in the last several years. Rehab U stands out because the whole “marketing” aspect of what we do is but a byproduct of helping our clients structure their clinics and business processes to improve the patient’s experience and outcomes. Since we start our process by focusing on the patient, we are able to affect real change to their experience and outcomes, not just coming up with a good logo or mission statement that really doesn’t do much to actually improve care.
What advice would you give to other healthcare leaders to help their team to thrive?
I say this a lot, but healthcare is really about one thing: the patient. Every decision we make as healthcare leaders needs to be centered around the patient; their experience, their engagement, their preferences, and their values. John Bogle writes in his book Enough that “the human concerns of the caregiver and the human needs of the patient have been overwhelmed by the financial interests of commerce.” How true is that? Healthcare clinics and organizations seem to focus more on metrics and KPIs rather than the people delivering and receiving their services. Any decision we make that moves us closer to that and farther away from metrics and numbers is a good starting point.
Ok, thank you for that. Let’s jump to the main focus of our interview. According to this study cited by Newsweek, the US healthcare system is ranked as the worst among high income nations. This seems shocking. Can you share with us 3–5 reasons why you think the US is ranked so poorly?
I hate trying to give definitive and simple answers to questions like this because it is a very complicated situation. Here are a few thoughts that I have about it. When we look at healthcare systems, we need to distinguish between cost and outcomes. The two are different, but when we have discussions (or arguments) there seems to be disregard for how one affects the other. When people tend to begin disparaging the US healthcare system, it is usually on the basis of cost and “access equality”. Example, in the study cited above, the researchers conclude that the US healthcare system “falls short” with cost and access equality, however when you dig deeper into their data, you see that the US ranks among the highest when it comes to clinical outcomes.
When you look at measures of cost and access equality, the US does rank lower. This is because the US spends far more on healthcare than other developed nations and there is an issue with poorer people in the US being less able to afford certain types of care. However, on the other side of the spectrum, the US ranks higher from everything from cancer survival rates to access and wait for diagnostic studies. For example, the US has many more MRI machines per capita than many other developed nations. This allows people to get MRIs faster, which may lead to earlier diagnosis, treatment, and better outcomes. This is a direct result of the US spending ‑or investing- much more money in healthcare.
Having said that, I believe the discussion around healthcare needs to be less about which system is “better”, but what type of system will provide the best clinical outcomes, more equitably, for the lowest cost. I would think that one of the biggest reasons that the costs of healthcare have risen in the US is a combination of government regulations combined with influence of large medical corporations and insurance companies guiding/directing those regulations. Take the Affordable Care Act as an example: essentially that law subsidized health insurance companies, guaranteeing them a profit, while making it pretty much illegal for citizens not to be customers of those same companies. When you have that level of corruption, where health insurance companies are writing or heavily influencing the laws that govern them, it’s no wonder that costs to the consumer will rise without any real benefit. The same can be true for the FDA, which in an effort to safeguard the public, places advanced regulatory burdens on companies to develop new drugs and treatments.
Like I said, it’s a hugely complicated issue that can’t be reduced to “this country has a better system than that one.” We need to have a clear discussion about what areas certain systems perform better in. Are we looking at cost, outcomes, access, access equality, or even patient satisfaction? There are so many aspects of healthcare delivery that we can’t simply reduce it to “better” or “worse”.
You are a “healthcare insider”. If you had the power to make a change, can you share 5 changes that need to be made to improve the overall US healthcare system? Please share a story or example for each.
Since my work really centers on patient experience, engagement, and outcomes, my 5 changes may be different than a public health official’s or an academic’s. Nevertheless, here are the 5 major changes I would implement in healthcare organizations, clinics, and wellness centers:
1) Change from time-based productivity measures to service-based or value-based measures. Because of the way reimbursement and payment is handled in the US, healthcare organizations and clinics focus on time-based productivity metrics. This is because clinicians get paid for the time they spent with patients, rather than being paid for the treatment itself. I wrote a piece about this issue here. What this leads to is patients receiving more treatment than necessary, and therapists being incentivized to work more slowly to deliver minimally acceptable quality. By focusing on measuring value, outcomes, or effectiveness of treatment — and using that to determine payment — healthcare organizations will be incentivized to deliver the most appropriate and effective treatment in the most efficient manner. This is already starting to happen, with Medicare moving towards Merit-based Incentive Payment Systems (MIPs).
2) Use technology to augment or improve human connection rather than using it simply for efficiency. When I was leading an outpatient rehab clinic at a VA hospital, management decided that they would implement a kiosk system in each clinic. Veterans in the waiting area could use the kiosk to schedule/cancel appointments, update contact info, see/pay any outstanding balances, and check-in to their appointments. On the surface, this sounded like a great idea. However, when it came time to implement the program, management also decided that the kiosks would replace clerical staff in these clinics. They took a useful and effective technology, and made it impersonal, confusing to operate, and largely ineffective during actual use. They could have made the program much more successful by providing the kiosks and using them to augment the user’s experience. A veteran could have walked into the clinic, and a friendly clerk or receptionist could have helped the veteran check-in to the appointment and then be there to provide any assistance working or navigating the kiosk menus. Instead, veterans were met with no human contact, and a machine that they didn’t know how to use to check-in to their appointment. So when implementing technology in healthcare delivery, we need to always keep in mind the human experience that will be on the other end of that technology.
3) Design the process of care to allow human connection and relationship. Again, healthcare is about people: patients and providers. It’s about a human person skilled in delivering treatment, serving and healing another person, who is on a unique journey to recovery. So how do you take this into account when designing the process of care? By focusing on the patient and the patient’s experience/outcomes rather than financial numbers and metrics.This may be as simple as allowing clinicians extra administrative time to spend reviewing medical records or even something as simple (and less costly) as training receptionists and office staff how to make the most out of a patient phone call. Are we simply using a phone call to gather the data necessary to check the boxes on an assessment form, or are we using that call as an opportunity to hear/listen to that patient’s story. Are we using that call to let the patient know that we care about them as an individual and not just how much their insurance company will pay? How we gather data is arguably as important -if not more important- than the data we actually gather on these phone calls.
4) Convince and show staff/clinicians that their jobs are part of the higher purpose of the organization. An example of this would be to craft some higher purpose statement for your healthcare clinic or organization to the effect of: “We help people with chronic back pain overcome disability and live the life they want” instead of “You work as a therapist in a back-pain clinic”. This is very much a change that comes from the executive leadership team of that clinic or organization. If the CEO is on a mission to help people live the life they want, that filters its way down to the front-line staff and clinicians. Organizational leaders should make it their priority to not only effectively communicate the organization’s higher purpose, but to make leadership decisions that prioritize it.
5) Change the way your messaging so your clients and prospective clients understand and buy in to your organization’s higher purpose. This improves patient engagement, experience, and even clinical outcomes. As with the example above, this starts with the executive leadership of the organization. Patients that know and understand an organization’s higher purpose will buy-in to treatment, become more active participants, and potentially achieve greater outcomes than patients who are simply going to therapy twice a week and doing exercises for their shoulder, as an example.
Ok, its very nice to suggest changes, but what concrete steps would have to be done to actually manifest these changes? What can a) individuals, b) corporations, c) communities and d) leaders do to help?
Again, individuals, organizations, and leaders should spend time focusing on the people they serve and the higher purpose of their organization. Then, keeping those two things in mind, they need to make decisions that reflect that purpose and improve care for those patients. As mentioned above, this could be something a simple as changing the way phone calls are handled at the front desk all the way to changes to the actual process of care. The important thing to keep in mind is that, as healthcare providers, we are in this field for more than the money. We are in the field to serve people, so we need to make sure our personal and organizations decisions reflect that. As an individual clinician, this would mean not sacrificing that conviction during the daily routine of treating patients. For patients, this would mean only going to clinics and providers that treat you like a person and not a number. For leaders and executives, this would mean making changes to processes and strategy that focus on delivering real, human care that prioritizes people and relationships over profit.
As a mental health professional, myself, I’m particularly interested in the interplay between the general healthcare system and the mental health system. Right now, we have two parallel tracks mental/behavioral health and general health. What are your thoughts about this status quo? What would you suggest to improve this?
This is a problem I am pretty familiar with. When I first branched into consulting, I contracted with a management consulting firm as a clinical expert helping a State Department of Behavioral Health and Developmental Disabilities transition individuals out of state hospitals and support them in the community. The largest obstacle with this project was just that, that mental/behavioral health seems to have been deemed “selective” rather than a “necessary” service. Part of this is probably due to the fact that we didn’t really have much knowledge about mental health until the past couple of decades. I mean, they didn’t really know what PTSD was until around the Vietnam war in the 60s. As such, we’re just now beginning to truly understand the interplay between the mind and healthcare. In fact, recent research and studies have begun showing the link between behavioral and cognitive factors and chronic pain. So, overall, I think we’ll see this improve over the next several years.
To improve this, I always recommend that healthcare organizations and providers begin to learn about the biopsychosocial model of healthcare and begin to implement that knowledge into daily treatments and processes.
How would you define an “excellent healthcare provider”?
I define an excellent healthcare provider (individual) as a clinician who not only understands the interplay between biological, psychological, and social factors in a patient’s overall health; but also uses that knowledge to inform practice. These are the clinicians that become sought after by patients for their ability to make a real human connection and deliver improved clinical outcomes.
Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?
My favorite life lesson quote comes from The Alchemist, where the narrator tells the story of a boy who travels to the wisest man in the world to discover the meaning of happiness. The wise man tells him he is busy, but the boy is instructed to look around the marvelous palace while making sure not to spill some oil that is placed in a spoon. The boy comes back and the wise man asked the boy what he thought about the gardens, the palace, and the views. The boy replies that he didn’t observe any of that. He was trying not to spill the oil. So, the wise man tells the boy to go back and take all the beauty in. He does just that and returns to the wise man. He tells the wisest of wise men how much he enjoyed the gardens, tapestries, and woodwork in the palace. The wise man then asks the boy what happened to the oil in the spoon. The boy looks down and realizes that he had spilled it all along the way. The wise man responds with this, “The secret of happiness is to see all the marvels of the world, but never forget about the drops of oil on the spoon.”
When I first read this, I immediately fell in love with this quote. Especially as healthcare providers, it is easy to get wrapped up in “doing” healthcare. We complete assessments, write our notes, and implement treatment protocols — all while making sure we’re meeting the set productivity and utilization metrics — without really thinking about why we’re doing it. For us healthcare providers, our patients are the drops of oil in the spoon. So the key to feeling fulfilled in your work as a healthcare provider is to learn as much as you can, implement new treatment methods and advance your career, but never forget about the patients you serve every day.
Are you working on any exciting new projects now? How do you think that will help people?
A couple of business partners and myself are actually working on developing some training material and courses aimed at clinicians and organizations that serve adults with developmental disabilities. The goal of the courses is to improve clinical knowledge of these organizations and providers so that they are better prepared to serve these individuals. We think it’s going to be a great way to help this underserved population. If you’re interested in that project, connect with me on LinkedIn, where I’ll keep folks informed about it.
What are your favorite books, podcasts, or resources that inspire you to be a better healthcare leader? Can you explain why you like them?
I’m a fan of the books Leaders Eat Last, Marketing Rebellion, The Business of Expertise, & Enough. All of those books have had a great impact on the way I approach business, management, and marketing. Each of those authors has a unique view on leadership, business, and marketing but they are all in agreement that human connection and relationships are the the most important thing in business; whether in healthcare or retail.
You are a person of great influence. If you could inspire a movement that would bring the most amount of good to the most amount of people, what would that be? You never know what your idea can trigger. 🙂
I’ve pretty much outlined that movement above, but I want to see a movement spring up among healthcare providers and organizations that place the patient at the center of everything. I envision a world where patients receive top-level care by organizations and providers that are expert-level practitioners that understand the reason they do what they do is the patient sitting in front of them.
How can our readers follow you on social media?
You can follow me personally on LinkedIn or follow Rehab U on Facebook or Twitter.
Thank you so much for these insights! This was so inspiring!
About the Author:
Originally from Israel, Limor Weinstein has been anorexic and bulimic, a “nanny spy” to the rich and famous and a Commander in the Israeli Army. Her personal recovery from an eating disorder led her to commit herself to a life of helping others, and along the way she picked up two Master’s Degrees in Psychology from Columbia University and City College as well as a Post-Graduate Certificate in Eating Disorder Treatment from the Institute for Contemporary Psychotherapy.
Upon settling in New York, Limor quickly became known as the “go to” person for families struggling with mental health issues, in part because her openness about her own mental health challenges paved the way for open exchanges. She understood the difficulties many have in finding the right treatment, as well as the stigma that remains so prevalent towards those who are struggling with mental health issues. She realized that most families are quietly struggling with a problem they’re not comfortable talking about, and that discomfort makes it much less likely that they will get the help they need for their loved ones. She discovered that being open and honest about her own mental health challenges took the fear out of the conversations. Her mission became to research and guide those families to the highest-quality treatment available. Helping others became part of her DNA, as has a commitment to supporting and assisting organizations that perform research and treatment in the mental health arena.
After years of helping families by helping connect them to the right treatment and wellness services, Limor realized that the only way to ensure that they are receiving appropriate, coordinated and evidence-based care would be to stay in control of the entire treatment process. That realization led her to create Bespoke Wellness Partners, which employs over 100 of the best clinicians and wellness providers in New York and provides confidential treatment and wellness services throughout the city. Bespoke has built its reputation on strong relationships, personalized, confidential service and a commitment to ensuring that all clients find the right treatment for their particular issues.
In addition to her role at Bespoke Wellness Partners, Limor is the Co-Chair of the Academy of Eating Disorders. She lives with her husband, three daughters and their dog Rex in Manhattan.
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