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August/September 2001

By C.A. Wolski

Joe Black, PT, SCS, ATC, helps a patient, who had an arthroscopic partial medial meniscectomy, perform reactive eccentrics. The patient is an all-state football player preparing for college this fall.

As physical therapy practices grow, typically they open more locations in an attempt to blanket their territories, but not the Appalachian Therapy Center, Maryville, Tenn. In September 2000, the center consolidated its primary practice into a central 11,000-sq-ft location. "[The consolidation] made us much more efficient," says Joe Black, PT, SCS, ATC, CEO and president, who founded the physical therapy practice in 1981. "There's no confusion for the doctors. If it's physical therapy, occupational therapy, sports care, there's one place to send patients and that's right here. That's what we want." In addition to its main center, Appalachian Therapy maintains three smaller specialty clinics: an industrial clinic, a pediatric clinic, and a general orthopedic center 20 miles away.

The Appalachian Therapy Center's main facility occupies the first floor of its building, and took 4 1/2 years to develop. The result is a facility that uses the treatment and office space in a much more efficient way than its previous location. "Wherever you are, you're never really that far from your patients," Black says.

The practice has not only added more space and specialty locations but more employees as well-eight new staff members have started since March-bringing the total to 51. This is a change from the early days of Appalachian Therapy, says Black. For the first 6 years, the staff totaled three. "We've never really measured our success by the number of employees," he says. Currently, the rehabilitation staff consists of nine physical therapists, six physical therapy assistants, four athletic trainers, and five physical therapy technicians.

Maintaining Quality Care

And though staffing is not the measure of success, it can be seen as a measure of quality. "We have a quality program where we look at everything from [the perspective of] what percentage of injuries we're seeing in the clinic, how many visits it's taking to get those patients well, how much money per case, how much money per diagnosis it is costing-not only what it is costing the patient, but what it is costing us as far as man-hours," says Tracy Martin, PT, ATC, CSCS, Appalachian Therapy's clinical director. "But when we get to the point [where] we're encroaching on the quality of care, that's when we go look for additional staff-we try to get that staff person before we get to that critical point." According to Martin, Appalachian Therapy has about 1,000 patient visits per week.

Quality control is also monitored by patient self-evaluations and questionnaires. If there is a quality complaint from a patient (the center receives approximately three per year that require review), it is brought to Martin's attention, reviewed by a four-person panel at the center, and finally turned over to the board of directors, which is made up of the seven full-time physical therapists, including Black and his two partners. "[The board] assesses the problem, looks into it thoroughly, makes sure the quality of care is there," says Martin. "And if we need to make changes or hire additional staff, we'll go in that direction."

Working for the Community

Customer service and a commitment to the community are a hallmark of Appalachian Therapy's practice. Its new pediatric center illustrates this commitment to its customers instead of just to the bottom line. "We were trying to do pediatrics out of our main office-and really came to a crux-we had to do this better and bigger or we needed to get out of pediatric care," says Black. "Our commitment was really to the service itself and to the people we hired to do that. So we went out and found a nice space in a building that was being renovated-actually our business office was already in that same building-and we put the pediatric clinic there. We opened it on the first of May [2001] and have already added two more professional staff members. Private practices typically don't get into pediatric care. If you make the decision based on business reasons, you don't even think about pediatrics. There's a tremendous amount of indigent care and a tough reimbursement issue. But we can break even on pediatrics and make a living off everything else we do. It's a great service for the community-you're treating disabled kids-and it's needed, and we feel that we do a great job at it."

The center offers a full range of rehabilitation services, including general orthopedics-which makes up about 70% of its patients-pediatrics, occupational therapy, preemployment screenings, wound care, and athletic training. The most popular programs are athletic training and general orthopedics; wound care is the least. Specialized programs include the fall prevention, golf, and aquatics programs. The latter is located off-site, as is the center's industrial clinic, which opened this May and is housed at the local Aluminum Company of America (ALCOA) plant. "It's actually in the factory itself," says Black. "We have a fitness center with it, but it's not just for physical therapy, there's a lot of ergonomics and education programs."

The center competed for the ALCOA contract with one of the largest rehab companies in the nation, which represents about 250,000 employees around the country. "Physical therapy private practice is going full scale," says Black. "You can compete with the big folks. [ALCOA] knew exactly who they were dealing with, they knew the kind of people we were from top to bottom. It was really a people issue. They knew the kind of therapists we were able to attract and retain, and I think that's what got us [the contract]. The company out of the Northeast simply couldn't guarantee that kind of quality personnel."

Sports Focused

New programs are initiated based on two criteria: need and a staff member who is interested in developing it. For instance, Martin developed the center's golf program because many of his patients were golfers who wanted to get back to the links and no other area therapy center was doing a golf program.

The Appalachian Therapy Center's main niche is sports, says Black, who was an athletic trainer at the 1987 Pan-American Games and the 1996 Olympics, which has changed the way he and his team provide therapy. "Our emphasis has shifted somewhat to be a whole lot more on exercise," he says. "If there's really been a paradigm shift here, it's certainly toward an exercise model for helping folks get better. And I have to think that part of that shift goes back to our sports orientation, which benefits everybody from the stroke patient to the back patient to the 75-year-old lady who had a total knee replacement."

However, Black adds, he and his staff have not abandoned traditional hands-on therapy-that is still and will continue to be offered by the practice.

The center's commitment to athletics extends beyond its walls. It trains athletes from six area high schools and nearby Maryville College. "Our standing policy is that any athlete can walk in here any day and get an evaluation by one of our athletic trainers," says Black. "But it has to be one of the schools we have an agreement with."

Because of its high motivation, the center does not need to pursue this customer base. "Athletes will do anything possible to get back as soon as possible," says Martin. "You don't have to motivate the athletes a lot. They're self-motivated. You've got to find a way to motivate the other patients. It comes on an individual basis-it depends on what patients' goals are, what they are trying to get back to, how active they were initially."

Though all treatment is directed by the physical therapists, Black says there is no conflict between Appalachian Therapy's PTs and its athletic trainers. "Being an athletic trainer makes me a better physical therapist when it comes to treating sports injuries," he says. "Being a physical therapist makes me a better athletic trainer when it comes to doing the same-the dual credentialing is a plus. It helps me, and I think there's some carryover to treating my other patients as well. Part of sports care is really orthopedic care. It just happens to be with athletes."

A Piece of The Pie

When hiring his professional staff, Black takes the long view. "We don't hire anybody who doesn't intend to work here for the rest of their career-we hire them for life," he says. "We intend to provide the job that they want to stay with the rest of their career. We don't lose anybody-we've had one occupational therapist that chose to leave us. Our retention works." Black adds that, except in rare circumstances, he will not hire new graduates, only experienced clinicians.

According to Black, a recent addition to the staff is typical of how many of his therapists come to the practice. "One of our main competitors across town was a good physical therapist, master's level, who ran this private practice-he didn't own it-and decided he liked the things our company stood for and switched," he says.

"We didn't go out to recruit him, but he was just a great therapist, and early on we said, ‘This would be one heck of a guy to be around'; fortunately for us, he was able to bring enough of a patient load with him to justify him being here." Black, who owns 50% of the center, and his partners also motivate the rehab staff to stay by allowing them opportunities to become partners in the practice. "We feel very strongly that's the way it should be," he says. "We feel that any full-time, long-term professional should have the opportunity to become a partner in the practice sooner or later. For the last two PTs we hired, I think, that was a factor in their joining the company-knowing that within the next year there was going to be an opportunity that was to be presented to them. We've created what we feel is a good company here, and we want to perpetuate it, and to do that you have to have others, particularly younger therapists, as owners." Three of the younger therapists are in the process of buying into the practice.

The Other Side of The Coin

The practice's success has not been without its setbacks. "We had elected to get out of home health care contract services for a variety of reasons," says Eric Haralson, Appalachian Therapy's administrator. "Monitoring them was one difficulty, and reimbursement was continuing to be another. So when the Balanced Budget Act hit, we were out of those two areas, but we did get hurt with our Medicare patient load. Our Medicare business, at the time of the Balanced Budget Act, was only about 18% of our portfolio. Even that hurt and hurt fairly severely. We dropped down to about 12% and now we're back up to 16% on the Medicare." The center's payor mix is 16% Medicare, 12% Tenncare (Tennessee's state version of Medicare), 22% workers' compensation, 49% commercial insurance, and 1% third-party insurance coverage.

The administrative offices are located two blocks away from the main office, and the separation has been a boon to Haralson and the business staff. "It's been a significant help to us, that we've been away from the clinic," he says. "There's not quite as much distraction. Folks here are able to concentrate on billing and collection, and it certainly has helped on our accounts receivable."

The center is also part of PTPN of Georgia and Tennessee. "PTPN has negotiated some good contracts for us," says Haralson, who is also secretary/treasurer of PTPN. "We [PTPN] are now going back and renegotiating some additional benefits like increased reimbursement and prompt pay clauses. Of our commercial insurance, 50%-60% is managed care-directed-you have to have those [contracts] to survive today."

The immediate future will bring few changes to Appalachian Therapy Center. Black and his team are going to take some time to adjust to all of the recent expansions to the practice. "[It's] time to stop and catch our breath right now," says Black, though he is already in the process of reviewing his next project-an addition to Maryville College's training facility where he hopes to move much of the center's athletic program.

C.A. Wolski is associate editor of Rehab Management.

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August/September 2001