In today's age of an ever-growing body of knowledge on the treatment of neuromusculoskeletal conditions, as well as health care reform and pay-for-performance, our profession continues to evolve for the better. Because of improved outcomes, the current literature supports the use of active care, where patients play a critically important and active role in their treatment plan. As far back as 1995, Twomey et al., demonstrated the importance of exercise and mobility in the treatment of low back pain.1 Evans et al., found that manipulation and low-tech rehab was better than manipulation alone or manipulation and high-tech rehab for chronic neck pain patients.2 Although outcomes were closely matched, patient satisfaction was the highest in the manipulation and low-tech rehab group. In a second, two-year follow up study, Evans et al., also reported that spinal manipulation combined with exercise yielded better outcomes than manipulation alone for chronic neck pain.2 Bronfort et al., also reported similar results: exercise and manipulation combined are more effective than either one alone.3 Many doctors of chiropractic today are also treating a wide variety of extremity conditions, such as rotator-cuff disorders, lateral epicondylitis/osis, plantar fasciitis and many other musculoskeletal conditions that require rehabilitation.
After seeing and hearing all of your chiropractic friends adding tools to their clinical tool box, you say to yourself, "It's time to implement a rehab program into my practice." The next thing you say to yourself is, "Where do I begin?" Well, here is your roadmap; a tried and true way to add needed services to your practice so your patients can reap the clinical benefits and you can reap the professional rewards. If you work consistently towards your goal, in 30 days you'll have a revitalized practice.
Step 1: Overview
Sit down, preferably with your staff to improve "buy-in," and discuss what you want your new practice to look and feel like in 30 days. Why should you implement a rehab program into your office? What goals do you have specifically for this program and how will you and your team carry them out? What are the benefits to the patients, the practice and the staff? What are the potential challenges? How will you and your team overcome those challenges? What are the new job roles for you and your staff? What process and schedule changes will you need to make, if any? How will you market these new services to referral sources and patients? The question of your space requirements needs to be addressed as well. Once you have answered these basic questions, proceed to Step 2.
Step 2: Compliance
When implementing a rehab program into your practice, it's critical to understand all the safety, state board of examiners/licensure/scope of practice, and coding and documentation requirements that are needed. This is where many doctors fail. The right thing to do is to go to your state board of examiners and industry experts to ask the necessary questions. Make a small investment in time and money and get the right answers the first time. Many doctors consult with practice-management companies that tell them how to grow their practices. Just make sure that all the hard work you do to grow your practice doesn't go to paying your future legal bills because you took too many shortcuts and got into trouble. Compliance is the cornerstone to a great practice no matter what type you have.
[pb]Step 3: Financial Projections
What will you charge for this service? Will this be a cash service or will it be reimbursed by third-party payers? If it's going to be third-party payers, what are the fee schedules for this service per carrier? Based on answers to the questions above and your existing internal data (weekly visits, case type etc.), you should be able to run financial projections. What you're looking to do is to identify how adding an important clinical component to your practice will impact your costs, and top (revenue) and bottom (profit) lines. By investing in the best low-tech rehab products, your up-front costs could be as low as $1,500-$2,000! That's right, resistance bands and loops, exercise balls, exercise stations, stability pads and wobble boards can revamp your practice look, feel and results for a fraction of the cost of those flashy, high tech products that are marketed to you. Once you've identified your capital cost (tax benefits) requirement, then you can use the following chart as a framework example to identify projected profits:
Step 4: Clinical Training
Chiropractic rehabilitation needs to provide a continuum of care integrating passive and active treatments. The goal of rehabilitation should be to support and improve the effectiveness of chiropractic adjustments, as well as achieving a positive effect on the entire kinetic chain. Active care needs to be outcome driven. Your treatment plans should document and support your in-office protocols and the on-going progress for the patient. Ensure you and your staff are prepared to deliver the finest possible rehabilitation program.
Remember your competition is not only the doctor of chiropractic down the street who has been doing rehab for 10 years, but also the six physical therapists in your town. This may seem like a pretty substantial obstacle, but if you're committed to improving your practice, it takes education, training and work. The good news is that there are many resources available. So, if you know the most current literature, you have the advantage over many who have years of experience and practice. Invest the time to train you and your staff. Your return on investment will be substantial.
Step 5: Create an In-Office and At-Home Rehab Protocol
An easy way to design a protocol is by body region. Protocols should be used as a guide, but should not create a "cookie-cutter" practice. Each patient has their own symptomatic and functional issues, and has their own goals. Make sure you tailor your protocols to meet the individual needs of your patients. Further, protocols should evolve based on current literature. Certainly, one of the great advantages of low-tech rehab products is home exercise compliance. Many patients will want to purchase these products for home use in order to maintain their clinical progress. Patient education on their home plan (maintenance of gains) and their in-office plan (continued functional improvement and fitness) helps them to understand why they are participating in both an in-office rehabilitation program and a home exercise program. Start simple, and as you practice, take what's working and expand on it, and eliminate what's not. Protocol modifications never stop, so understand from the beginning that it's an ongoing, fluid process.
Step 6: Purchase Your Equipment
Now that you know what exercises you'll be giving your patients for care both in-office and at home, you're ready to invest in your equipment and your product inventory. Remember, your equipment choices reflect directly on your quality of care. Go with quality products with trusted progressions so that you know safety and quality meet with the highest level of professional standards. Furthermore, you want to send your patients home with those same products to demonstrate safety, consistency and value.
Step 7: Have Fun
Implementing a comprehensive rehab program that addresses the individual needs of the patient is incredibly rewarding and fun. Communicate with the patient so they understand why rehabilitation is being added to their treatment. The more they understand, they happier they will be. It's important to be flexible as you move through the first 90-120 days of implementation. You'll achieve successes and meet a few challenges. That's all part of the growth process. Have faith in yourself, put trust and training into your team, and watch everyone, especially the patient, win.
References
When I graduated from chiropractic college in 1981 and started practice, I heard it all, and very little was positive. “You are a quack; you do not know what a subluxation is; you couldn’t get into a real health care program, so you chose the one that is slightly above a mail-order degree; you have no proof that chiropractic works; Are you really licensed?”, and so much more.
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