Episode 5: Managing COVID in the Outpatient Therapy Setting

Richard: Welcome back to Agile&Me a physical therapy podcast series. A podcast devised to help emerging experienced therapy leaders learn more about various topics relevant to outpatient therapy services. This is episode number four of the podcast series titled Managing Covid in the Outpatient Therapy Setting. Today my two guests are Lindsey Nicholson, vice President of operations for Alliance Physical Therapy, and Kelly Marvel, director of human resources for Alliance Physical Therapy. Welcome. To kick off, what I'd like to do for our guests is really have an introduction of yourselves. So Lindsey, would you be kind enough to start and introduce yourself to our listeners?

Lindsey: Absolutely. As Richard said, I am a Vice President of Operations for Alliance Physical Therapy Partners. I am a physical therapist by trade and treated about, five years in the clinic. I still treat today. I went to Grand Valley State University, graduated my doctor of physical therapy, and then started my career in the Chicago land area with ATF Physical Therapy. In September of 2019, I joined this amazing team at Alliance and have been here. Ever since supporting our outpatient partners, mostly on the East coast, but I do support Texas, Arizona, and New Mexico as well. I've been in various leadership roles over the past eight years in the outpatient therapy setting, across a wide geography and my passion is helping people and getting them better as well. Supporting the team that we have at Alliance and its outpatient partners.

Richard: That's fantastic. Thank you. And Kelly?

Kelly: So as Richard mentioned, my name is Kelly Marvel, and I'm the human. director at Alliance Physical Therapy Partners. So after graduating from Grand Valley State University with a dual degree in management with a HR emphasis on marketing, I joined the organization known as Agility Health, and I was fortunate to remain with the company as it transitioned into Alliance Physical Therapy. I've been with the company now for coming up on nearly 12 years. I currently oversee the HR talent acquisition and payroll functions for the company.

Richard: Kelly, 12 years is almost a life sentence in England, so congratulations for your tenure with Alliance and Agility Health. Thank you. So to kick off, obviously we want to talk about managing covid and really want to focus on the present and future impact of Covid. There's obviously been a lot of information, webinars, presentations, looking at the impact of Covid on therapy services in 2020. But really what’s gone is gone. Past is the past. What really what we want to look at is now in the future, how can we manage the ongoing situation pandemic, and what do we believe are gonna be the key challenges? To start really, I'd like to ask Lindsey if she'd be so kind as to provide us with an overview of how COVID 19 is currently impacting the outpatient therapy services from the patient perspective.

Lindsey: That's a great question. So as I'm sure with all of you, Covid 19 continues to impact our day-to-day function as a business, and that includes the outpatient physical therapy setting, although much less so than in March and April of 2020 when we saw over 50% reduction in our volumes and there were so many unknowns. So I think patients have kind of, not just patients but society in general has kind of become burnt out of covid. It's been going on for 10 months now, and to be quite honest, patients are more comfortable coming into the clinic, procedures and policies in place to make sure that we're screening every single patient. Our team is wearing masks, other PPE requirements as well. We're doing temperature checks on our staff as they're filling out a screening form each session including our team as well, and anyone who marks any of those symptoms are sent home. So we're trying to keep anyone who's covid positive out of the clinic. Then of course, we're trying our best to abide by the social distancing as well. Our team has been very diligent and continues to be so. We disinfect after every patient, we're cleaning high touch surface areas all the time. So I think with that and showing our patients that we're taking this seriously and that we have their as our number one priority, they are more comfortable coming into the clinic. I think this is kind of gonna become our new normal, especially for a while until vaccines are widely available to the general population.

Richard: Yeah. It's really interesting you say that the fact that that patients are more comfortable society and the whole is more comfortable, there's certainly, certainly a degree of covid fatigue isn't there? But what I find most interesting is the fact that covid cases are obviously continuing to rise as a nation. Deaths continue to rise at a rate, really not seen in the past, but society and patients seem to be almost returning to an alternative normal and just perhaps continuing through their day-to-day functions and activities as they did before, but certainly our volumes are down like everyone else's. So it's not a return to the prior normal, is it? It's kind of the new normal?

Lindsey: Absolutely. I mean, our volume is still less than pre covid, but again, not as much as it was in March and April. I think more of that is related to patients who are actually testing positive for covid or coming in close contact with someone who has tested positive and they have to quarantine, which then results in a loss of volume at the clinic. With that, we try to convert those to telehealth if the patient is feeling up to it. Cause as there's a wide variety of symptoms. Some people don't feel much at all. And then, people are unfortunately in the hospital on ventilators fighting for their life. We've had the staff challenges as well. Yes, the staff test positive and then that ultimately affects. Our ability to take care of our patients while maintaining distancing.

Richard: Yeah. Talking about staff and employees, I'd love to know from Kelly, a HR perspective. What's the current situation that pertains to Covid 19 and how it's impacting employees currently?

Kelly: Yeah, so I think from aside from the obvious physical and mental toll that it's taking on our staff and really the world probably as a whole. I think as Lindsey mentioned our staff are still navigating challenges such as either testing positive for covid themselves or their loved ones testing positive and all the nuances that go with that. But then there's other staff that are facing the challenges of having to pick up that slack in the clinic, so to speak in the instance that we have multiple staff members that are out of a single clinic at any given time and other staff are continuing to have time off or to have some flexibility in their schedules because their kids were switched to virtual learning or some of those other changes in daycare or school care. So all of these things really make managing the clinic schedule more challenging. We're certainly continuing to rely on our staff to continue to be team players and to be flexible with each other as we really strive to balance the continuum of care and our day-to-day life activities as well.

Richard: Yeah. You bring up the subject of essentially family and I think this is a really good point to emphasize is the fact that we focus on our employees directly because they're the ones that turn up to work, obviously. But really the ability for an employee to function at a high level is really dependent upon the safety of the family and their family. When I use the term safety, I use it in a kind of a fairly general sense. Obviously the family needs to be safe and they need to have the appropriate resources in order to allow the employee to continue to work. Kelly, what type of issues, concerns, questions specific to Covid are, are you currently addressing as a leader of HR? What are employees reaching out about? What are their anxieties and concerns?

Kelly: We're still certainly getting our fair share of just those general questions related to the topics that I just mentioned. Including how to best navigate various quarantine situations how to coordinate the usage of paid time off and possible unemployment benefits and things of those nature. But those are slowly becoming fewer. Over time we've been able to implement pretty clear policies and guidance on how to navigate most of those general scenarios. But I would say now we are experiencing a shift in those questions and our department is really now focused on questions and concerns regarding specifically the Covid vaccine. As you can imagine the vaccine itself as well as the administration of the vaccine is a pretty hot topic that's being discussed at a variety of HR and legal levels. With the initial delay of any formal guidance from the EEOC and without any relevant case law to consider the question about whether to make the vaccine mandatory or not was really a question that was at the forefront of a lot of discussion that's coming up now and as you can imagine our staff are are no different than anyone else in this country, right? They all have varying thoughts in regards as to whether to get the vaccine or not. Some are quite willing and see it more of kind of their moral obligation in order to protect those around them. Then others have vary degrees of hesitancy and question whether the vaccine is safe and whether maybe the approval process was rushed or if that could have unforeseen health complications. Then we just have some that are dead set against it for other reasons. So we're definitely seeing a trend in questions, kind of again, relating more tothe vaccine and kind of what this means for them. We're also seeing a fair amount of uptick in questions just regarding about the supply of the Covid vaccine and how limited it is in the states and staff are reaching out about how they can go about obtaining that vaccine and how to coordinate that care. So it's really been a shift from just kind of those general questions and concerns, really centered more about the vaccine topic at the moment.

Richard: That's interesting, Lindsey. Before we talk specifically about the vaccine and how we are managing it as an entity specific to outpatient therapy setting. I'd obviously like to know what you think the likely trends are in Q1 and Q2 of this year as it pertains to referrals and staffing because at the moment we have two vaccines that approved and likely more coming in the months to come. But certainly the number of people who are vaccinated is still low. So I believe it's still going to impact Q1 and Q2. What are your thoughts?

Lindsey: Yeah, I absolutely agree with that. We are gonna be in for a ride Q1 and Q2. We're gonna see challenges in regards to referrals and then therefore visit volumes until vaccines are widely available. To the general population and based on the information that we've been hearing and what I've been reading from our local health departments and hospitals, they're hoping to have that vaccine available in early spring. But who knows? So as covid cases continue to increase, as you alluded to earlier, Richard and hospitals are at or near their capacity, elective surgeries are gonna continue to be put on hold. With outpatient therapy, we treat a lot of post-op patients. So if those surgeries aren't happening, obviously we're not gonna have those referrals coming into the clinic, converted to visits for us. So as long as our referrals and visit bones are challenged, We're gonna have to continue to adjust our staffing levels on a weekly basis to make sure our cost doesn't exceed our revenue so that we can be sustainable in the future. Hopefully, again, we won't face the same situation as March and April in 2019 where we had to furlough. A significant amount of our team introduced pays, but we will be in for a ride Q1 and Q2 in my opinion.

Richard: Yeah, it's reassuring to know that we won't go back to the early days where visit volumes dropped over 50% for most organizations, but certainly still gonna be a rollercoaster ride, isn't it? We'll continue the conversation after a short music break and advertisement. Agile EMR is a comprehensive, all-in-one electronic medical. Solution created by physical therapists or physical therapists. Features include everything you need to run your physical therapy practice in one place. To schedule a demonstration of agile emr, visit our website at www.agiletherapyemr.com

Richard: Welcome back. If we move on to to discuss vaccinations, Kelly, from a therapy clinic owners thinking about mandating Covid vaccination for its employees. Can you walk me through your thoughts on whether vaccination should be mandated and the issues one needs to be aware of when making that decision?

Kelly: Sure. So I guess from an HR and even legal perspective, I mean there is lots to consider here and quite honestly, this could probably be a separate discussion in and of itself. But in general I think it's recommended for employers to offer vaccinations to employees on a voluntary basis. However, employers in most states may be able to mandate a Covid 19 vaccine plan as long as the employer complies with the Americans with Disabilities Act and title seven of the Civil Rights Act. That guidance really indicates that an employer must consider reasonable accommodations for their employees with disabilities and those employees whose religious beliefs conflict with actually receiving a vaccine. To take that a a little bit further specifically title one of the Americans with Disabilities Act requires employers to provide reasonable accommodation to qualified applicants and employees with a disability and less. The employer can demonstrate that doing so would create an undue hardship to the employer. Or pose a direct threat to the safety of the employee or others in the workplace. So to continue to on the the technical path, , employers also have an obligation to accommodate an employee's sincerely held religious belief under Title VII of the Civil Rights Act. Unless the accommodation creates again, an undue hardship. A sincerely held religious belief can include an employee's religious base objective to vaccinations. So it should be noted that TE Title VII requires employers to accommodate only those religious beliefs that are sincerely held again, which could almost be a another separate topic of discussion, but as a general best practice, I would say that because the definition of religion is so broad and it protects beliefs and practices with which the employer may be unfamiliar with the employer should ordinarily assume that an employee's request for a religious accommodation is based on a sincerely held belief. If, however, the employer has an objective basis for questioning either the religious nature or the sincerity of a particular belief the employer would be justified in seeking additional supporting information. Upon learning of the need for a possible accommodation employers rather really need to be prepared to engage in that interactive process to make sure that they can offer those accommodations if need be. So that was a very detailed kind of legal overview of what employers need to consider if you are evaluating going that route. But I would say also that you really need to conduct an honest evaluation of your company's bandwidth and resources at which to be able to efficiently and consistently track compliance to that policy as well as thoroughly be able to document that interactive process. I would say the final piece would be that you would also need to be prepared to see it through, so to speak, if one of your key performers refuses to get that vaccine mandatory implies that your policy will be and should be consistently enforced. So you just wanna make sure that have you planned for a reasonable accommodation for employee or are you prepared for their possible departure if you continue to potentially press that, that issue. So we're certainly all permitted to have our own perspectives in that regard. But for many people this is definitely a topic of great personal importance.

Richard: Absolutely. Thank you. I know that as an organization in Alliance Physical Therapy, we've really battled with this question of mandatory vaccination. Well, I've battled with, as the leader of the organization and deciding whether it should be voluntary or mandatory, given the fact that we are caring for patients and the moral question as it pertain to making sure that we, we do not harm the patients in any manner. However, we took the decision, didn't we, that we would make it a voluntary to employees, whether they decided or not to take the vaccine. I've been really pleasantly surprised in the initial stages by the proportion of employees that actually have decided to, to receive the vaccine. I would say that the majority of employees have actually decided. Is that correct, Kelly?

Kelly: Yes. I would agree that it's been pretty well received thus far from the employee perspective.

Richard: Yeah. Lindsey, what have we done as an organization? What has Alliance done to help educate an employees and encourage 'em to get vaccinated? Cause obviously we are doing things that are helpful because based on the proportion of our employees that, that have received at least their first vaccination. So I'd love to get your insight.

Lindsey: Yeah. So we have a vaccine task force that was created and they meet on a weekly basis to figure out how best to promote this and to get information out to our employees because we all know there's been limited information and guidance on how to not only get the vaccine, but pertaining just to the vaccine in general. So, I think the most important thing as a leadership team that we've set the example and have promoted the vaccine and focused on health and safety of each individual and patient. Richard was just on our social media outlets, your vaccination cards. We have also aided our partners in reaching out to their local health departments to get accurate information about the administration of the vaccine. We do have partners who have already got their first dose. Some are on their second dose and some are still waiting to get their plan from their local health department. So in various states to all over the board where we're at, the HR team. With Kelly's lead is sending out a weekly email just with frequently asked questions and information pertaining to the vaccine. We're also putting that on our internet page so that it's readily available to our team.

Richard: Yeah, and the other thing that we've done our alliance has done that I think has been. surprisingly, it's been well received. I didn't expect the response in which I did was making sure that the employees knew that if there was any out-of-pocket cost of having the injection, that Alliance was prepared and willing and certainly able to reimburse that cost. I found it interesting that that was mentioned a couple of times by employees as, as really supportive of our employees. The other thing that I understand that we are going to be doing is some sort of, of monthly drawing to promote vaccinations. Kelly, do you have any information?

Lindsey: Yeah.

Kelly: Yep. So we're definitely exploring the idea that incentive program further, I think a financial incentive is a pretty universal preference for a lot of folks out there. I think it can actually be very impactful that it kind of brings a sense of, or maybe not challenge, but just kind of a sense of camaraderie maybe that reminds folks that this is a company held concern. It just kind of encourages that collaboration and if there's a carrot out there that's appealing enough to those folks.I think it just kind of brings a different level of interest to getting the vaccine.

Richard: Yeah, I think there's lots of ways isn't there as an organization that the leadership and human resources can encourage employees without obviously mandating. I think the more things that we do the more we encourage, I think it will allay fears, anxieties of employees and the more that will get vaccinated. By having employees vaccinated, obviously from an operational perspective, that's advantageous. What do you, what are the clear benefits of making sure that our clinicians and those that are supporting our clinicians in the clinics what are the benefits of having them vaccinated? What are we seeing from an operational point of view?

Lindsey: Yeah, so first and foremost to me, the biggest benefit is the health and safety of our employees, their families, and our patients. So knowing that clinicians are vaccinated and reduced rate or cannot pass the virus onto a patient is a huge sigh of relief. Cuz in a lot of our clinics we work with a very old population who are considered higher risk. So if our clinicians that step and get the vaccine knowing that they're keeping those patients safe. That's a huge just a huge win. We've been diligent with our PPE and clinic cleaning procedures to maintain patient safety and comfort in the clinic, but this really will take it a step further. Additionally the vaccination should help to prevent a shutdown of entire clinic due to all staff being out at once, which is a game changer. Kelly, we both know. Richard, you as well, that we've had multiple clinics within our organization who have had, if not more than 80%, almost their entire staff out with Covid, which really alters our ability to take care of our patients and give them the care that they need. So it's going to allow. To not only continue to provide the best care to our patients, but also to meet our financial goals.

Richard: Just keeping the doors open, isn't it? It's just the, the practical component. We'll continue the conversation after a short music break and advertisement. Most orthotic manufacturers take a one shape fits all approach to solving lower body pain and symptoms. They focus on arch support for temporary pain relief, which can end up leading to inefficiencies in injuries.That's where bio correct is different, more than just an insert. Bio Correct is a fully customizable foot orthotic system engineered to address and treat biomechanical imbalances of the entire body and we're backed by more than 25 years of experience. To learn more, visit us at Biocorrect.com

Richard: Welcome back. If we think about the future from an operational perspective, Lindsey, what do you think will be the main challenges in the short term for instance, the next three to six months as it pertains to managing through the continued covid pandemic?

Lindsey: I think from an operational perspective, we're gonna see more of what we've seen these last months, October to December. I think we're gonna continue to be challenged the next three to six months, not so much with patients and staff fearing the virus and staying away from the clinics, but with staff and patients contracting covid, especially as we talk about covid fatigue and maybe not maintaining distancing and being compliant with PPE as we have been in the past. Also with staff and patients possibly having to quarantine. Our staff out, it becomes challenging to see the visits that that person had scheduled while maintaining distancing. When you have staff out a lot of times you're gonna lose some of those visits. So it will impact our business with patients being out due to covid or being in contact with someone for our visit volumes also decline. We have continued to try to promote our telehealth services in those instances when the patient and the staff feel well enough to participate. But as you can imagine, we're not capturing a hundred percent of those visits. So again, until the vaccine is readily available, we're gonna see more of what we've seen in the last three to six months.

Richard: Yeah, that's great to to understand that as we said earlier, continued pressures a bit of a rollercoaster ride and obviously clinic in clinic visit volume is slightly depressed and will continue to be depressed based on people continue to contract the virus that who ha people who haven't been vaccinated. Even just from the mechanics, lower elective surgeries perhaps, or physician visits that reduce referral volumes. But on the flip side though, we can certainly, I believe, capture some of those visits through virtual care. Do you have any information, what's your thinking as it pertains to virtual care over perhaps the next six months?

Lindsey: I would expect that our clinicians are going to see an uptick in our telehealth. Virtual care volume is a great way for patients to continue their care if they have to quarantine or maybe they're not comfortable coming in the clinic. But I would expect that that volume would start to increase at the beginning of the pandemic. We quickly put out a solid telehealth platform and a decent number of visits and then as the pandemic went on that volume started to decrease and I would expect we'll start to see an uptick again.

Richard: Yeah. There seems to be a continued necessity, doesn't there for a virtual telehealth platform to continue. It'll be interesting to see whether even as the vaccination rates improve and perhaps the importance of telehealth as a medium for providing care for safety reasons, subsides, I think the convenience factor actually will stick. So I think there'll be a number of patients in society as a whole that that will perceive telehealth in a different way and understand that it is here to stay and it is an alternative medium, not necessarily all the time, but certainly for proportion of their care. And I think therapy will benefit from that.

Lindsey: Absolutely. I think of when I was treating in the Chicago area and a lot of my patients they commuted downtown from from Andersonville, which isn't that far away, but Chicago traffic, it makes it far away and they've gone business trips, or they'd be here and there and they could only come like once every other week because of their travel schedule. Those are the perfect patients to see 'em in clinic when they're around, but to continue their care while they're out of state, we can, pop on the computer, pop on your phone, and you can have that visit. Not have to drag therapy out. You can continue to progress. But Richard, one thing that just kind of came to mind, I think as these months go on, we're gonna be challenged a little bit as far as buy-in to PPE and other safety procedures. Not only with some of our patients getting the vaccine and thinking that they shouldn't continue to wear PPE, but also again, just the fatigue. So I can see it's gonna be harder to maintain those standards in our clinic with our patients.

Richard: Yeah, that's a really good point. So if we pivot towards employees or back to employees, Kelly, how can we support employees during the next few months to help ensure their safety, but also minimize disruption to them.

Kelly: Yeah. So I think one of the obvious answers right, is continuing to promote and connect employees to the vaccine. Certainly as it becomes available. But I think also just some generally best practices would be for us to continue to educate ourselves and staff and remain current on all the directives and guidance that are made available to us. I'm sure most of us are aware those directives and the guidance seem to change almost daily, making sure that we stay on top of the most up-to-date information. I also think it's important that we continue to offer a flexible scheduling staff whatever possible. Really continue to encourage cross-training amongst your teams and fostering that team player attitude as well as how we just talked about promoting those, those telehealth services perhaps as an alternate source of care. I would also promote any wellness or employee assistance programs or resources may be available as we kind of touched on just briefly earlier, I think there, there's a lot of our folks that are struggling to maintain both our physical and our mental health during these challenging times. I think it's very important that we continue to check in with each other and support one another as best we can.

Richard: What we often overlook, isn't it? We focus on the physical impact of Covid, but certainly there's definitely a mental health component and even a financial health component that I'm sure many employees have are battling with at the current time as direct result of the anxieties caused and continue to cause. So what I have been impressed with as an organization is, Level of communication and the continued communication provided to our employees about every facet of code and how we're trying to navigate through it and reassuring employees and the positivity that we, we, we have through those communications. Do you agree with that? Is key to managing or the continued management?

Kelly: Yes, absolutely.

Richard: if we look further ahead after the current wave of infections are settled, which they will might take a little while, but they will settle in a significant proportion of the population has been vaccinated. Looking at the Crystal Ball Lindsey. How do you think the business will have been changed? Will there be any fundamental changes to what or how we provide therapy?

Lindsey: Yeah. So life as we know it has changed forever. Well, whether or not we wanna accept that or not due to this pandemic but it doesn't mean that all of these changes are necessarily bad or negative. Covid 19 has as you have said many times to us Richard, in our meetings has been a catalyst for change. With that rapid change we have all adapted we're all here we've made it through it. We've figured out ways to provide carrier using different methods, which we've already touched on telehealth, but society was kind of already pushing. The medical world in a more virtual experience already. I think Covid just helped to speed that up. I know for alliance it for sure helped us to speed up and get that platform up and running. While there's always going to be a need for in-clinic visits as some patients need that manual hands-on component virtual care visits are likely going to increase. Out of convenience. So I think the way in which we treat will likely change as well. We're gonna be more forced to focus on payer type and reimbursement just to ensure that we are viable and sustainable in the future. We'll continue the conversation after a short music break and advertisement. The world around us is changing at a rapid pace, and so is our preference for how, where and when we choose healthcare. That's where Agile virtual care answers the call. Agile virtual care is a comprehensive telehealth, so. Revolutionizing physical therapy by making PT convenient, safe, and accessible across the entire country for providers and employers looking to offer employees different options for preventative and continual care. Agile Virtual Physical Therapy delivers the comfort and convenience that patients want and the quality care they deserve. From experienced licensed therapists.

Richard: Welcome back. To wrap up the conversation as times ticking by we've all had plenty of time to really think about the Covid pandemic when we've been quarantining with our families. When you look back, this is a question for both of you, but we'll start with perhaps Kelly. When you look back, what have you learned from the experience of leading through a a life-changing major pandemic that hopefully will not be repeated within our careers?

Kelly: Oh boy. Where to begin? I'm not sure that we have enough time to cover everything that I have learned personally, but I would say one of the key takeaways for me was probably the importance of.Grace. Covid has impacted so many of us in so many ways and I've actually, I've heard it best described is that we are all in the same storm. We're not necessarily all in the same boat, but we're all in the same storm. Right, these were and continue to be just uncharted waters and many of us just got a crash course and topics that we never thought that we'd have to deal with, right. Such as navigating employment system for the first time, having to make tough choices between our careers and remaining home to provide care to our kids, the struggles of adjusting to e-learning and hybrid schedules for our kids, just feeling isolated and removed from our families and friends and just kind of battling that decline in both our physical and mental health. These are all struggles that we've never had to really face before and continue to be in a state of learning and continue to adjust to these new circumstances that we find ourselves in. I think extending that grace and compassion to one another has really been one of the most important aspects. I would say probably the other piece to value for me was just kind of that general sense of appreciation as we've discussed. This pandemic has really rocked us all to our core and it's disrupted our day-to-day lives as we know it. Many of us are always on the go and ultimately just kind of chasing that dollar, but at the end of the day, none of those dollars really buy you anymore time. So choosing to spend your time well, doing the things that you enjoy with the people that you love, I think is really important. I think for me personally, just kind of being able to take a step back and really appreciating what matters most I think has been the most impactful.

Richard: Yeah, I would agree. I've certainly changed the style of leadership. Obviously it's dependent upon the events and the environment normally, but certainly I've had a I wouldn't say necessarily a paradigm shift, but I certainly flex significantly.

Lindsey: Yeah. I echo everything that Kelly and Richard, you as well have, have said, I think the biggest thing is not to take anything for granted, right. From being able to, to come to work to. Earn a living to support your family. Like, not, not everyone is fortunate enough right now to have that ability, so not to take anything for granted, including your health and your safety.Even to be able to treat a patient without wearing a mask and being able to see, that patient's face is just such a different world right now. One of my clinics, they have pictures of themself up on the wall because their patients haven't actually seen their face. And that kind of hit me. Things have changed, but we can't take a minute for granted because like Kelly said, we don't get any more time. Buying more time. I've learned a ton, but I like to have control. This pandemic has definitely taught me to roll with the punches that as much as you plan, you might as well just throw your plan out the window cuz something else is gonna happen and you're gonna have to, you're gonna have to pivot, but it's okay because things always do work out. I used to stress over looking back now, the littlest things. It always worked out, but , why have that stress and most of the time it works out for the better. I've always managed and believed that supporting your team and doing the little things for them is how you retain them.Employees, especially those good ones and how you get them on board and drive initiatives forward and drive change. But as we navigated through Covid 19 and the hard conversations that we did have to have in. Furlough and pay cut. None of that is possible if you don't have trust and buy-in from your team.

Richard: That's perfect. Well, I'd like to thank you both tremendously for being guests on the podcast today. This was brought to you by Alliance Physical Therapy Partners in Agile Virtual Care. For more information, please visit our websites alliance ptp.com agile virtual care.com Make sure to follow us on social media and LinkedIn. Where you can learn more about Alliance Physical Therapy partners in Agile virtual care.