Podcast | Episode 7: Outpatient Rehabilitation with Victor Derienzo and Sara Cristello

Clinical Expertise

Feb 7, 2020

Welcome to the Brooks Rehabilitation podcast where we talk to our rehabilitation professionals to shed light on the stellar programs and services we offer to help our patients reach their highest levels of recovery.

In this episode, we learn about Brooks Outpatient Rehabilitation from Victor Derienzo, VP of Outpatient and Sara Cristello, PT and Outpatient Services Supervisor.

Send us an email with your questions, comments or podcast ideas to [email protected]!

Listen to the full episode on your favorite podcast app! Search ‘Brooks Rehabilitation Podcast.’ You can also listen online. Below is a transcript of our newest episode.

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Podcast Transcript

Michele Orallo: Welcome to the Brooks Rehabilitation Podcast. My name is Michele Orallo.

Tracy Davis: And my name is Tracy Davis. On this episode, we feature our outpatient business line. Outpatient has been a part of Brooks for over 25 years, starting with our first clinic at Healthcare Plaza on University Boulevard here in Jacksonville, Florida. Also, this episode is part of our 50 years. What I mean by that is, throughout the year, we are featuring blogs, podcasts, and videos. All of them will be shared on BrooksRehab.org if you click on blog, you will see them there. What we’re doing is just putting out different stories, whether it be the business parts of Brooks, a lot of our patient stories, employees. We’re going to be featuring a ton of stuff, and this episode of the podcast is going to be a part of that. Make sure you check that out at BrooksRehab.org/podcast.

Tracy Davis: On this episode, we had Victor Derienzo, who’s the VP of outpatient, and Sara Cristello. She’s a physical therapist and the fellowship coordinator for the Brooks Institute of Higher Learning, and also she is the Outpatient services supervisor. Really happy to have both of them on. We learned a whole lot about outpatient and the types of patients that we serve through outpatient, why we have so many clinics, what we look for whenever we’re going to be expanding into new areas, why they make some of the decisions that they do.

Michele Orallo: If you’d like to send us an email, you can send it to [email protected].

Tracy Davis: If you’d like to contact us on social media, just look for @BrooksRehab on YouTube, Facebook, Instagram, LinkedIn, Twitter. We are on all those places. Be sure to check out BrooksRehab.org for every thing Brooks in one place. Let’s get right into the episode.

Tracy Davis: Victor, do you want to start by telling us a little bit about your background and how you came to Brooks? Like where’d you go to school and all that kind of thing?

Victor Derienzo: Sure. I want to PT school at Utica College. Graduated in 1998. Practiced out in San Diego for about six years or so, and then have been at Brooks ever since. Came here to be closer to family. Been with Brooks for about 15 years. I started as a center manager over at our Beaches Clinic.

Tracy Davis: You joined as a center manager?

Victor Derienzo: I did.

Tracy Davis: You were hired to be a center manager.

Victor Derienzo: I was actually on the phone with your newly hired president of outpatient, Michael Spiegal, when I was flying back to California, who said, “Just come on board with us and I’ll find you a management position.” He actually made me float for a couple months. I was a float PT for Brooks for several months before I landed by first center manager job.

Tracy Davis: Okay.

Victor Derienzo: Which is now the Ponte Vedra Clinic. Kind of how I moved up a bit was just taking on more responsibility and proving results. The better results you have, the more responsibility you get. One turned to two clinics, turned to nine. Turned to the division.

Tracy Davis: All of them.

Victor Derienzo: Yeah, I know. Where Amanda Osborne and I were married for a while there, co-leading the division.

Tracy Davis: Work married, so every knows.

Victor Derienzo: Work married. Work married. Right. For several years.

Tracy Davis: A little closer on the mic.

Victor Derienzo: And then she went over to run the hospital and I took over, solely, the outpatient division now probably for the last three, four years.

Tracy Davis: Yeah, it’s been a few years. Okay. Sara, how did you join Brooks? What did you do before? How did you school and all that, and then how did you join Brooks?

Sara Cristello: I went to the University of Florida and then needed to get away from Florida for some period of time, so I went to Arcadia University which is in Philadelphia. That ended because it’s cold, so I came right back to where I started in Jacksonville. I worked for a private practice for a little while and all the time knew that residency was the route for me. Brooks had a residency, and I met a therapist that used to manage the Amelia Island clinic. He was very convincing around Brooks. Then the reputation. It was sort of, if I’m not going to school in Jacksonville for college, I didn’t know where I should work as a physical therapist. When I was in private practice, it was outside of Jacksonville. It had to be Brooks. When I came, I came a little over almost 11 years ago and I haven’t left, but I started as a center manager at the Amelia Island clinic.

Tracy Davis: What was it about Brooks that attracted you the most to work here?

Sara Cristello: I think people cared about me and they cared about patients. I think our care for putting the patient first in our mission and values really stood out, me as an employee as well. I just felt like I belonged and people cared about my wellbeing and believed in best practice for rehabilitation. My growth personally, my growth professionally, which then turns into better outcomes for our patients. I don’t know, I just like it.

Victor Derienzo: Agreed. That was one of the things that I’ve noticed, too, as well. Coming from a for-profit out in California, the culture when I first experienced it here was you have your orientation, you’re sitting having lunch with the CEO of the organization. That just doesn’t happen. The culture almost seemed unreal fake. My guard was up. It’s been the same ever since. It’s been employee oriented, patient oriented from the top all the way through the bottom. Fifteen years later, I would even say that it’s even stronger.

Tracy Davis: Yeah, and Doug still does that all the time. It’s like you’re always waiting to find out when the behind the mask, but it never happens.

Victor Derienzo: Exactly right.

Tracy Davis: Brooks just is the way that it is.

Victor Derienzo: Exactly. Definitely starts at the top. I want to add something to, to Sara. I know what’s interesting is that I interviewed her as well for that Amelia Island position years ago. She started off at Nassau PT, who we just ended up acquiring last year. Jim Marino was in the community for over 30 years. Great guy. Culture aligns with ours, too, as well. She comes from good roots. It was probably a fairly easy transition for her to come over to us from Jim.

Sara Cristello: Yeah, I phone interviewed with you. I was a nervous wreck sitting outside. I was in West Philadelphia just sitting outside with all this traffic. Now that I’ve met you, I was like, I don’t know if that was just my lucky day or what. Just a phone interview and it went really well.

Tracy Davis: We should say, too, what your role is now at Brooks.

Sara Cristello: I have two roles. I work in outpatient administration in sort of a operational support role. It’s multifaceted. I work with Jennifer [Hagist] and sort of lead some initiatives around programmatics, new employee onboarding and clinical training, regulation, policies and procedures, accreditation. Just sort of a multifaceted role. Then I also coordinate our orthopedic manual physical therapy fellowship for the Brooks IHL.

Tracy Davis: Okay. Enough about the two of you individually, let’s talk about outpatient.

Victor Derienzo: Or we can keep going.

Tracy Davis: Now I’ll hit the record button. How many clinics do we have now? Whenever I started in ’05, I think we had less than 10. Obviously our employees were far less and we’ve slowly grown. How many are we at now and then how does Brooks look at outpatient as far as why have we been adding so many clinics over the years?

Victor Derienzo: We technically have 37 unique locations. We’re as far north as Amelia Island, Nassau County. We have about 18 or so clinics in the Jacksonville Market greater metro area, all the way through Daytona, Orlando. Then we have a few clinics over in the Pasco County, north of Tampa, Hillsborough County market, too, as well that we’ve been there for a long, long time, since before I started with Brooks. We have a real focused growth around outpatient. I know just as an industry, the outpatient division, or industry has been growing leaps and bounds. There’s a lot of private equity money going into the market. More so, because there’s money to be had. For us, it’s to really spread our expertise and to treat more people, expose more people to the expertise that we have in a multitude of areas where others just don’t. There’s far inferior care across the Orlando market, I’ll say, that we can provide better expertise and handling those particular conditions.

Victor Derienzo: We have plans over the next 5 years to expand to about 20 locations, additional startups. We’ll look at acquisitions too, as well, as they come up, but we’ll be mostly focused on the Orlando market. What’s unique about that is that we’re coming in in a different fashion than how we’ve typically grown in the past. We’re coming in with a cluster of clinics every year in a condensed sub market of the entire metro area. We’re bringing specialty whereas, before we didn’t do that. We’re coming in strong with what we do really well, which is treating that neuro patient. Again, we are trying to emulate what we have here in Jacksonville because we’ve been so successful over the last 50 years that we’re trying to bring what we do well here in Jacksonville down to that Orlando market.

Victor Derienzo: That includes a whole host of relationships that we have with the acute care entities here, educational institutions like UNF, Jacksonville University. We’re trying to do that there with the University of Central Florida. We have several projects already in the works. We’re going to build a network around the city, down there, again, over the next four or five years, and also couple that with some of our other divisions as we continue to expand in that market, too.

Sara Cristello: You know Victor, you said, or Tracy said why did you come to Brooks, or what keeps you at Brooks. I think Victor’s comment about it’s not just a monetary reason to go down to Orlando, but really it’s about what’s best for the patients in that market. It’s classic. There’s good car mechanics and bad car mechanics. There’s good lawyers and bad lawyers. There’s, unfortunately, within our profession, a lot of variability in the quality of services. I think it’s really cool that we keep ourselves at just … We just raise the bar as far as the delivery of care and the expectations that we have. It’s really exciting, as you phrased that, that it’s really about the patients and being able to bring that level of care. Not to say that there aren’t some practice … I don’t really know the practices throughout Florida, but just if you think about rehab in general, there’s a lot of variability and we would be going into markets really raising the bar with patient focus, and that’s really exciting.

Tracy Davis: We’re not planning on going to Miami anytime soon or anything really past Tampa as of now?

Victor Derienzo: Correct. As of now, we have plenty to grow in Orlando and then next phase will be in that Hillsborough County, Greater Tampa market. There’s about three million people in the four counties around Orlando. You got about another million and a half just in Hillsborough County out in Tampa alone. There’s plenty of opportunity in those two areas.

Tracy Davis: Before we move on, while we’re talking about how we expand and all that, what are you guys looking at whenever you are thinking of moving? What data points are you looking at to say, and I know I work right beside of our team that looks at a lot of these things, the business team. But, data points you’re looking at for we should go in this market, we should go in that market, or this county or that county, or purchase maybe this company.

Victor Derienzo: I know we have been the most sophisticated in our analysis with this one more so than any other that I’ve ever been involved in for outpatient growth. We were trying to get to a point where we want business development to tell us where we should go versus us tell business development we want to put a clinic here, here, here. The market should tell us. Just like with any other national chain, national big box, there’s a reason why they’re side by side in a particular corner all over the place. There are certain demographics that lead them to whomever they’re catering their business and/or service to.

Victor Derienzo: What we did is that business development ran a very large regression analysis and had all these variables to factor in based on a particular margin that we were trying to replicate of our more successful sites. We looked at our locations that do really, really well with patient satisfaction, and margin, and so forth and so on. We try to look at the demographics in and around those particular clinics and run that analysis down in the Orlando market. What that showed, it really boiled down to four variables. We used those to help us drive different zip codes in the market, or different pockets in the market that we should at least start because we have the highest probability for success if we opened up clinics in and around those areas. It took into account average house, household income, some competition and a few other variables that are in our secret sauce, Tracy. I can’t tell you.

Tracy Davis: Can’t give it all away. How does the Colonel make his chicken or whatever.

Victor Derienzo: Yeah. It’s chicken. That’s all you got to know. Again, the department of business development has really gotten to a level that’s helped us drive our decisions versus us telling them where we should go, which is how it out to be.

Michele Orallo: What are the differences between Outpatient, Inpatient, Home Health, and SNF? All of our different divisions?

Sara Cristello: Oh my god, that’s a crazy question.

Michele Orallo: It’s a loaded question, I know.

Tracy Davis: It’s tough.

Sara Cristello: Fundamentally, you could probably just start with the types of patients that we see. Ultimately, there’s an acuity level, right? Straight from an acute care hospital, if you are at a certain acuity level, you’re going to go to the inpatient rehab versus somebody who would be able to go home or to go to outpatient. With that comes the need for a significantly more close knit interdisciplinary team of physicians, and dieticians, and psychologists, and rehab, and nursing, and nursing assistants, and the whole gamut versus somebody in outpatient is able to get out of bed, get into their car with maybe some assistance of a caregiver, but traditionally, some part independent or a little bit of assistance.

Sara Cristello: Then, in that aspect, we just have front desk staff, some therapy techs, and we have therapists. Staffing is significantly different. Then I don’t know, from that comes a zillion different things as far as what’s the safety risk? What’s the documentation needs around that? What’s the care conferences? We do a lot of things where we’re communicating with physicians outside of our network. We’re really reliant on just being really good partners with the community. So is the other divisions, because there’s I need to get those referrals and patient admissions, but I don’t know, that’s one place where we could start. We could take it a whole nother route as far as what the differences are, but really, the skill level and the type of skill needed based on the acuity and the amount of people in a patient’s care significantly lessen as you go throughout the divisions.

Tracy Davis: No, that was good. Yeah.

Victor Derienzo: Yeah. I’ll just add to that. That was good. Patients coming from an acute care overnight setting, definitely more involved with the neurologic conditions now that we primarily see in our IRF setting, in our hospital setting. Kind of moved out the majority of our orthopedics into more of an outpatient and/or home care type of a setting. As the transitions of the patient have happened over the years, the hospital is now seeing different types of patients, more to Sara’s point, very high acuity are in the top percent or two in the nation with the complexity of the patients that are seen there. As you make your way through the continuum, it would be in a Skilled Nursing Facility, overnight care settings. Again, it’s more of step down. From there would be more of a home care, you’re home bound, you still might need nursing care and rehab. Then stepping down from, that would be on the outpatient setting, where the only care setting that doesn’t offer nursing. Again, the stability of the patients and/or the acuity will actually drop. We’re have healthier, more mobile patients in the outpatient setting, is how things typically progress.

Sara Cristello: Yeah, and the majority of our patients come from the community, so they recently have not been through any other health system. Something as simple as my son has an articulation disorder. He’s walking himself into the clinic or somebody just has a recreational type athlete injury. Then we do get those that transfer through our system, as well. That tends to be more our neurologic population.

Victor Derienzo: I would add, I know that outpatient sees every single patient that comes from all of our care settings, overnight settings. We can see everything, I always say, from a baby to a 99 year old. From orthopedic to a neurologic condition, from an ankle sprain to a spinal cord injury. We have clinicians that are specifically trained to handle those types of patients. We have clinics that are equipped to handle those patients. He have IHL trained residency and fellowship clinicians in the outpatient division that will handle those types of patients. We see kind of the gamut of everything that’s out there, on a multitude of levels, too, as well.

Michele Orallo: What kind of outpatient services do you guys offer that people around Brooks wouldn’t know that we have?

Tracy Davis: Maybe to tie into that, too, is how do you decide which ones have … or they all don’t have PTOT and speech. How does that get decided as to which clinics get which disciplines?

Victor Derienzo: Correct.

Tracy Davis: I know some other things, like Michele said, what do we offer that people might not …

Victor Derienzo: I’ll give you an overview and then I’ll have you talk about some of the programmatics that we offer. Some of the emerging programs and services that we’re also working on that they might not know. I can tell you that most of our clinics are non-hospital, meaning we offer PT only services. We primarily see orthopedic types of patients. Then we have about 12 of our clinics, 13 that see the gamut that are hospital based that are PTOT Speech that will be able to see a more breadth of patient, which are neurologic patients that might require all three disciplines, pediatric patients that might require all three. We have those around the city. Interestingly enough, is that we’re bring that tri-discipline model down to the Orlando market, because that’s really what’s missing. Then when you ask how do we decide, we will have an area of town kind of anchored by one of our tri-discipline clinics, and then we’ll have several PT only clinics surrounding to also service the vast majority. Most of the patients that we see in outpatient are muscular skeletal orthopedic types of patients. A lot of our specialty programming is housed within those hospital based clinics, but again, then we offer breadth of services and programs across the entire division.

Sara Cristello: I think I’m still learning and I’ve worked in outpatient for almost 11 years. One of my roles is to help programmatics grow. Through that, we have six programs. We have oncology, sports, neuro, women’s health, pediatrics, and orthopedics. Each of those are really working on developing subspecialties. Some of the subspecialties we’ve had for some time, and then some are newer. You can think about concussion programs. Really, that being that interdisciplinary team of people working on a specific population. We are really working to move forward a pediatric infant feeding program. That would be a combined program with occupational therapists and speech therapists. I’m not that well versed in it, but I know we do have Mandy over at our San Pablo clinic just got an amazing certification to be an OT certified in infant feeding. It’s really cool. Little things, things like you have an aversion to the texture of food, all the way to aspirating when you swallow. A variety of things within that program.

Sara Cristello: Our oncology program has really grown, so really being able to work with patients who want to focus on not just kind of surviving the treatments of cancer, but then actually having quality of life either during treatment or after. That’s OTPT and Speech program as well, so we’re growing there. Women’s health.

Tracy Davis: For the oncology one, I just did a photo shoot out there. We did it at Orange Park. That was the thing she was trying to bring home is that everyone thinks of lymphoma or something like that with that, but it looks just like ortho, a lot of therapy that they’re doing for oncology patients.

Sara Cristello: I think you think about, I don’t know the numbers of the percentage of people that either have had or are currently receiving treatment for cancer, but sometimes it’s some sort of chemo therapy intervention effects your balance 10 years later. So really, her kind of push to scope that, any patient that walks through our door might not have active treatment right now, but they could still have considerations that affect your plan when you’re working with them.

Tracy Davis: You were mentioning women’s health when I cut you off.

Sara Cristello: Really expanding through, really our residency program plays a big role there in making sure that we have women’s health specialist sort of throughout our market that can see a variety of conditions, male, female, pediatric, adult, pelvic concerns. We’re working currently on expanding our presence around the amputee population. Even within each program, we’re just really trying to make sure that we have kind of the best of the best specialists, so making sure our network of consultative practice is there. Within the neuro population, having experts in brain injury and spinal cord injury, and movement disorders like MS and Parkinson’s. Those experts are also, you could be a speech expert, or an occupational therapy expert, or a PT expert. There’s a lot out there. It’s hard to think of…

Tracy Davis: There’s something for every need, any patient that needs anything, it can pretty much be covered in outpatient, as far as post-inpatient care and that kind of thing.

Sara Cristello: Absolutely, yeah.

Tracy Davis: Everything’s covered.

Sara Cristello: Then probably some additional things that would only affect the population coming from an outpatient setting.

Victor Derienzo: I’ll just add, too, is that we’re trying to offer a different level of care for our concussion patients. We’re trying more of an integrated medical approach where a patient would come in that experienced a concussion and in that same day, they would see a physician, get examined. They would have a neuro psych eval completed, all the testing. They would be examined and have an initial eval by a PT, by an OT, to assess the full gamut of that particular condition from a neuro psych to learning to balance and vestibular. You have everything in that same day, so it’s not a fragmented approach towards care, because it’s such a complex condition that can effect everything.

Tracy Davis: Or making them come back for more sessions.

Victor Derienzo: Exactly. It’s that, will they show up? Okay, is that timely? The whole team is talking together. We’re just trying to put all the pieces together right now to roll that out in pilot in 2020.

Tracy Davis: Sure. Okay. Kind of back to what we were talking about earlier about just how outpatient plays a role in our whole system of care. You were kind of mentioning the differences and everything, but almost every podcast we do, it kind of gets brought up somehow of how Brooks is at least the only one around that offers a whole continuum like we do, a whole system, that a patient might need. We’ve had patients that have come in inpatient or somewhere else and they’ve made their way around the entire system. It’s very unique. If we can replicate that further south, too, starting with outpatient, that’d be huge.

Victor Derienzo: That’s the goal, yeah. The goal isn’t for outpatients just go and grow in a random market. We want to compliment our services with our other divisions in time. That’s just going to come with partnering and anchoring in the market and getting a foot hold there, but definitely not stopping there. We really want to service the people in Orlando the same way that we do in Jacksonville.

Sara Cristello: Yeah, I think that just lends to, and I’m not sure the plans for this, but even things like the clubhouse in adaptive sports, where that’s a transition. Sometimes I think about outpatient is sort of the end, but really it’s not. It’s that community integration. We then still help facilitate patients going there and then are very grateful for that transition to be able to help them have some opportunities outside of outpatient.

Tracy Davis: Sure. Let’s talk about healthcare plaza really quick. That’s our oldest clinic. That’s where I started, over in medical records over there, way back in the back over there. What are the expansion plans right now, I know it’s going to be growing, right?

Victor Derienzo: Yeah. Actually exciting. This will be the first time that we embark on a full reno there.

Tracy Davis: It’s always been done in pieces.

Victor Derienzo: It’s so piecemealed out. It’s been, like you said, about 25 years in the make. We have had so many small partitioned renos and finishes.

Tracy Davis: There was two while I was there, I think, in the few years I was over there.

Victor Derienzo: Right. When you think about it, it’s 43,000 square foot. It’s the same size as the building that we’re sitting in now, except it’s all horizontal. When you think about that, the sheer size, we house the administrative offices in there, the business office, medical records, the motion analysis, the physician practice.

Sara Cristello: Research.

Tracy Davis: It is really big when you think, I didn’t think about how big it was.

Victor Derienzo: It keeps going on and on.

Tracy Davis: It is very big.

Victor Derienzo: It just keeps going on. The project will take about anywhere between 12 and 14 months once they start. Right now we’re in the design phase. We’re using a company out of Michigan to help us walk through and gain efficiencies in not just how we want to put the four walls up, but how does each entity within the plaza function with the patient being at the center of what we’re focusing on. It’s the patient experience. We have several goals in working with this individual. Number one is we want to make sure that the patient experience is unlike any other. Want to make sure that our staff has a great experience when they come into work, too, as well. We want to make sure that it’s efficient for them. They have partners in adjacencies where they can leverage their expertise to come and look at patients, and then as well as making sure that we can do it in a way that’s somewhat affordable. When you talk about that size of a clinic to renovate, or a building, it comes at a high cost. That’s always the caveat to all this. We want to make the Taj Mahal and then we have to pay for it.

Tracy Davis: And keep it operational.

Victor Derienzo: Exactly.

Tracy Davis: While it’s being renovated.

Victor Derienzo: Exactly, while seeing patients through all that reno. The phasing and the stages will be unlike any other. We’ve never done this before to this scale, so it will be a well orchestrated phasic approach, moving people in and out with trying to preserve the bulk of the patient care areas with minimal disruption, but yeah, it will be a challenge over a years time.

Tracy Davis: Sure.

Sara Cristello: So no new windows?

Victor Derienzo: Just my office.

Sara Cristello: Okay, just your office.

Michele Orallo: Are there any new services that you guys are planning on having in the near future?

Victor Derienzo: At the plaza?

Tracy Davis: In general.

Michele Orallo: In general.

Tracy Davis: Anywhere. You could think of possibly, that you’d like to do.

Victor Derienzo: Things that we would like to do, I know we’re focused on the services that Sara had mentioned, enhancing some of the ones that we offer, and creating new ones around demand being, one being, which she mentioned, oncology. That ones growing. We actually hired a rehab navigator around oncology patients that we’re piloting in our joint venture with Halifax. We’re working with their oncology group, and the number of patients that need care but were not receiving our services, weren’t even getting referred to us, is absolutely amazing within the first three months of launching that new position. We sent about 90 patients through for a screening of which about a third of them can and should receive care. That’s been one that, again, we just started in quarter four of 2019. I mean as far as new services, I know we’ve been talking about launching a few specialty lines, one around psychologically informed physical therapy, and really addressing some of the acute pain patients that we have that turn chronic, and being able to identify them much earlier and sending them to the appropriate clinician and/or psychologist for services. I know that has been one of our initiatives.

Sara Cristello: Yeah, I can’t really think of any other new services other than there has been a lot of focus on making sure that we are really elevating our level of training in clinical expertise. If we say we’re experts in treating the patient who needs oncology services, we really are experts in it. We’re really focusing on that. Within all of the programs that I mentioned, we’re really just making sure that we have sort of the gold standard of education plan, and we’re helping therapists who have an interest in any of the specialties really develop that specialty. They all sort of fall within PTOT and Speech, but again, there’s a lot of niche practices that maybe are under utilized in the Jacksonville market and then potentially in other markets, that we’re really just trying to identify and build expertise around.

Tracy Davis: Just a couple other quick questions before we wrap up. A couple things came to me. Firstly is technology. I was working on a video early last year. I think it was at the 25 year our time capsule event downstairs in the hospital. I was asking some people who have been here for a long time, like Virgil, Russ Addeo, Jim Edwards, all these guys, and saying how has rehab changed over the years since 25 years ago to now? With all the technology and stuff that we have, I was shocked to hear that they said that it hadn’t really changed a whole lot as far as rehabilitation and the patient comes in, they have a need. A lot of the techniques and things are still the same.

Tracy Davis: How is technology … If you go into any of our clinics, there’s going to be some crazy equipment, like center for sports therapy, the antigravity treadmill, and all these crazy things. How do you guys look at, and whenever we’re going to purchase a new piece of technology to put into a clinic, what does that thing need to do? Why is it worth the purchase? How do you look at technology in general for rehab?

Victor Derienzo: If you just go downstairs and look at our neuro recovery center, you’ll see hundreds and hundreds of thousands of dollars of equipment. I guess we would look at certain pieces of equipment that align with the types of patients that we’re seeing. Will it help get us better outcomes for that patient? Is it a valid piece of equipment? We have a fund that we use for new and emerging technology. We’ll do trials and we’ll have vendors come in that will allow us to utilize their equipment for x amount of months to do some sort of a pilot to see if it’s beneficial, see if we’re actually seeing results with the types of patients that we’re seeing, too.

Victor Derienzo: But you’re right, fundamentally, rehab has not changed in the last 20, 30 years. It’s being sprinkled with new technology, but fundamentally, it really hasn’t changed. Looking at some game changers and leveraging artificial intelligence is coming up, telehealth, Cyberdyne as well, being another piece of technology that we actually brought to the US. Some of those are really game changers, but definitely one offs and not in the core of how we deliver our services.

Tracy Davis: Right.

Victor Derienzo: We’re evolving to that, but it hasn’t been a steady progression. It’s been more so recent within the last decade, I would say, that we’re really starting to utilize and leverage some of these new and emerging technologies as they’ve come about.

Tracy Davis: The Cyberdyne team did tell us that we’re going to try and start having some in clinics and things like that and expanding to get outside of just here at the treatment center.

Victor Derienzo: We’ll have two in outpatient this year.

Tracy Davis: Oh, great.

Sara Cristello: I’m an orthopedic therapist, so when you say technology, patients will come in, “I need to tour your site and see what equipment and technology you have to see if this is the right clinic for me.” I’m like, well here’s my hands, and there’s a treatment table. That’s kind of really all we need, but it’s completely different for an orthopedic therapist than other types of our rehab professionals. The one thing I think of, other than maybe equipment, when you say technology, is something that we are really working on is using data and predictive analytics. A huge initiative that we’ve been working on in outpatient is really figuring out, in the simplest way, can we all enter information into the computer the same, which sounds so silly, but it’s really hard. I would write 160 degrees and Victor would write 160, and then Michele would write within normal limits, and you would write, no pain, and then the computer says what do I do with that information? We’re really just starting. We’re trying to get in where all the other types of fields beyond healthcare have gone with data. We’re really just trying to gather.

Sara Cristello: With that, we’re really giving a push towards collecting outcome measures, so patient reported outcomes and how they’re doing so that we can use different forms of analytic platforms to tell us that we are really excelling in some areas, and there are some areas where we could do some educational pushes because our patient outcomes aren’t where they are. I think about the actually technology piece, and you say, if we bring in a trial of piece of equipment and it doesn’t change our patient outcomes or our patient experience, if it doesn’t help them regain their function anymore efficiently or quicker, then maybe that’s not a piece of equipment that has some longevity with us as an organization. It’s really more of a computer science type form of technology, but really where every type of company is going, as far as using data to help predict what the future will look like. We’re trying to do that with our patients as well.

Tracy Davis: Brooks is on the cutting edge of rehab technology, it’s just that rehab in general, like you said, it’s still very much clinician or therapist to patient.

Sara Cristello: Correct.

Tracy Davis: These things are just helping maybe shorten the amount of time that a patient would have to do a certain thing. Stuff like Cyberdyne is kind of out of nowhere. That’s definitely leading edge, but it is just funny to me to see all this crazy technology, and it’s all very good. Patients are down in the neuro recovery, like you said, and they’re able to do things without a therapist having to be there because they’re on a certain piece of equipment. A lot of that stuff has changed.

Tracy Davis: Two other things and you guys can split these, is IHL, the Institute of Higher Learning. We haven’t had them on the podcast yet. How have the fellows and residents effected outpatient? I know that they’re all over outpatient, and then the clinical research team, which we also haven’t had on. How does the stuff that they discover and the things that they’re doing drive? I don’t know which one wants to take either question.

Sara Cristello: I’m an employee of the IHL, so I guess I should take that one.

Tracy Davis: There you go.

Sara Cristello: I think ultimately, our motto, just our motto we’d say behind closed doors is “you can give a man a fish, or you can teach him how to fish.” We really focus on teaching people how to fish. Whether that is using research or consulting with a colleague who has a little bit more experience than you, but really, being curious. Are you curious and non complacent for your patients? With that, it is just a mixture of looking at the evidence, looking at expertise around you, looking at your experiences, and then making sure that we do not settle for the status quo. I think that that curiosity then just bleeds into those who may not, just doesn’t work for their family/life balance to ever do a residency or fellowship, but it just sort of helps to create a culture of curiosity outside of if you don’t do a residency or fellowship. Ultimate, the patient’s outcome is really the focus of it. It’s really just, I think, what really helps us elevate as a company, the level of care. You’ll hear Bob Roe say there’s 18 line highway of how therapy is delivered and we probably just need four or five. I think the residency and fellowships helps narrow those lanes and encourage people to be curious. What are you doing over there? Oh, that’s interesting. Then helping each other grow.

Tracy Davis: Can you give the what is the Institute of Higher Learning, just kind of the elevator speech as to what it is so people know?

Sara Cristello: I don’t want to say it wrong, but the Institute of Higher Learning has, I think three, maybe four components really focused around clinical education. We have residency and fellowship programs both for physical therapists and occupational therapists. That’s where we sent all of our student internships. Anybody coming through to do an internship with Brooks for any of the disciplines.

Tracy Davis: From anywhere. We get people from all over.

Sara Cristello: All over the country. We have a continuing education branch. That’s really focused on delivering CEU quality, whether that’s through the BAPS program or through onsite programs or even traveling courses to help deliver some of that quality content.

Victor Derienzo: I’ll just add to that, too, as well. With the evolution of the IHL and us graduating more and more residents and fellows over the years, it really has added to our culture of moving towards. You hear a lot of people talk about evidence based out there, but this is a truly an embedded part of the culture of IHL, and that bleeds over into other clinicians and to your point, Sara, spurs the curiosity in the clinic. When they see someone like Sara coming in and/or Trent and/or some of the other coordinators when they’re in a mentoring session and they’re both working on a patient and Sara is stepping back and questioning, and asking the why, helping them to think through why they’re doing this test, why they chose this particular innovention. It’s just taking things to the next level. They see that and they want to be part of that. You start to create that infectious type of curiosity culture. We market this. We mirror it after the medical model, so physicians understand what a residency and what a fellowship is. They’re just great representatives of our organization. With each passing year, we just get that much stronger and moving towards reducing that variability of care.

Tracy Davis: I think patients like hearing that, too.

Victor Derienzo: They do.

Tracy Davis: That we have therapists that are wanting to go beyond their school training to continue their education and reach the highest. You’re never going to stop learning, but you know, to go further. That’s why it’s the Institute of Higher Learning.

Victor Derienzo: Correct. I’ll just add for research, too, as well, headed up by Raine Osborne. I know that we’ve been doing some fairly unique things over the last year, really wanting to implement what the research is telling us and/or trials, and bringing that into the outpatient setting more so right in the care setting. How do we integrate? How do we implement what we’re learning? How do we make that in a practical application to me treating a patient in the clinic, versus that’s good to know? More research is needed. Let’s take it the next step. Really looking at how do we integrate that into true patient care.

Victor Derienzo: We’re also looking at our satisfaction scores. We have a decade plus long list of many, many data points on tens of thousands of patients that we’ve seen over the years, and really starting to break down and working with our partners at University of North Florida to run a research endeavor around are there variables? Can we predictive model, right? Can we look at the data that will tell us which patients have a tendency to have a poor experience? Which patients have a tendency to have a high experience before they even come into their session, based on X, Y, Z. We’re running that analysis now through our researchers and through our research department to tell us unique … It’s not always around clinical care. It can touch many, many different points. It’s been exciting.

Tracy Davis: Like we were saying earlier with technology and all that, research is important because that’s how rehabilitation does go further, through all these studies that we have going on. We’re getting some big grants to do a lot of these studies for maybe multi year or very specific things. Then maybe some technology gets invented because of some research that was found, maybe not necessarily here, but here’s a new piece of equipment that research shows will help X, Y, Z. Research is really the way we’re going to keep going forward.

Victor Derienzo: Yeah, and we fund a lot of that, too, with EI Squared grants. Brooks funds a lot of that as well. It’s been interesting to know that we’re moving forward a lease with the concept of having our own innovation center which will be built around the sole purpose of solving clinical problems. We’ll have a combine of maybe a physician, a physical therapist, an engineer, whomever, to solve whatever unique clinical problems that we have, and for folks to just collaborate on different things and different ideas. So as a brain trust, if you will, a center that would foster that. We look at how do we change education? How do we change clinical practice? How do we evolve in technology, would be the three buckets. Research is at the center of all that and touches each area. It’s a whole multitude, integrated team approach, again, with the notion of the over arching theme as to solving clinical problems, at least in our market, and then ultimately become a destination center for others to use.

Michele Orallo: What are some lessons learned while you guys have been at Brooks?

Victor Derienzo: How much time you got?

Tracy Davis: Just a few minutes.

Michele Orallo: Four minutes to be exact.

Victor Derienzo: I have learned I can’t even begin to start to wrap my head around lessons learned. It has been, to your point, Tracy, it’s been a constant education, constant challenge. All for the good.

Tracy Davis: Maybe focus it around leadership lessons learned, like some top leadership things that you’ve learned since being VP.

Victor Derienzo: Yeah. The biggest thing that I have learned that no matter how intelligent a leader is, how driven a leader is, they can’t get anything done without just an amazing team, not behind them, beside them. That’s the only way we get anything done. I’m going to tell you right now, and to the level that we do in the outpatient division is that we just have a very, very strong, highly motivated, talented, intelligent team around the table every single week. These are the folks that come up with many of the ideas and/or say yes and/or foster the ideas that come in from the field to make us what we are today. To allow us to grow. To allow us to be successful, have the highest patient satisfaction that we’ve ever had with each passing year. For me, I can have all the ideas in the world, but they would fall flat without a solid team around the table. That’s what I would say.

Victor Derienzo: Again, you hear people talk about oh yeah, team is everything. Unless you live it, believe it, and breathe it, I mean, it really is. That’s been a huge lesson learned to knock over the head for me as I’ve evolved.

Tracy Davis: Sure.

Sara Cristello: Just speaking of somebody that works with you, you feel it and then it’s fun because it opens up sort of a safe space so you can have opinions and debates and challenge each other, which really is really great for moving forward. I would say that my, this is really hard, but I think there’s probably one thing that overlays any growth or lessons learned, would be the importance of self-reflection. Really, just thinking about what went well and why and potentially it’s because you had a really strong team beside you, or what that might be, and what didn’t go well and why. Bob Roe is really been crucial in the education around how to take feedback and not make excuses for feedback. Really, I think just that self-reflection to say when things didn’t go well, just being open to really reflect and think about things that you could have done better and actually really working hard to do something different and better the next time.

Sara Cristello: Really, it’s just kind of being on that continual growth of I’m going to do things well and I’m going to celebrate those and really think about why they went well so that you can repeat those things in the future and then really learn from mistakes as opposed to it’s just a hard pill to swallow. You make mistakes. Really reflecting on those has really helped. Then there’s a zillion lessons that came from all of that reflecting. That’s something we really try to do in the residency and fellowship, too, just sort of I can’t as a mentor give you your answers, but if you can reflect, then essentially you’ll come to a good conclusion yourself.

Tracy Davis: Never think you have it all figured out. Always keep learning.

Sara Cristello: Right.

Tracy Davis: Okay. If someone wants to get outpatient therapy, is going through the CIU the best way to do that? To first contact Brooks? Say someone is listening to this and they sprain their ankle or worse, or whatever, or less, and they want to come to outpatient. Is the CIU the best way to do that?

Victor Derienzo: Yes, they can just go to the website. They can either email, call, and/or fax. All the information is on there.

Tracy Davis: Actually write the phone number down. If someone is listening right now and you want the phone number, it’s 904-345-7727.

Victor Derienzo: Perfect. Thank you, Tracy. Finder’s fee.

Tracy Davis: Yeah, that’s right. BrooksRehab.org. I think it’s BrooksRehab.org/outpatient and you can get right to the page to learn more. Thank you guys for coming on.

Victor Derienzo: Thanks for having us.

Sara Cristello: Thanks for having us.

Victor Derienzo: It’s been great.


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