OT Across America: Scottsdale, AZ with Brenna and Andrea
For OT Across America: Scottsdale, AZ edition, we got to meet and interview Brenna Ehrhard, COTA/L and Andrea Brennan, OTR/L about their experiences working in Scottsdale, AZ while we enjoyed a Mexican happy hour at Salt and Lime by their workplace.
We had such an interesting and insightful conversation with them and learned so much, and think you definitely will too!
Tell us a bit about your backgrounds and what drew you to occupational therapy.
Brenna: I float between inpatient and outpatient. Inpatient rehab facility with outpatient as well. I was drawn to OT as soon as I found out what it was. I went back to school after being a teacher to find out what I wanted to be when I grow up. And I took a career exploration class. Occupational therapy kept coming up and I never heard of it. So I looked into it and the light bulb went off. That’s that’s what I need to do. So, here I am!
Andrea: My name is Andrea Brennan. My professional credentials are: I have a Bachelor of Science in Occupational Therapy. I have a post-professional doctorate in Occupational Therapy with a focus in Administration and Management and Lymphedema Management. I am a Certified Lymphedema Therapist. I’m board certified by the Lymophology Association of North America. I am Casley-Smith International Certified. And I am also a certified international instructor by the Casley-Smith technique. And I’m wound-care certified.
I graduated in 1978 before OT was even reimbursed by insurance. And how did I choose OT? I was at Emory University and I was a general liberal arts major. And my sister at the time graduated with a Bachelor of Science in French flipping crepes in a restaurant in New York City. So my parents said to me “You cannot have a liberal arts degree, you’ve got to pick something.” So I went through the Dictionary of Occupational Titles. I knew what I had for my pre-reqs. I knew what type of field I wanted to be in and when I matched everything, occupational therapy came up. And I applied and I went to Tufts University Boston School of Occupational Therapy. So that’s how I found OT. That’s all I do.
In 1978-1996, I was in acute care. And at that time acute care was what inpatient rehab is today. We had acute strokes that were in my hospital for 10 days so we were able to treat them and then transfer them to rehab. And then I did acute work and then I did outpatient, home health, and skilled nursing. And then I worked with a private business. I had my full time job then I did nursing homes in the morning, and home health in the evening because I wanted to get the children’s college funds in the bank.
So in 1996, Medicare changed their rules. And the rules were that you should now have scored nursing facilities in the acute care setting. But they changed the rules so you could not do skilled nursing in acute care setting anymore. So then there were lots of therapists out of a job. So somebody said to me “Do you want to do lymphedema?” I said, “I don’t know what it is but if it gets me hours I’ll do it.” I did my first patient and I was hooked. And in 1996 to present, I created an opportunity to only do lymphedema.
So I created five different programs in the Valley. And each time I had a different goal. One was just to do inpatient lymphedema. One was to do outpatient lymphedema. One has to create a program. Then one has to be in a cancer center and then ultimately be in a rehab center where I was inpatient, outpatient, home health, and aquatics. So that’s where I am. My goal is I’ll be retiring in just under four years – maybe four years plus or something. Occupational therapy has changed dramatically. Not only the profession but the people who are entering the field and the clinical thinking and judgment of the skills of the therapist has also changed.
Brenna: I’m certified in three different aquatic methods. So I specialize in occupational therapy in the pool with aquatics. And we are getting ready to start treating Andrea’s lymphedema patients in the pool. She’s already doing some of them but now we’re going to be partnering.
Andrea: It’s fantastic for them. However, we have to bill. And the income that I was generating was not enough reimbursement so I had to justify my position and figure out a strategy that would reimburse at a higher rate. Aquatics is one of its highest. So now I reimburse I bill for three aquatics and one decongestant so I’ll have to share with you what I do for the decongestant. Aquatics is incredible. In my Casley-Smith re-certification that I just had in Rotterdam in the Netherlands, we are now starting to teach aquatic therapy as part of our lymphedema certification. So with that, and knowing ahead I can meet the business end, but also meet the biopsychosocial needs of the patient not anybody could say that they have the ability to do it in the facilities -the magnificent facilities – that Brenna keeps up.
Brenna: I don’t mean to be negative but I feel like here in the states we’re so far behind in aquatic therapy compared to what they’re doing in Europe.
Andrea: Oh honey. Not just in aquatics. I go to the UK every year for a week because I get my training and I go for conferences – international conferences. Because there is nothing here. What is here is perpetuating an old school mindset. Nothing new based on evidence. I’m an evidence-informed practitioner and our clinicians locally – or at least nationally – do not read the evidence. Every day I get a ding on my Google Scholar alert and I read the evidence. And I change my practice each day based on what I find.
But that’s what my training was in 1978 as a clinician. As a therapist, you cannot use a recipe. You cannot use a computer that puts everything in for you without knowing why you’re doing what you’re doing. So that’s that’s my pet peeve with therapists today. And that’s not any one profession, it’s really throughout.
Tell us more about Occupational Therapy in Aquatics and your outpatient practices.
Brenna: It’s emerging for OT. It’s very PT dominated. I’ll just jump back to the Netherlands – we’re lucky enough to have people that come over from the Netherlands International Aquatic Faculty and certify us here in the states. So we’ve been really lucky in that regard. But, I’ll say that it’s still very PT dominated. But there are even speech therapists that attended. You can even do speech in the pool.
Andrea: Just like just like Brenna said, all my training is in the UK, Europe and Australia and it is a PT-dominated field. And I’ll go one step further. You’re not gonna believe this. I have a school [The Brennan School of Innovative Lymphatic Studies] and I teach. So I called AOTA, and I said “How can you as an organization help me do my lymphedema?” And guess what they said: “Nope. OT should not do lymphedema. It is not occupation-based. Therefore we’re not going to support you.” So here I want to support my organization. So what I had to do was contact my PT friends. And now I’m an uber APTA member on their rehab oncology section and on their Lymphedema listserv because OT was not interested in it at all. And what’s really interesting between my OT practice generally and my Lymph practice. And the PTs who practice Lymphedema – they do not have a creativity or the wherewithal to do what we do as an OT. So it really is OT-based and occupation-based and it blows my mind that AOTA is not interested.
Brenna: The methods that I’m certified in are clinical tai chi which focuses on Meridian stretches. And it’s great for balance. It’s about the base of support. And also the water-specific therapy which is about motor control. And then another one for neuro patients that uses patterns and facilitation of muscle activation in limbs that are flaccid or hypertonic.
Andrea: What is the current evidence on PNF? It is fantastic for lymphatic drainage and I’m doing a lot of that. So that skill set I can give you the article to show you how to marry those two techniques.
Brenna: Yeah they’re all evidence-based as well.
What do both of your typical days look like?
Brenna: It’s rare that I work an 8-hour day just because – especially in the summer around here, we just don’t have the caseload. With a busy pool season, I’m in the pool maybe two or three hours a day. There are certainly weeks when we’re slow when I don’t get in the pool at all. But in a typical day we do 45 minute treatments back to back. I typically go in at 7:00 and I’m usually finished treating by 1:45-2:30. I see a lot of neuro patients, mostly strokes. My time is pretty evenly divided between inpatient and outpatient. We all share one gym, so it’s not like I’m having to go to go somewhere else to see the outpatients. I have to go down the hall to get a new patient. A lot of neuro, lot of ortho, a lot of strokes, a lot of brain injuries. And then our facility is certified in hips, stroke, and Parkinson’s.
Andrea: I have no openings. I’m busy from 6:00 AM to 6:00 PM (or 7:00 PM or 8:00 PM). Based on cancer survivorship, the official concept is this: When a patient has gone through cancer treatment – of course they have to take off time from work – then they have to use their FMLA. Then they use all their paid time off. And now they have survived the cancer. But now they have to deal with the sequela of the cancer treatment. And they no longer have FMLA. They no longer have PTO. And they need treatment and they have to work for their benefits. So guess what happens? Unless the therapist will work with them and offer them treatment before or after work hours. So I am seeing before 6 AM, 5 AM, 7 PM. And then like this week for example, I was 6 AM to 8 PM and then I’m 7 AM to 5:00 and then 6:00 to 2:00 and then whatever my hours are to get 40 hours. Then I either take off Thursday afternoon or all day Friday (maybe Monday) and I adjust accordingly. You know because it’s not about “Oh I don’t have boundaries.” It’s just that if I’m going to practice what I preach, then I gotta do it. And so that’s what I do.
Can you say a little bit about your productivity?
Brenna: They want us to be at 100%. If I were to work eight hours they would want me to see 12 patients in that day. So that would require doubling up on patients at least for one or two sessions. We have a fair amount of groups for inpatient so that can help with productivity as well. Because we’ll have up to six patients in a group. And the regular groups that they offer are tai chi, yoga, or games. They have a discharge goals group. They’ll have a couple of different ther-ex groups. I used to run a cooking group, but haven’t done that lately. It’s very functional, but that gets really busy really quick. You have to have the right patients at the right level and have them standing up for them to get the most out of it.
Andrea: I’m one on one. So this is what I do. About 80% of edema that I see is lower extremity. And the problems can be very mild. There’s gynecological cancers, and urological cancers, and there’s malignant melanomas, there’s chronic venous disease, there’s diabetic microangiopathy, there’s wounds, morbid obesity induced, primary lymphedema, people are born with it, babies are born with it. Like I’m having a four year old come over and I have to fit her for garments. A sixteen year old got a fracture on her ankle playing soccer which triggers their primary lymphedema. So it’s more a lower extremity than upper. And then for upper extremity, it’s more of the breast than the arm and then upper quadrant scapula displaces dysfunction and things of that nature as well as post-mastectomy pain.
So it’s really a manual therapy and I was just over at Midwestern University teaching for the morning trying to tell them chronic lymphedema is not about that little bit of swelling. It’s a manual technique that’s an adjunct to their modalities that they learn in OT school. People think it’s just fat, but it’s a manual technique in how your hands can be used. It’s not about ultrasound. It’s not about anodine. It’s not about the upper body or ergometer. It’s your hands. And you can learn and palpate and do magnificent things with your hands. So that’s what I teach and that’s what I do. I’m hands on for 53 to 54 minutes.
But then because it’s so busy and there’s not sufficient help, I have wipe down out all my supplies and clean up for the minutes in between just to get my next patient. And because I’m a hands on the whole time, I can’t do any charting. That’s why at 3:00 AM I have to document. Pam says I don’t have a life balance, but I can’t. I can’t. And some people who balance it will use a vasopneumatic compression pump. And that is an adjunct to treatment. And 90% of the patients have a pump at home. So to put a pump on the patient when they have it all at home, I can’t justify it.
How many patients do you see in a day on average with your productivity standards?
Andrea: Well let’s put it this way. Average per day I’m going to get about 30 units. So 30 units a day divided by 15 minute increments is 7.5 hours and I have a half hour for lunch. However, in my role I do a lot of marketing. I have physicians consulting me on the phone. Every morning that I come into work. I have 10 to 15 phone calls. And I get about 10 to 15 emails a day. And I have to measure for garments. And I have to verify DME. And if I need pre-authorization, I have to sit on the phone to get the order. So I’m really a one person department. When I worked at the other hospital, I had my own COTA and technician. And we were still busy.
My standard is supposed to be 3.25 out of an hour. But it’s not about productivity. It’s about reimbursement. Reimbursement is so low that for the organization – whether it’s Encompass or anybody else – has to justify the expense of the staff, the non-productive staff, the hospital staff meaning those who do not produce like the insurance people, people that answer the phone, the technicians. It’s so expensive. Like for me, for every patient I see it might not even meet my salary because of what I bill. So with the higher the productivity standard maybe they’ll meet revenue.
Brenna: Yours is 3.25, mine is 2.8. But as a PRN – and I feel very fortunate about this – productivity is not a factor. It’s a factor in my evaluation, yes. I’m excited to meet it. But I’ve never gotten in trouble for not meeting it. I feel too one wonderful thing about our facility is that our director is an OT. And it’s just a very relaxed atmosphere. Our team does a lot of teamwork. We don’t have a whole lot of turnover. And she really strives to hire people that she thinks will fit in well with our team.
What do you like most about your job?
Brenna: I’ve tried to leave several times. Actually because I used to live down the street, now I live 30 miles away. So yeah I’ve tried to find other jobs and I’ve gone to other places – even some world-renowned places in the valley here and I just don’t find same teamwork.
Andrea: The reason that I’m still at Encompass is a couple of reasons. Number one, my patient demographic is fabulous. Most of my patients are Mayo referred. Their Mayo program is not as patient-oriented and they wanted me to go over to Mayo but they said they don’t want to Mayo-nize me. They would rather have me have autonomy. So I have autonomy and the type of treatment that I need to offer these patients. And our boss – who is really quite a realistic person in what we can do and what we need to do. She’s allowed me that autonomy. So one, I’ve got great demographics because they can afford the products because insurance doesn’t cover their supplies. And they can afford co-pays.
Number two, yes Pam is exceptional. She’s a fairly new grad, however she was a therapist at our facility. She really understands the nuances and frustrations we have as a clinician. But her ability to manage the needs of her staff and meet the needs of the organization is very, very good. It’s a very hard role. So when my boss says to me, “Is there any other way that you can generate revenue?” I’m on it and I will do it like gangbusters because I tell my boss if I can make you look good then you’re happy and I’m happy. So that’s number two.
Number three, we have inpatient, outpatient, home health – because I’ve trained some home health therapists – and aquatics. And there’s only one inpatient facility here in all of U.S. that has the skill, the wherewithal, and the desire to treat patients like I just showed you. And that’s Encompass Health because I have worked with our management to look at that. And the admissions people are really, really on top of it. And then we have a whole continuum of service: inpatient, home health, outpatient, outpatient with aquatics.
Number four, I live around the corner and I don’t even have a light to get to work.
What is the biggest challenge you face in your current position?
Andrea: I feel like Rodney Dangerfield. I get no respect.
Brenna: I think you get a lot of respect from my point of view, you do. You might not feel it. But I think it’s there.
Andrea: When I have to wash the bathroom floors, when I have to clean the toilets, and I have to wipe down things. I am the last priority; PT goes first. Oh I have to help them walk a patient when there’s two other people there and I have a 150 pound leg I have to lift. So I don’t feel that those in my work field respect what I do. And if they do respect what I do, I don’t know what they respect how much work I have to do behind the closed door because I’m exhausted at the end of the day. I cannot chart. I am lifting these patients up. I am moving these patients up. I am psycho-socially trying to deal with their issues. I try and I ask for help, and I don’t get it. And when I asked for help, “I’m too busy. I’m too busy.” Could somebody make a phone call for me? Fact: there are days that it takes me four hours of faxing. It takes me an hour to be on the phone for pre-auth. In the office, Melissa could stay on the phone. I don’t have any of that help. I have absolutely no ancillary services.
Brenna: I agree with you in that regard as far as our techs. I don’t feel like they’re very supportive. I feel like they’re more about gathering patients, which is a whole other topic. I feel like patients should be getting themselves to the gym if they can. And I get a lot of push back from the techs too. Like today I didn’t get lunch because I couldn’t get anybody to help me in the pool. That kind of thing. That’s a big frustration.
Andrea: I barely get a lunch and I’m up at 3:00. I do 60 to 70 hours a week because my job – the part of it as a lymphedema therapist – is measuring for the garments, getting the DME equipment, making sure everything works, organizing that, doing my emails, my marketing, and that does not come out of my productivity. And so that’s one of the biggest things I really don’t feel I am respected for what I do and what I bring in. And even though I love my boss and Pam knows it – and I’m saying this out loud because we have discussed it – her job is to meet the needs of the organization and there’s no question about it. The mama ship has to be fed. All needs, all staffing needs are based on the mama ship. So mama ship is low census, guess what? Our outpatient techs go home, the front desk goes home, COTAs go home, which means housekeepers go home. I don’t even wash the toilets in my house, I’m washing toilets too. So that’s my issue.
The other area is I don’t mind helping inpatient staff on weekends and doing a rotation. However, when I take a day off during the weekend on Saturday, I have patients that are only like 20 visits on a therapy threshold. If I don’t see them for 4 or 5 days – because I have to take off a day – because I’m working so much. A) My revenue goes down in outpatient and B) My plan of care gets screwed. It’s like having a cardio-thoracic vascular surgery do Family Medicine. I’m not used to doing the general stuff. And when I do it, I’m not complaining. However, I know that the paperwork and the FIMs – everything is so important and I don’t want to screw it up.
So now at least when I do it, I talk to the FIM lady and she always checks my work at the beginning of the day of the weekend because I mess it up all the time. And I don’t want my fellow therapists to have to fix up and clean up what I’m doing. And by and large, it would just be easier but they say it’s not fair to the other therapists. You’re no different. I’m not different, yet I have 40 years of experience. I have a specialty. I am bringing in revenue for the inpatient side. And it’s not fair really when the other PTs each have a PTA that they can pull on and I got jack. So I’m a one-person department. It’s not that I’m a diva. I’m looking at generating revenue and I’m trying to help the inpatient staff to not fix my mess because I only do it once every 3 months. For 19 of those days I get to do what I love. For 1 day I can do what I don’t love.
What would you say the job market is like for OTs and COTAs in Phoenix and Scottsdale?
Brenna: I think it’s wonderful. We’ve had a couple of people move: one to Ohio and one to Wisconsin. Both of them were shocked at the limited opportunities. It was one OT and one COTA, and they both really struggled to find jobs. And I feel like here I could change settings tomorrow, I feel like the world is my oyster.
Andrea: For me, if my boss said let’s hire another lymphedema specialist tomorrow, I could do that. If I hired another lymphedema full-time therapist, my waiting list is so long right now that I can have two people full-time be busy. But it’s not their priority. Their priorities are to feed the mama ship. And I accept that. But then they cannot say, “Get people in, and get productivity up” because I can’t work any harder. I’m trying to work smarter, but without the resources it’s very difficult.
Are there other Lymphedema-Certified OTs that you know in Phoenix?
Andrea: If I went to the Brennan School of Lymphedema Education and I took a three hour course by Graham I would be certified, and it’s only three hours! “I can practice and I can write CLT because I got certified!” So there’s no criteria for that. That’s why there’s all the initials by my name. It’s not to show, “Oh, wow, look she’s got all this training.” But because demographically my patients are smart. They can read the alphabet soup and see they’re getting a post professional doctorate – that usually means quite a bit – as well as I’m wound care and board-certified. So that’s the challenge about making sure they’re a good therapist.
Is there anything unique about Occupational Therapy in the Phoenix region?
Brenna: Financially they will come from Uma, California, Puerto Rico, I have people from Tuscon. They will travel 1-2 hours or 4 hours. They are very dedicated. Because of where we’re located we get a lot of higher income.
Andrea: The newest evidence is patient-driven care and concordance, compliance, and adherence. I personally don’t use the word compliance because that’s very paternalistic. So I will say to the patient, “How can we plan some type of treatment that you will be able to adhere to make this chronic issue not so challenging for you?” Because some therapists will say, “You have to wear that garment 100% of the time.” You know darn well they’re not going to. So I ask, “What will it take for you to be successful?” So when I change my focus to adherence and not compliance, I get much better outcomes.
Brenna: I use that method with the home exercises as well. It’s about asking them what they can do. And we’re really slow in the summer because the snowbirds all come down during the winter. That’s more of a Scottsdale thing because I have friends in the East Valley or when I worked for St. Joe’s downtown they weren’t as affected by the seasons as we are here in Scottsdale.
What are your future plans for your occupational therapy careers?
Andrea: Since I’m a certified instructor in the treatment of lymphedema and chronic edema – and it took me two and a half years with training at the University of Glasgow – I’m now training people and my goal is to do two training programs a year with me. Maybe either do it part time here or consulting, but I don’t see myself ending treating because I love it too much. But I do want to do teaching. And I’m hoping this will be my last job.
Brenna: My long-term plan will be to own my own aquatic facility. I don’t have any sort of timetable on that at all. I’ve explored options. I also want to get the word out about aquatics and OT with what I’m currently working on. I’m preparing a little handout so that all Andrea’s patients will get the information of aquatic therapy as well as the availability of community program or continuity of care. We also run a community program for the pool as well. Some of the women have been coming for 20 years. Their doctors tell them “You’re as healthy as you are because of the aquatic program.” I did a case study on dementia and we’re hoping to do more research. Just being immersed in the water without movement increases the cerebellum blood flow.
We want to again extend a huge thanks for Andrea and Brenna for taking the time to talk with us! If you’re an OT practitioner working in these settings, or are in Scottsdale, we’d love to hear your thoughts and experiences in the comments below.