Rafael (“Rafi”) Salazar is an OTPreneur, consultant, and founder of Rehab U Practice Solutions. He’s the quintessential renaissance man in the non-clinical OT world!
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What is your full name and title at your current job?
Rafael E. Salazar II, MHS, OTR/L
I have a few different titles:
- Principal Owner, Rehab U Practice Solutions
- Integrated Clinical Support Specialist/Healthcare Consultant, CRA Consulting
- Part-time Assistant Professor, Augusta University Department of OT
Where are you located?
I live and work out of my office in Augusta, Ga.
Where did you go to OT school, and what year did you graduate?
I went to what was then called the Medical College of Georgia (now we’re Augusta University). I graduated with my MHS in OT in 2012.
What did you do when you first finished school, and for how long?
My first job out of school was as the sole OT in two skilled nursing facilities, working in the rehab contracting department for a larger medical corporation. We were basically contracted to manage the rehab needs for these two facilities.
I was the only OT, so I split my time between the two facilities, managing the caseload between them both and supervising 5-7 COTAs. It was a lot for a new grad (talk about getting thrown into the deep end!).
The majority of the caseload at one facility was subacute rehab, so patients would stay 30-60 days or so, then discharge home. The other facility had a heavier caseload of long-term care patients. So I ended up doing a good bit of long-term care, contracture management, etc., and subacute rehab.
I worked that job for around 6-8 months or so.
What did you do after that, and for how long?
From the SNF position, I moved to an outpatient specialty rehab clinic at my local VA hospital. The bulk of the caseload was UE orthopedic rehabilitation, but we served patients from Rheumatology, Neurology, Neurosurgery, Primary Care, Pain Management, and even the Emergency Department.
I started off as a staff therapist in that clinic, and stayed there for about 4 ½ years. By the time I left, I was a lead clinician in that clinic and worked as the clinical education coordinator for the OT department, managing contracts with universities, orienting new students, etc.
I also had the opportunity to participate in the VA’s leadership development program, which provided certifications and courses in:
- Project management
- Data analytics
- Policy writing
- PR (public relations) and customer service projects
By the time I left the VA, I was “on the management track” there, and had also begun teaching in an adjunct occupational therapy faculty position at Augusta University. I was also serving on the GA State Board of OT.
What did you enjoy about your early roles? What didn’t you enjoy?
I think the main thing I enjoyed about my early career roles was the interaction with patients. I have learned so much from patients whom I have treated (as well as their families/caregivers).
I also enjoyed the opportunities that the VA provided in their leadership development program. I learned many valuable skills that I have been able to leverage over the course of my career.
What I didn’t enjoy was the seemingly dominant strategy of healthcare management as a “quantitative” vs “qualitative” approach.
What do I mean by that? I mean that, given the incentive structures provided by third-party payers and regulations, healthcare organizations spend too much time focused on the “objective” outcomes and measurements, reducing each healthcare interaction or patient engagement to a series of numbers.
This was definitely true in the SNF setting, where RUG levels & treatment minutes dictated care in the facilities (we’ll see how the new payment model works out). As I’ve written about here, time-based productivity has greatly altered the focus of healthcare from individual patients to metrics. This causes the needs of patients to go unmet, or even unnoticed, by clinicians and organizations more worried about metrics than impact.
Interesting! Can you give an example of this issue?
At the VA, I worked on a project that was—on paper—supposed to increase access to care while improving quality. The result of the project was a shift away from time-based productivity for each clinic (which was a positive) in favor of a “utilization” metric.
The theory was that, by measuring clinic availability, we would be able to make sure that we weren’t incentivizing therapists to “hit 90%” productivity, but instead to spend the bulk of their time doing direct patient care (by having their clinics booked to a benchmark capacity).
The problem was that one of the major metrics or data points used was “unique social security numbers.” That meant the hospital was looking more at the number of unique visitors to clinics—and this meant that clinicians who spent “too much” of their time treating the same patients over longer periods of time were pressured to see those patients less often, in favor of scheduling new patients.
That being said, working on those types of projects gave me a great deal of insight into healthcare management, administration, and culture development at healthcare organizations.
At what point did you realize you wanted to become an OTPreneur, and why?
About 3 ½ years into my career at the VA, I realized that I did not want to simply be a clinician for the balance of my career. I had considered getting my CHT (certified hand therapist) certification, but was beginning to think that it would lock me into being a clinician until I retired.
Because of some of the projects I was doing at the VA, I realized that I wanted to be in a position to affect greater change on healthcare systems than could be done by treating individual patients. (I wanted to be able to “scale” so that my efforts could positive affect more patients.)
About that time, I began reading, writing, and thinking a lot about healthcare, patient experience & engagement, and how effective care involves understanding how patient engagement, retention, and experience impact their clinical outcomes. That’s when the idea for what would become Rehab U Practice Solutions came about. Back then, I thought it was going to be mainly an online, course-based business, though it has evolved since then.
Cool! Before we delve deeper into Rehab U, what about your OT consultant role?
About the time I was considering this online business venture, I happened upon a post on LinkedIn. A connection of a connection posted a job for an “occupational therapist consultant.” That sounded interesting, so I reached out to the person who posted the job.
The job was to be an independent healthcare consultant, subcontracting for a management consulting firm that was helping the State of Georgia’s Department of Behavioral Health & Developmental Disabilities transition people out of state hospitals and with other issues around clinical oversight, policies, procedures, etc.
It sounded like one of those opportunities that don’t come around often, so by the end of that next week I had met with some of the other team members, signed a contract, and put in my notice at the VA. Since then (fall of 2017), I’ve been working as an independent healthcare consultant, with the bulk of my work on that Georgia Project, and then other work coming in from Rehab U.
What are you doing these days?
Now, my time is split between teaching, consulting, business ownership, and a couple other extra curriculars (GA OT Board, and Board of Directors for NBCOT). I teach part-time at Augusta University, in the OT Department. I’d done some teaching for them over the years as an adjunct or limited-term instructor, then moved into a more permanent role near the middle of 2019.
I still consult on the Georgia project and enjoy that work tremendously. Coming from the world of UE orthopedics, the idea of working with adults with developmental disabilities and behavioral challenges was intimidating. But I’ve grown to love this population and enjoy the work we do to make sure people are living safe and meaningful lives in the community.
When I left the VA to start consulting, I was already developing material for Rehab U. I ended up contracting as a PRN OT at an outpatient clinic in the area, at first as a treating clinician. One thing led to another, and I ended up helping the clinic owner with some marketing, staff engagement/training, and patient engagement & retention. That opened the door for a lot of the work that I do through Rehab U now: speaking, training, and advising outpatient OT/PT clinic owners on patient engagement, satisfaction, and retention. I’ve also started building out those courses I had originally planned on creating from the beginning.
Aside from that work, I still serve as a licensed board member on Georgia’s Occupational Therapy Licensing Board. In August of 2018, I was elected to the Board of Directors for NBCOT, and do that as well.
Are you still treating patients?
Part of my advisory/consulting work on the Georgia project involves clinical assessments and advisement/recommendations/training. So, I do get to interact with some patients, though I don’t provide any treatment.
Our team typically completes assessments, provides recommendations, and then completes any staff/caregiver training that’s indicated. We also help case management with equipment procurement and fitting. It’s a nice blend of clinical & non-clinical OT work.
About what percentage of your time is spent clinically vs. non-clinically?
I’d say 10-15% of my work is face-to-face or “direct contact” clinical work in the form of assessments and trainings. The bulk of my time is spent on all the other stuff, such as:
- Developing training materials
- Attending meetings (gotta love ‘em!)
- Participating in communication/hand-offs
- Teaching, etc.
How long have you been in your current role?
I’ve been mostly non-clinical since the fall of 2017. I’ve been teaching part-time since the middle of 2019.
How did you find your jobs? Did you apply or find them through connections?
The “job” that opened the door for me into the non-clinical world was the healthcare consulting contract on the Georgia Project. I found that via LinkedIn (I always tell students that LinkedIn is a goldmine if you leverage properly).
Since this “job” was as an independent consultant, I opened an LLC and began working simultaneously on building out Rehab U.
As far as the teaching goes, I ended up getting that through connections at the university. I ended up doing a couple guest lectures when I was a clinician. I became aware of a position that was opening up at that time. I applied and did not get that job, but I ended up making connections with the faculty members and program director. They ended up needing an adjunct instructor a little bit down the line. So I taught a couple of classes over the course of a couple of years. Then, when another position became available, I applied to that one.
Did you do anything special to your resume and cover letter to land the jobs?
I did not, mainly because my non-clinical healthcare consulting contract came about through connection and networking. I actually ended up printing off a PDF version of my LinkedIn profile and giving that to the clinical coordinator for the consulting firm, just so I would have something to hand them.
When I applied for the teaching position, I did the same thing: just a copy of my profile. Since you’re able to list courses, certifications, etc. on your LinkedIn profile, I’ve found it to be more useful than a resume. Besides, most employers or clients these days will end up googling you when you apply anyways.
What were the interviews like for the roles?
For the consulting firm
It was a phone call with the principal. Then, I ended up meeting with a couple other members of the team. Most of the questions and conversation revolved around my project management, PR, and policy work that I did at the VA.
Some of it revolved around the differences between straight clinical work and clinical advisement. I was told afterwards that there wouldn’t have even been a meeting if the first phone call didn’t go well.
They were looking for culture fit and skills/mindset more than anything else. I ended up getting a lot of on-the-job training as far as the nuts and bolts of healthcare consulting goes.
For the teaching position
A more formal interview process took place. I ended up doing a panel interview with some students, a panel interview with some faculty members, a professional presentation to faculty, students, and the Dean of the Health Sciences University, and then an exit interview with the program director. It was a drawn-out and tiring process, for sure, but nothing unbearable.
How did you start Rehab U Practice Solutions?
For my work with Rehab U, that just started as me forming the LLC, building a website and creating content. When I was working as a contract therapist for that outpatient clinic, I ended up running everything through that LLC to keep things simple, which made it easy to begin doing the nonclinical work like marketing, staff development, and patient engagement/experience projects.
I have connected with other entrepreneurs in my area and sought out mentorship as well, which has made a big difference in managing the stress and uncertainty that comes with building something on your own.
Did you get any special certifications or training along the way?
I did take a project management course at the VA, which has helped with some of the consulting and advising work I’ve done on the GA project. I’ve also done some work involving case management and other policy/procedure work in this role as well. Those skills also came from trainings I did at the VA.
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What has helped you most on this journey?
What has helped me along my career more than any certifications, has been the project-based work I’ve been able to do. From board meetings to projects at the VA, I’ve been able to gain insight and expertise that I can leverage in by business and career.
Like I’ve posted here on LinkedIn, some of my work at the VA around patient experience is still relevant and applicable to my work with Rehab U today. I always encourage people I talk with to consider volunteering for projects or task forces at their current role in order to build skills and then leverage those experiences later down the line.
What do you think served you best to land a lot of these roles?
As mentioned earlier, I took the initiative. I volunteered for projects and task forces. I proactively looked for areas of improvement and then present those opportunities to management/leadership.
When did you start Rehab U?
I started it at the same time I left the VA to begin working as an independent healthcare consultant. That was in 2017.
Where did you get the idea for your business?
I actually got the idea for Rehab U Practice Solutions when I was working on a project at the VA. It was a roll-out of a program called relationship-based care. It was aimed at improving both employee and patient engagement in the treatment programs and healthcare services.
That project opened my eyes to the problems that currently exist in healthcare. I mean, we all know that increasing productivity demands and metrics-based healthcare management isn’t good for clinicians or patients, but I got to see behind the curtain so to speak.
I got to see the drivers behind these decisions and more importantly, I began to form a vision for how healthcare could be better.
That sparked the idea behind Rehab U: the idea that patients aren’t numbers on a spreadsheet, but unique individuals with a unique set of circumstances, on a unique road to recovery—and it is our job as clinicians to meet them where they are and help them achieve their goals.
We shouldn’t try to fit patients into our mold for treatment programs, but rather we should mold our treatment programs around the individual circumstances of each patient. That why the first course I developed as part of Rehab U’s online offerings is on the Biopsychosocial Model and its implications for rehab practice.
What types of products or services do you offer at Rehab U Practice Solutions?
I also offer online training programs and courses that focus on improving patient experience and changing the focus of healthcare to individual patients, rather than metrics and numbers.
How have people reacted to you leaving patient care?
Most people I talk to about my career path are actually pretty intrigued. I originally thought that I’d get disapproving looks or reactions from other die-hard clinicians, but it’s actually the opposite.
Most people that I talk to about my work think it’s great. In fact, I take calls all the time from other clinicians wanting to make the jump from staff clinician to business owner or some other non-clinical role.
What’s a typical day or week in the life like for you?
So, since I’ve got a lot on my plate, no two weeks ever really look alike (which is something I enjoy about my work these days). The bulk of my time is split between healthcare consulting, teaching at the university, and working on projects for Rehab U.
I tend to start every work day around 08:00, checking email and planning my day. Depending on the day, I may end up traveling for a meeting or assessment. If I’m staying local, I will work on reports for the consulting project, respond to client communications, build out content for courses/trainings, work on marketing/promotion, and do work related to the university (lesson plans, grading, prepping, etc). Depending on the day, I usually wrap up work around 16:30-17:00, though some days when I’m traveling can end up being much longer.
So…what about that personal life? 🙂
I also have a very full and busy personal life. I have four kids, so my wife and I have our hands full around the house! Since I’m able to work from home a good bit on the consulting & training work, I’m around to help out with lunches and the occasional midday distraction of one of my kids wandering up to my office to “work with dad.”
Because my work as a consultant can literally be nonstop, my wife and I have been very deliberate about how much I work and when I work. So for the most part, I try and work enough to get my “top priorities” for the week taken care of, and leave enough time for me to spend time with my family and doing non-work things (like gardening).
Sometimes, this means that I work half a day one day, and then work a really long day later in the week (depending on travel and the like). Sometimes, it means one week of a regular 5-day schedule. My goal is to be able to complete my deliverables and priority tasks, and then focus the rest of my time living the life I want, rather than waking up in 20 years and realizing that I never took the time. I actually talked about this on a podcast interview I did this year.
What are some of the challenges of your role? What are the rewards?
I mentioned the main challenge and that is this: there’s always work that needs to be done. Especially running a business, there is no “off-time.” If I’m not creating content, communicating with prospective clients and clients, or marketing my products and services, then the business doesn’t make money. So in that regard, it can be something that takes a lot of my mental time.
However, I’ve also come to the realization that “there’s always work to be done” :). That means I can take a day off here and there (or a week).
As long as I’m always moving forward, towards my goals and priorities, then I’m good. That’s probably the main reward: I’m in more control of my schedule. When I work, and what I work on is for the most part, up to me. That can be a double-edged sword, but so far, I’ve been able to get what I need to get done accomplished.
How do you think working as an OT prepared you for this role? Which skills transferred?
Working as a staff clinician let me see first-hand the challenges in healthcare, with productivity requirements and the like. Then moving up through the ranks to work on projects involving patient engagement, clinical outcomes, utilization, and clinical education gave me more skills and insight that directly transferred over to my work as an independent consultant and business owner.
For example, my work on some policies and procedures at the VA helped me with some of the policy work I’ve done as a consultant. The project I did helping to roll out relationship-based care ended up providing insight and expertise that I use when writing and creating courses/trainings for Rehab U. And my clinical work in an outpatient orthopedic specialty clinic, as well as my consulting work, has provided insight and expertise that I use in my role as a professor and educator.
I think we should always be looking at how potential opportunities we may have in our career path can build on each other. If you do it right, you can end up finding yourself building on skills and insights that you learned years before and have been refining since then.
Roughly speaking, how are the hours and pay compared to patient care?
Well, as an independent consultant, the money is better. However the downside is the tax liability and nuances that come with that. I’ve had to work with my accountant and payroll company to make sure that everything’s looking good from a tax standpoint. I formed the LLC and setup the structure that I now use based on the recommendations of my accountant and have regular check-ins with him to make sure everything is on the up and up.
As a business owner (or self-employed person), you will find that there is really no limit on your potential income other than those you place on yourself. If you build products and scale your business, you can make many times more than you could ever make as a clinician.
Of course, the trade-off is that if you fail, there’s no safety net for you.
As an OT professor, the pay is comparable to some clinical work out there, however I’m sure you can make more as a service line director or executive in a rehab company somewhere. You really have to love teaching to get into it, because there is a lot of work that goes with it that’s not necessarily paid for (like grading papers at night). However, it provides flexibility with your schedule and challenges you to keep sharp (students can be brutal feedback machines).
What type of person do you think would do well in your role?
Since consulting is a people-centric business (much like healthcare), people skills are definitely a must. There have been times when I was able to complete a project or finish up a deliverable on time or early simply because of the relationships I have built.
When you build trusting relationships with people, they’ll give you information or let you know things simply because they trust you. We’ve been able to get ahead of potentially problematic situations because someone we worked with let us know of a potential issue before it became one.
On top of that, consulting (especially independent consulting) requires strong time-management skills. There’s no boss sitting behind your shoulder making sure that you’re doing the work. You’re expected to get your deliverables turned in and your projects completed. This requires time management, attention to detail, and even some project management skills.
Do you work remotely or onsite?
I work both remotely and onsite in all of my roles. As a professor, I teach at the university (obviously, you’ve got to go where the students are), but I also grade and do lesson planning at home sometimes. For the consulting, I work out of my home office, but I will travel to meetings, trainings, assessments, and hand-offs. And with Rehab U, I can do much of that work remotely—especially calls and online courses/training programs— though I do travel for speaking engagements & onsite trainings/advisory projects.
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Does your organization hire PT, OT, or SLP professionals into non-clinical roles?
Universities are always looking for professors, it seems. The catch is that, if that’s your desired profession, you may have to move to where the work is (I actually interviewed at a college in Virginia before starting consulting).
As far as consulting goes, networking, LinkedIn, and keeping an eye out are the best strategies. There are not too many management consulting firms out there posting jobs on indeed or anything, so you have to build relationships and network.
For business ownership, anyone can do that. Heck, even start it as an OT/SLP/PT side hustle and build it while you’re working your clinical job. That was my plan with Rehab U. I just ended up landing the consulting contract about the same time, which freed up some of my time and schedule.
Did you read any books, take any courses, or do anything special overall to get you where you are today?
Of course! I think I have read more books in the past 2-3 years than I have throughout schooling. Here’s just a short list of books that I recommend to anyone looking to make a change in their career:
- The Business of Expertise – David C. Baker
- Ready Fire Aim – Mike Masterson
- Made to Stick – Chip & Dan Heath
- Radical Candor – Kim Scott
- Company Of One – Paul Jarvis
- Enough – John C. Bogle
- The 1-Page Marketing Plan – Allan Dib
There’s countless other books, but I do find myself going back to these every now and then. I’ve also taken online courses on online business, marketing, sales, etc.
What is a typical career path for someone in your role?
For consulting, I don’t really know. I’ve met and spoken with others who have started out as independent healthcare consultants who went on to start their own business, launch non-profit organizations, or become executives/directors in other healthcare organizations. I imagine any of those are viable options for folks working as independent consultants.
For teaching, I imagine it’s something along the lines of getting a doctoral degree and working through the ranks of the university system.
What is next for you? What do you want to do with your career long-term?
I don’t really know what’s next for me. Once the larger contract on the GA Project is over, I’ve considered a few options. I’ve still got work coming through with the university and with Rehab U, so I’d look to expand that.
But I’ve also considered other ventures, both for profit and not-for-profit. My long-term career goals really include creating more of an impact than individual patient interactions, so whatever I do will have some sort of scale with it, whether it be more training/courses or starting/management in a non-profit healthcare organization. I do enjoy teaching and will find a way to keep that as a core element of my career going forward.
What would you recommend to someone who is considering going into a role like yours?
When people ask me this question, I typically respond with this: “understand your own risk tolerance”. Unlike working as a staff clinician somewhere, there is no safety net when you’re an independent consultant. If you don’t complete your work, you won’t get paid.
There are no sick days, vacation days, or PTO. There’s also no provider-sponsored health insurance plans (which means that you’ve either got to be OK with that, or you’ve got to earn enough income to pay for private healthcare insurance or cash-pay for your healthcare).
Try to look at your career as an investment portfolio. There are “safe” investments, like CDs and bonds that pay a guaranteed return (much like a salaried job). Then there are speculative investments, on the radical ends, like options and day-training. They may pay out big, but you may lose everything (much like leaving secure employment to start a new business).
I recommend trying to build a “portfolio” of work that takes into account your risk tolerance and provides you with the income and opportunities you want.Editor’s Note: I totally agree with this! I have ongoing freelance writing contracts for this very reason!
For example, I work part-time as a professor (more or less secure income), and I also work as an independent consultant (less secure income, as it’s contract-based), and I run Rehab U (even less secure as it’s all on me to make the money).
If you’ve got less tolerance for risk, perhaps you should consider finding a W2 position with some firm that is hiring clinical consultants. If you’ve got a greater appetite for risk, perhaps you can line up some work/clients and then leave your clinical role to pursue that. What you want to end up with is a work life that provides the income you desire with the opportunities and work-life balance you want long-term. That may evolve and change as your age, state in life, or roles change.
What would you like to change most in your profession, and why? How would you propose doing so?
The biggest thing I would like to change in my profession is the whole idea of time-based productivity and time-based reimbursement. The fee-for-service or time-based reimbursement model of healthcare has had more of a negative impact than I think people realize. It incentivizes organizations to look at patients as treatment units or revenue numbers. It forces clinicians to try neglect “non-billable” but important aspects of healthcare delivery. It also leaves patients with a less-than-stellar experience.
I firmly believe the way to change this involves a two-pronged approach. First, independent clinic owners and clinicians can start experimenting with alternative payment models. Cash-based and value-based payments models, treatment bundling or programs, and the like have been gaining popularity as of late. And there’s even some evidence that I’ve read suggests it’s more clinically effective as well. (In fact, APTA published an article about it at the beginning of 2019).
More clinicians moving in this direction will begin applying competitive pressure to traditional healthcare organizations, which will hopefully get them to change their methods as well. This, in-turn, could cause third-party payers and regulators to begin to change the way they do business also (we’re starting to see that with value-based payment models in SNF and HH settings from CMS).
The other avenue is to begin changing the culture of healthcare organizations. Whether this be through training, staff engagement, or something similar to relationship-based care, healthcare organizations need to begin focusing more on patient engagement than on metrics. The reality is, engaged patients are more likely to complete their plan of care, experience greater clinical outcomes, and have higher satisfaction levels. I believe that greater patient engagement starts with delivering a uniquely impactful patient experience, one of true human connection and care; rather than running patients through a check-list assessment and treatment protocol.
If you could give yourself one piece of career advice you wish you had during your OT program, what would it be?
The one piece of advice I would have given myself was to think bigger than just “clinical expertise.” It wasn’t until I began working at the VA and ended up in their leadership development program that I began seeing opportunities outside of clinical care; opportunities that came with more impact.
You should never view yourself as “just a therapist” or assistant. Your schooling, training, and interpersonal skills lend themselves to other roles outside of the clinic, but you have to be looking for them.
If you could teach anything to today’s graduate students in your profession, what would it be?
What I try and instill in every student that I teach at the university, or who go through my courses/training programs, is this: ultimately, healthcare is a human experience. It is one person skilled in delivering healthcare/treatment serving another person who is on a unique road to recovery.
We need to keep in mind that the patient, that unique patient sitting across from us in our clinics is what it should all be about. Treatment techniques, productivity, utilization, etc. play a role, but it should all be about the patient. The patient should be the center of all our activity.
Do you have any special advice for others who want to follow in your footsteps?
I’ve mentioned it before, but become actively engaged in professional networking and relationship-building. Be always looking for opportunities to work on projects that can expand your skills. And always keep your eyes open for chances to make the leap when you’re ready.