Intro To Voices In Health And Wellness

Dr Andrew Greenland 0:00

Welcome back to Voices in Health and Wellness. This is the podcast where we explore the real stories behind running and scaling modern healthcare practices. Today's episode is especially relevant for anyone navigating the complexity of growing a specialist clinic while trying to do everything themselves. I'm your host, Dr. Andrew Greenland, and today I'm joined by Tiffany Miller-Bolerjak, Office Manager and Administrator at Dallas Neuro Rehab Centre, where she plays a central role in overseeing the operational and administrative side of a highly specialised neurorehabilitation practice. Tiffany also brings a broader perspective as a CEO and managing member of Dragon Slayer's Credentialing and Consulting, giving her unique insight into both the internal workings of a clinic and the wider systems that support healthcare businesses behind the scenes. So, Tiffany, without further ado, I'd like to welcome you to the show and thank you so much for joining me today.

Tiffany Miller-Bolerjack 0:49

Of course. Thank you for having me, Dr. Greenland. Really happy to be here.

Dr Andrew Greenland 0:52

Wonderful. Would you mind perhaps sharing a little bit about your journey and in terms of what's led you to where you've currently ended up? Because I think that'll be fascinating for people to hear.

Tiffany Miller-Bolerjack 1:01

Yeah, of course. In high school, I found that I was passionate about mental health care. I had a number of friends that were going through different situations with their families. I had my own experiences with my family. And sort of it sort of all barreled into I really want to work in the medical field. And I was planning to go into medicine and be a physician. And that is the journey I set out on going to college. I was pre-med and graduated with you know the double major and had all the plans. And much like things do, nothing exactly went the way that I planned. My senior year, uh final year in undergrad, both of my parents got really sick. And I knew that I could not commit to a medical school because on my mind constantly my parents would be present. I would want to be able to drop everything and go to them if that was where we were at. And you can't really do that in medical school. You have to be there. Um so I pivoted and I looked back at my unique skill set and things that I had found through different activities in college and even back in high school that I excelled at and found that I was very good at administrative work, that I could navigate bureaucratic processes, that where other people would hit walls, I would, you know, build a ladder, so to speak. And so I pivoted and decided to pursue a master's degree in health services administration with the intention of going into practice management and administration. And that's exactly what I did. Um throughout college, I worked as an in-home health aide, so I was providing hands-on care from the time I was 19 until oh 2018. I don't want to date myself, but for about five years, well into my mid-20s, and then pivoted from there. I did a little bit of case management, working with workers' compensation, injury patients at the state and federal levels, and pivoted from there into graduate student government while I was in my master's program, and then got my first job as the practice manager for a psychiatric clinic. And I did that for oh right at two years on the dot. And then eventually made my way here and have done a little bit of everything in between care coordination and inpatient supervision. And uh now, of course, I'm the practice administrator and practice manager here, which basically just means three things at the end of the day. And I've I've explained this before. The patient's unhappy with the doctor, you go back to the doctor and you figure out how to improve that experience and what to do in those specific cases where maybe all of our protocols and policies and processes could not help us. So, you know, what do we need to change, if anything, so that this situation doesn't repeat? If the doctor is not achieving compliance with the patient, if we've got patients trying to get up and walk out in the middle of an assessment or coming back to us afterwards and saying they had all these problems that we didn't know about the day of, what can I do with the doctor and with the staff here to ensure that our patients are compliant to the extent that the doctor's licensing requires? Because at the end of the day, it's their career on the line if patients are consistently not doing what the patients need to do. And then finally, you know, unfortunately, if you work in health insurance, I'm fighting you in some way, format, or fashion every single day because I have to. Uh, because that's how we get paid, right? If we're seeing an insurance-based client. So that's a little bit about what I'm doing now and how I got there. As far as the credentialing and consulting work, I didn't intend, again, best-laid plans and all of that, I didn't intend to go into that at all. Uh, that ended up being a skill set that I had to develop at my first job at the psychiatric clinic. And unfortunately, once people in healthcare find out that you're competent at something, they keep trying to make you do it whether or not you want to. So I again, very good administrative and bureaucratic processes, and that is all that insurance credentialing is. And that's what a lot of the consulting work is, too, is okay, here's how you can build a better policy so you're not having this issue over and over again with your patients. Here's what you need to do to make sure you're doing all of your pre-check steps to ensure your appointments are going smoothly. So it's a little bit of the credentialing, a little bit of the consulting work, and all of the overlap areas where they impact one another.

Dr Andrew Greenland 5:41

Amazing. No, thank you very much for sharing it. It's such useful context to understand what shapes you in terms of you know your career and your training and how you've ended up doing what you do. So thank you for sharing. Yes. And thank you for distilling down those sort of three key roles that you have in your administrative role at Dallas Neuro Rehab Clinic. But how does that pan out in terms of what does a typical day look like for you? I know no two days are going to be the same, but how do you how does your day work out?

Tiffany Miller-Bolerjack 6:07

Well, the the setting for in a neuropsychological clinic is pretty similar day to day. Monday through Thursday, two patients a day per clinician. 9 a.m. to 1 p.m. is patient one, 1 p.m. to 5 p.m. is patient two. Um so the actual structure is pretty much the same Monday through Thursday. What's different and interesting and unique are the actual patients themselves. So at this clinic, we serve the lifespan. So we're working with children as young as six years old up to geriatric patients that could be 100 plus. Um and yes, we have seen one patient that did fall into that basket, you know, in the time that I've been here since 2024. So every battery of tests that you're giving these patients is depending not just on their age, but on their demographics, including their education level. So a patient that comes in that's 20 years old, that's a Latino woman from the United States that went to school through a bachelor's degree, is not necessarily given the same battery of tests that somebody who is exactly the same in every single way, but they have a PhD, is gonna be given. The standards for performance we would expect to be higher for someone with a PhD. So you could have two patients that seem to be exactly the same on a surface level, but they're not going to take the same tests, and the normative data that's being used to score the test performances are not gonna be the same sets of data. And that's how it should be. Um so every patient is presenting a unique challenge, and some of them you're having to start the testing process with an interview with the doctor because based on their past medical history and you know, fears or anxiety that they may have, it's best to start with the doctor so the doctor can set the tone. Here's what's gonna happen today. What concerns do you have? Let's talk through them now so that when you get into their room to do the testing, they're not freaking out as much. Um, neuropsych testing is kindly put, for a lot of people, the worst day of their life because if they're a dementia or an Alzheimer's patient, um, they're afraid that they're gonna come in here, they're not gonna do well, and the end of the appointment, we're gonna sit there and tell them you can't live independently anymore, we're taking your car keys, we're taking your bank account, you can't have a phone anymore. They they really think that's what's gonna happen. And for the record, that's not what we do. That's not at all what neuropsych testing is about. Um, they might be a six, seven, eight-year-old child that family suspects ADHD, teachers suspect ADHD, and we're asking them to sit still for three to four hours and do some puzzles that are gonna require them to concentrate. It's not, you know, it's not fun for most people that come in here. We try, we try, we we have snacks, we take breaks, we we have good attitudes on the testing side for the staff and the clinicians, we make sure the rooms are comfortable, we decorate, we do everything we can, right? But it's it's just not a fun process. But the results ultimately contribute to these robust treatment plans where we talk about diet, we talk about water intake, we talk about movement, we talk about sleep, we're making recommendations for cognitive exercises and puzzles, we're giving them valuable data they can give to their PCPs or their psychiatrist or their neurologist or their brain surgeon, whoever needs this data besides the patient. And it all comes together to ensure that the other members of their treatment team, that their family, that their neighbors, whoever's involved in their care and wants to see their continued quality of life improve, that data and those treatment recommendations are fundamental to all of those people's next actions moving forward.

Dr Andrew Greenland 10:06

Thank you. So you've touched in great detail on the patient journey, so starting off with the testing and then leading through to recommendations. What does it take operationally to support this process from your perspective?

Tiffany Miller-Bolerjack 10:19

Operationally, so staff before a testing psychometrist, they're called psychometrists or psychometricians, they are going through typically about six weeks of training before they ever get to sit with a patient. So we're talking about six weeks, 40 hours a week of shadowing the clinician, shadowing current psychometrists, reading up on the test, studying the tests, scoring materials, handing them back to the clinician or the other psychometrist to check their work, going back and saying, here's where you did well, here's where you need to keep improving. So from a staff standpoint, I've got six weeks of training I have to put them through that is just money. It's being invested, right? The idea is we invest the time, we invest the money, we do the training, and then they're able to start seeing patients. But financially, that's just a drain. I mean, it's six weeks of a drain. Um, on the clinical side, nursepsychologists are extremely expensive. And if we don't do our due diligence in ensuring that we know exactly what a patient is here to see, if I put them in front of the neuropsychologist without checking the referral, without talking to the referring office, without ensuring I understand what the patient's expectations are coming in, uh it may end up being that they meet with the doctor and then they're gone. In which case, I just used a slot for something that could have been handled at intake because we could have determined on the front front end at the front desk that this was not going to be the right setting for them, that this was not what they're expecting it to be. So there are a ton of pieces that go into this. We're talking about thousands of dollars are spent monthly, monthly, on materials, on testing materials, on the online reports that are generated where we we plug in the data and it generates the actual report and where the scores fall within the normative data sets. We're talking about ongoing training at least once a month where we're touching base with the clinicians and the psychometrists to say, here's something new we just learned about one of the tests we're giving, or um the uh waste five just came out. That's the Weschler scale of intelligence. That's a whole new system. That's you know three to five thousand dollars out the door, and we have to retrain everyone because it's not the same as the waste four that we've been using up to this point. Um and we never know exactly. I mean, there there are signs, right? There's there's notices that start to go out, there's rumblings in the community, so you have an idea of when a test is about to get fundamentally overturned and redone, um, kind of like moving from DSM four to DSM five, right? It's new information you're having to take in and learn. It's the same. Now imagine that, but it's every single assessment we give that can happen at any point in time. And if it does, we have to re-evaluate the methodologies we're using, make sure our technology is up to par and can handle the new programs. I mean, it's a lot. There's a lot. Um, also, most neuropsychological testing assessments, it used to be you bought them and then you had them. And you could run the scoring and you could run the report and you could do that an unlimited number of times forever. Almost every assessment has moved over into the space where they are now requiring annual subscriptions. So we don't buy it and own it, we're subscribing to it. And if we don't keep up our subscription, we can't use it.

Consulting Lessons Across Specialist Clinics

Dr Andrew Greenland 13:42

Got it. Interesting. Um, how so how does your consulting work influence how you think about running the clinic?

Tiffany Miller-Bolerjack 13:49

I get to encounter a number of different specialties through that work. Of course, most of the individuals I'm currently working with are mental health practitioners, psychiatrists or neurologists. I have a couple that are more on the physical medicine side, but you get to sort of see the differences in number one, volume. So, like I said, we're only doing one or two patients per day per clinician. That blows most people's minds out the gate because they're seeing three, four, five, six an hour. Um, so that's immediately a key difference that crops up where if I was drawing up a consulting plan for patient for generating patient referrals, for example, for a psychiatrist, that's not going to look anything like what I would draw up for the clinic here because we're not always targeting number one, the same patients. Our work does cross over. We both work in mental health, but we're not always targeting the same patients. Number two, patients are a lot less keen on a very long appointment versus something relatively short. They go in, they talk about how they're feeling, what's going on, and they have some immediate solutions on the table. Our process is longer. We need to see for this long, we need time to process the data, we need time to write it up, and then we need time to go back to the existing literature to make sure that the recommendations we're making are in line with current research on what helps somebody in your situation. So when I'm doing the consulting work with my other clients, I get to see a glimpse of through their office managers and their administrators what they're uniquely challenged by and what problems they're encountering. And a lot of times they're actually not that far from our practice. And so it'll be interesting to have the experience of I have two psychiatrists that are in the same area. One of them is having no issues with patient volume and referrals, and the other one is struggling to have enough patients to fill one clinical day. And then talking to them about, well, how are you going about reaching the community? And you learn a lot about, well, interestingly, what their programs taught them and their careers have led them to at the current pacing. Um, I think everybody, I feel like patients often try to put doctors into and and clinicians in general into boxes and act like every clinician's the same, every office is the same. They're not. They have also been the products of the medical schools they attended, the residencies they had, the trainings they've encountered, the places they've worked, the families that they've seen, where they grew up, how they grew up, you know, all of those things come together and how they approach their patients. And it necessarily impacts their operations. You get to see immediately who values what. I learned pretty quickly who's valuing their administrators and their office managers and who's not. And I have gotten to have some of those tough conversations of, hey, you really need to work with your office manager. And when they're giving you this feedback on your staff, on your operations, on your patients' outcomes, you know, what they're hearing on the front end, you need to listen. If they're telling you they're that the patients are saying they're unhappy with their care, you need to listen. If they're telling you that they're really happy with one particular MA or one particular nurse practitioner, not another, you need to listen because the managers only we only get involved typically when somebody's unhappy. I never get called to the front because somebody is absolutely delighted and just wants to let me know. Like that's the sad reality. I only hear about it when it's bad. So some of the clinicians and some of the practitioners are excellent internal advocates for their clinics in listening and responding and incorporating the feedback they're getting. And some are not. And the ones that are not are typically having more problems, and that's why they're calling me in.

Dr Andrew Greenland 17:52

So, what major shifts are you seeing in neural rehab or specialist clinics right now? I think you're very well positioned, you're obviously running this operation, but what are you seeing in the wider space?

Deductibles Drive Seasonal Demand Swings

Tiffany Miller-Bolerjack 18:03

Well, right now I'm having a number of patients delaying assessments for financial reasons. So that's been a sad shift that I've seen from 24 to 25 and 25 to 26. And it's unfortunate and at times heartbreaking because you do get to, you know, know the patients and understand that they really are struggling. They really do want to do this, they want to have answers, but they're having to delay that for reasons outside of your control or their control. So I am seeing that. I am seeing a lot of people delaying care that or treatment and assessment that would help them because they feel like they don't have another choice. So, and that's an unfortunate reality and problem. It's an unfortunate reality and is the core of the problem with accessibility and affordability of health care, both in Texas and the United States as a whole. I don't think anyone should ever have to delay getting an assessment that would fundamentally change how they approach work, how they incorporate coping mechanisms when they feel emotionally overwhelmed, how they think about their sleep habits or their eating habits or their water intake. These are all things that if you leave these to their own devices long term, these same patients who we could have done something now, and your outcomes five years later would have been improved. If we leave it to its own devices, now you're degrading. And we often can't reverse degradation. We're trying to prevent it. We're trying to improve outcomes. We don't want them to plateau, and we do not want them to ever degrade if it can be prevented.

Dr Andrew Greenland 19:58

That's really helpful inside. I'm just thinking that I mean, sad though it is, I mean, this must also impact on you as a business because if people are delaying treatment and they would otherwise come and see you, then that presumably will affect your business and your growth strategy. And it does. It does, yeah.

Tiffany Miller-Bolerjack 20:16

It does. The first quarter for neuropsychologists, the adage is that the first quarter is bad for all neuropsychologists because the way that insurance typically operates is that they have a deductible. Um so there's a certain amount of money that the patient has to pay out of pocket before the insurance kicks in. Um, most of the time, they then kick in and they're paying 80% of whatever the bill is. So if it's a thousand dollar bill, once the deductible is met, the insurance will pay $800, patient pays $200. So what we see is patients will call January, February, March. Hey, I'd really like to do this. Could we look at something in April, May, June, July, August? And so we get busier as the year goes on. But the first quarter in neuropsychology as a whole, basically the only patients you can consistently see are going to be Medicare patients. So that's patients that are 65 plus. And it is because Medicare deductibles are about $280, $290. That's not a lot compared to a $5,000 deductible. So we'll see a lot of geriatric patients, January, February, March, and even a little bit of April. And then we start seeing more of the kiddos and the adults April onward. And then in the same way that the first quarter is just bupkis, the last quarter is insanity. October to December is constant calls, constant us having to tell people I'm so sorry. You know, the wait list for us is up to six weeks, which means the first appointment is now, maybe next year in January. And that doesn't work for them. They need to get in now because they've met the deductible, they can actually do the testing now. And so we've even started telling patients as early as June. In July, if you're waiting to meet your deductible, schedule the appointment now. Because if you wait until September or October, we won't be able to see you. There will be no room on the schedule. So it's constant patience not canceling, patience not no showing, which we love as a business, right? We love it when you show up. We love it when we don't have to go chase down last-minute appointment to fill in, appointments to fill in. But it's also a difficult time of year for us having to turn people away because we can't fit them in. And then they don't want the appointment in January or February because that's when the insurance is going to reset. And they're going to be right back to square one of you got to pay this amount of money out of pocket before you can go see anybody and it be a covered visit. So it's it, they're like the worst bookends you can imagine. It's uh feast on one end at the end of the year and famine at the beginning of the year, and everything else is kind of more, you know, some cancellations, some no-shows, and we fill them in as we go in the middle.

Dr Andrew Greenland 23:07

And have you found any ingenious ways to kind of level things out? I mean, I guess some of these things are outside of your control, but just to manage the peaks and the trough, because at the end of the day, you're a business. You still have your outgoings, and yet you have these kind of periods where it's slow and then periods where it's completely mental. So I just wonder how you deal with that.

Tiffany Miller-Bolerjack 23:26

So I found that adding in greater flexibility has actually increased patient communications. So when I came on, it was very, it was a little bit more rigid. Um, very, hey, if they no-show, if they cancel with less than 24 hours notice, uh, it's a $400 no-show fee because that is what it costs just to have the clinician have the staff here. That's not making a profit, that's the break-even point, it's $400. Um, and that's to be honest with you, I've looked at the numbers and that's being kind of conservative. I think it's really closer to $500, but that's the no-show fee. That's the late cancellation fee. And I did something a little bit interesting when I first came on, and I asked the question of hey, if they call the day before, even if it's after hours, we don't talk to them, but they leave a voicemail, and I get that voicemail the night before and I see it, and I'm able to notify you, and we're able to come in the door the next day, knowing they're not gonna be coming in, making the calls, trying to get somebody else in, do we still want to charge the no-show fee? And they kind of kind of thought about it, and the owner came back and said, No, I think that would be fine, because the main issue is that if we don't know they're not gonna be here, we can't do anything about it. That's the main issue. And so when we started telling patients, hey, let us know, even if it's just a call after hours, if it's midnight, call, leave a voicemail, I'll count it. It'll count. You won't have to pay the no-show fee. Number one, we started getting notifications much quicker than we were, even with the threat of the $400, right? You would think a $400 no-show fee would be enough to convince people, like that would really stick in their memory, they'd remember, they would be more communicative, but not really. But that with the there's some flexibility here, and we're really trying to work with you on this. It's not just us trying to punish you. We genuinely just we need to know so we can adjust our schedule. We started getting more communication from the patients in these situations, even in the emergency situations, they were more likely to call. And so that's actually helped improve in filling the dead spots, so to speak, filling the gaps, because we're learning sooner that we're going to have a gap in the schedule. So, I mean, out the door, that was one of the first things I implemented, and it had pretty immediate results. I then was able to take that combined with revamping our wait list process, basically of re-implementing a wait list because they had sort of stopped doing one, um, and using those two tools together fill the gaps faster. So that meant we were losing less money by just virtue of having a more full schedule.

Dr Andrew Greenland 26:25

Really neat, really interesting feedback loop. So thank you very much for sharing that. I'm sure that will um be of value to people listening. So, aside from the insurance, navigating the insurance thing and patients trying to delay or causing you these bottlenecks, are there any other sort of patient expectations or referral patterns that are changing the way that you have to operate as a business?

Tiffany Miller-Bolerjack 26:45

Hmm. Going into pediatric care has been a shift for us. So we were always, I would say, lifespan light. Our clinician could see children, but didn't prefer to see children. And when they had to step back for you know their reasons, they're not seeing patients and haven't been for some time now, and the newer clinician came on and they said, I don't see children at all, we stopped seeing kiddos. Our newest addition to the staff is a pediatric neuropsychologist. They exclusively work with children, they can see adults, but they really like working with the kids. That has been a completely different population of referrals compared to the adult referrals and the geriatric referrals. Adult referrals are almost always one of two things. Almost always. Adult ADHD assessment, adult autism. So those are those are psychiatric referrals. Those are almost always coming from a psychiatrist, um, and less commonly a PCP. Or both. They both sometimes are involved in sending two referrals for the same patient. The geriatric referrals are almost always Alzheimer's, more generally, dementia, memory problems, or pre-surgical candidates. So patients with Parkinson's disease or essential tremors that are looking at deep brain stimulation to you know reduce some of the symptoms they're experiencing, improve quality of life, extend that quality a little bit longer with the surgery. And we basically, with those, are determining whether or not they're cognitively flexible enough to undergo a brain surgery without terrible results, without ending up worse than they were pre-surgery. So those are the geriatric patients. The children have been completely different. Of course, there's some ADHD, of course, there's some autism, but there's also behavioral issues. There's also learning disabilities, there's also a little bit more depression and anxiety. Those are elements, all of those things are elements of what we see with the adults and the geriatric patients. But with the children, sometimes that's the primary issue. And that's a little bit more that border between neuropsychological assessment and psychological assessment. Um, the kids and the geriatric patients both really don't want to do it, and there's a little bit of a similar approach for the psychometrists in um encouraging them. It's almost like a bell curve, like the the bell is the adults, and each end of the curve, each end of the bell are the the kiddos and the geriatric patients. They're a little bit similar, they have some similar tendencies, they really don't want to do it, and they require more encouragement. Um yeah, so I it's been interesting just watching those referrals start to come in for the children in their completely different needs and assessment requests compared to those other two populations. Um and watching the staff also sort of learn how to respond to the children has so far been interesting of ah, I'm not the kids, we've never done the kids before, we've never worked with the kids, like it's gonna be all right. Um, again, retraining, retraining, retraining. This is you know what it's gonna be like working with the kids versus the other two populations. Here's how you can prepare for this.

Dr Andrew Greenland 30:17

Thank you. So looking at this uh Dallas Neuro Rehab as a business, what are you most proud of? What's working really well for you now as you look at that whole operation?

Tiffany Miller-Bolerjack 30:28

I think the thing I have been most pleased with immediately has been the reduction of staff turnover. So when I came on board, they were seeing psychometrists turning over about every six months. They would get a lot more what we would call transitional psychometrists or transitional staff that are intending to only be here for a short amount of time. Whereas the staff we have right now want to be here, they want to be here because they enjoy the work that they're doing, because they enjoy the staff that they're working with and they are feeling positively about the work environment that we've been able to build. Doesn't mean there's never hiccups, it doesn't mean everybody's happy 100% of the time. But again, I found that in generally speaking, in being more flexible, we've had better outcomes. The rigidity can provide rigidity can provide structure, and structure is wonderful. We love our bones, right? That's how we stand up. We need our bones, but the flexibility allows people to be a little bit more human and to enjoy the actual work itself. You spend 40 hours a week at a job, that is the majority of the time you have in your waking hours. If you don't enjoy that time, you will leave. You will go find something better, bigger, faster, stronger, whatever adjectives you want to use. So my goal coming in was in part to make the work they do here more enjoyable. I can't change the fact that it's neuropsych testing. I can't change that patients are gonna be unhappy, that sometimes we're gonna get yelled at, sometimes we're gonna have to be sitting with our box of tissues and it's gonna be okay. But I can control how we operate trainings, I can control the support that me and the other administrative staff are able to provide. I can control the way that we choose to go about corrective actions or corrective conversations. I can control those things. And those things, if positive, improve that working relationship and it makes the time spent here more enjoyable. It's something to look forward to, not something to dread.

Dr Andrew Greenland 32:56

Thank you. And on the other side of the coin, which sort of challenges or bottlenecks are most impactful in the business right now from your perspective?

Tiffany Miller-Bolerjack 33:04

Most challenging bottlenecks at the moment. I would say we are in, I use the word transition again. We're in another transition period right now. So we're moving from our old clinician who had a set established network of referrals and referral sources that you know he worked with and that he had his rapport with and so on. These two doctors that I have now do not have that. They don't have the rapport with those referral sources and those same clinicians that he was so accustomed to working with. And so, number one, we're having to sort of reintroduce ourselves as a clinic to the established sources to say, here's who we have, here's what their specialties are, here's what they can do, here's what they can't do. Um and it and that, number one, out the door that trying to reintroduce ourselves because they got very used to things being done a certain way, and these are not those people. So, number one, that. Number two, um, finding new sources and trying to connect with other offices to introduce ourselves and say, this is who we are, this is what we do, we'd love to work with you, and building rapport from nothing. Honestly, I've almost found it easier to build the rapport from nothing than I have to try to build rapport off of somebody else's established relationship. It's been easier to build it from new than to try to rebuild an existing structure.

Dr Andrew Greenland 34:40

Thank you. And if you had a magic wand and you could fix anything in the business tomorrow, what would that be?

Tiffany Miller-Bolerjack 34:48

If I could fix anything in the business tomorrow, I would have a clinic that was open longer hours. I would have daytime staff and afternoon evening staff so that we could actually see more patients that either can't or won't take off time from work, um, or the children who they don't want to take them out of school to do an assessment, which is you know reasonable fare, um, they'd have more options to get seen. Uh, the reality is that having a clinic open from nine to go from nine to five to something like nine to eight, nine to nine, that's a large operational burden on us, um, not just financially, but having the staff present and working with staff members who have their own scheduling needs. They want to live their own life too, right? They have a job, they have life outside of the job here. Trying to do that in our current setup would be next to impossible. We'd have to change quite a few things, but it would open up a lot more opportunities for the patients and would provide greater flexibility for the patients and even to some extent for you know staff that want to work later hours and have a delayed, you know, start point, or however you want to frame that. Not delayed, but a shifted start point.

Dr Andrew Greenland 36:16

Is that so is that still an aspiration? Would you like to be able to move to that point?

Tiffany Miller-Bolerjack 36:21

100%. I would like to do that or look at weekends because we have people that they just want to come in on Saturday. And I can't I can just can't accommodate that right now. I have some staff that would be willing to come in on some random Saturdays, but the the other side of it is making sure that somebody else is always here. We never want a staff member left alone with a patient for safety reasons, both for the staff and for the patient, but also just because I never want anyone in here without support. If something does go wrong, I want me or the assistant manager to be here in case you need us, because that's part of my job. That's, you know, item number one: patients unhappy and clinician needs support or staff needs support. That's my first priority every time.

Dr Andrew Greenland 37:11

You mentioned staff a lot. Um, I'm just very curious to know how you've navigated to hiring and building a team that really understands the complexity of neurorehab care, that really kind of works in your setup.

Tiffany Miller-Bolerjack 37:21

Neuropsychology is a small field. So, to be honest with you, most of the staff we have are people that have reached out to us looking for work or having gotten our name from a professor that was in a red in their postdoctoral training with one of our clinicians or that worked with one of our clinicians at another clinic, and you know, the person went to them first and they weren't hiring, but they said, Hey, I have this really wonderful colleague that I love. Let me refer there over here. Here's their number, go talk to them, see if they're hiring. Most of it's referrals. I mean, we rarely have had to post an actual job ad. Rarely. And typically only when we're dealing with something very specialized. So, for example, if I needed a, and I have a Vietnamese-speaking staff member that's also a psychometrist, I would love to find a Vietnamese-speaking neuropsychologist. That's an ad that I've put out. No bites yet, but that's an example of the only time I've ever actually had to publish work ads has always been when we needed something specialized. Psychometry is flexible enough that if somebody has a bachelor's degree and the desire to learn it, you can learn it. You have to knuckle down, you have to really put on your thinking cap for some of these assessments and how to deliver them and how to score them. But anybody that really wants to learn it can. Clinicians, you gotta have a license. I mean, I can't work with you without a license, but you know, psychologists that are approaching us or neuropsychologists that have approached us in the past about working here always met that requirement. So, not an issue.

Dr Andrew Greenland 39:01

So, what's next for Dallas Neuro Rehab? Where would you like the business to be in 12 months' time? What are your kind of personal goals for the business?

Tiffany Miller-Bolerjack 39:09

We want to bring on one to two more full-time clinicians. We would like to find someone that can handle epilepsy cases specifically, because while most neuropsychologists do have some training in epilepsy, it is a little bit scary for them to take on without more specialized training. It's just one of those disorders that puts the fear of God in them, so to speak. So we are looking for somebody right now that would have that level of comfort in working with patients that have seizure disorders, in particular epilepsy. The other area of interest we have, we do serve on occasion some legal groups, uh, similar actually to the workers' comp case management I did years ago. They're typically in similar situations where there's either been some sort of a workplace accident or there's been a car accident, or you know, this is a real example, somebody working and working away, and everything's fine, and there happened to be workers on site in their office building that day, and a man fell through the ceiling on top of them. Brain injury, you know, um things like that, legal cases. It takes additional training in forensic neuropsychology to have a level of comfort needed to see a legal case or a case that could become a legal case. Um we don't always know when we see somebody that they may become a legal case, but you know, if we had an inkling or suspicion, we would want to make sure we had a neuropsychologist that was prepared for that. So that's where forensic neuropsychologists come in. So I'd love to get a forensic neuropsychologist, and I'd love to get one more person with lifespan experience that can handle seizure disorders. So that would be my next two clicking those boxes. It'd be cool to have somebody Vietnamese speaking if one or both of them did that. Then I could actually see that patient population because I already have a staff member that can fill that need and would like to fill that need, really wants to work with that population. So I guess that's me sort of listening, doing what I said I want clinicians to do when I consult with them, right? I listened to my staff and I heard this feedback and I heard this desire and this passion to work with this patient population, and I'm trying to build the field of dreams where they can actually do that.

Dr Andrew Greenland 41:34

Amazing. With that, Tiffany, I'd like to thank you so much for joining me today. It's been a really insightful conversation. I've really enjoyed hearing about your journey, the work that you do, your approach to business has been really, really fascinating. So thank you so much. Really appreciate it.

Tiffany Miller-Bolerjack 41:46

Well, I appreciate you and the opportunity to engage Dr. Greenland. You know, I think that I certainly didn't know going into this that the field was as needed as it is, but also that it's as small as it is. There's not a lot of neuropsychologists, and I think everyone at some point in their life should get a neuropsych assessment. I think everyone should. I think everyone should have an idea of how their brain is functioning and the potential reasons why, and also have the knowledge of if you don't like how these certain components of your life play out, if you don't enjoy the issues you're dealing with, executive functioning or with memory or mood, that there's somebody that can help you identify those strengths and weaknesses and that can give you a plan for what to do about those things if you want to do something. I think everyone should get a neuropsych assessment. Thank you.

Dr Andrew Greenland 42:48

I will cut that.