Welcome to the Evolution of Medicine podcast! In this episode, James talks with Keri Sutton, NP and Heather Haun of Kare Health & Wellness in Springfield, MO. The registered nurse and office manager duo have transformed the practice from insurance-based to a cash-based model by implementing a well-thought-out marketing strategy, patient orientations and group visits. Throughout this transformation (even in the time of COVID-19), the pair focused on prioritizing connection with patients over simply sharing information, and the results have been incredible. This episode has tons of information for any practitioner looking for a blueprint to running an efficient, effective practice. Highlights include:

  • Keri’s journey to functional medicine practice, and how her story became an integral part of patient orientations
  • How they pivoted in-person orientations to virtual during the pandemic
  • Why they decided to prioritize connection over information in patient interactions, and what that looks like in practice
  • Keri’s advice to practitioners making the jump from an insurance-based to a cash-based practice
  • And so much more!

Resources mentioned in this podcast:

Practice Marketing Series, Episode 7: The Orientation—The Missing Link in Efficient Practice

James Maskell: Hello and welcome to the podcast. This week we feature Keri Sutton and her office manager, Heather Haun, as they talk about their practice marketing structure and specifically practice orientation. There are a ton of great moments here, lots to learn. They talked about how their orientations came into being, how they pivoted those orientations during COVID. Why they decided to prioritize connection over just more information and some other tips on how they shifted their practice from an insurance-billing model to a cash model in Springfield, Missouri. Tons of great information for any practitioner wanting to run an efficient, effective practice. Enjoy.

So a warm welcome to the podcast, Keri Sutton and Heather Haun. Welcome.

Keri Sutton: Hi.

Heather Haun: Thanks for having us.

James Maskell: We’re super excited to dive in a little bit more about your practice and its evolution over the last few years. So Keri, why don’t you just start us right at the beginning. How you got involved in functional medicine and what the early days of your practice looked like?

Keri Sutton: Well, I got into functional medicine originally because of my own health journey, which seems to be the common theme amongst most functional providers. I was in the traditional system working as a hospitalist and developed some symptoms of my own and went down that pathway with traditional medicine and wasn’t able to get answers, so that’s when I turned to functional medicine. I was able to really alleviate my symptoms, find the answers for what was going on with me. And that’s when I decided that I was going to treat my patients from the functional medicine perspective as well. So we were not a functional medicine practice at that time. We were primary care practice, billing insurance, doing weight loss and some other things, but we decided to change the direction of the practice and make it more into an integrative or functional practice, and also transition away from billing to more of a cash-based practice.

James Maskell: So what were the first steps that you took in that transformation and what was the sort of path to that transformation?

Keri Sutton: We really had to transition patients slowly. So, we first started incorporating an additional fee for, let’s say, hormone patients, which is really outside of your primary care sector. So we were billing part of their visit, collecting additional fees for the time that was involved in some of the additional services we were doing. And that seemed to go well, we did that for quite some time. And then we started transitioning more of our other services, like weight loss to cash-based. And then we finally decided we were just going to be more functional and everybody came into the practice as cash and we would then transition them as they made it through our process of basically doing their lab work and evaluations. Then as they got better, we would make them an integrative wellness patient, which is our term for primary care, and then we could utilize their insurance.

James Maskell: Yeah, that’s super interesting. What were some of the mechanisms that you used to facilitate that? Because I’ve heard great things about your practice orientation and I’d love to hear a little bit more about how that started, what started you on the path to thinking that would be a good idea and how it’s evolved over time.

Keri Sutton: So originally the way that we brought patients into our practice, our nurses were screening them individually. So they would have a one-on-one appointment that could take 20 to 40 minutes with a nurse. They would gather a lot of the information on the patient, not provide a lot of information on us, but rather gather the information from them. Then they would determine what kind of patient they felt that they were and schedule them appropriately. After we became busier and busier, the nurses were booked with those appointments most of the day, which from a cost perspective at the same point didn’t really make sense. And what we found was that the patients were not getting any information about us, but more we were just gathering information from them.

So we tried to come up with a solution that would give patients more information about us and what to expect and what they might encounter in our practice since we were so different than a traditional primary care practice. And that’s when we developed our new patient orientation that we did once a week on Fridays for about an hour. Basically every patient that wanted to establish with our practice, are scheduled for that one hour orientation. Originally, when we started that, we were giving a lot of factual information. We were giving a lot of data about us and timeframes, and just a lot of information that they really didn’t care about.

So as we did it every week, we would adjust—maybe next week we try this and next week we try that, and we would amend our PowerPoints and our presentation. It was myself and my husband originally doing that orientation. It came to our attention that maybe patients wanted to know more about me or our providers or how the practice came into evolution and what we were about. At that point, we decided to incorporate my personal health journey, which I just shared a little bit about, but there’s a lengthy version of that.

So every orientation that we do starts with that story of mine, whether it’s an in-person story for myself, or it’s a video version if my practice manager, Heather, is doing the orientation. That seemed to really change things, just from giving a little bit of information about me. It was like patients then became more relatable to the journey that I had and the struggles that I had. Most of the ones that were coming in as patients have been through those same struggles, so it was nice that they could relate to me in that perspective.

Then what we found is that we were actually attracting patients that were a good fit for our practice. So none of those patients that would come in and then be upset that we ask them to take five supplements or to change their diet. There was none of that tension or a patient just not getting better. Patients were much more informed, for sure, we were still giving them some information, but it was more of a two-sided conversation. It is more of a two-sided conversation, still. Heather does some of those groups now, or a lot of those groups now, I’ve transitioned from doing so many of those. So she has more to share about how she conducts it and how it’s evolved over the last year and a half.

James Maskell: Heather, as you stepped into that, what were some of the things that you were looking for to know that the plan was working better?
Heather Haun: I think for me, originally when we talked about orientation, it was what do we think the patients want from us? Well, they want information, right? They want to know how we’re going to bill their visit. They want to know where to park outside. They want to know how many times they’re going to have to come to the office. So that’s why at the beginning, we would tell them everything that we want to tell them. As we changed and grew and learned more from that orientation, we realized that it was less about information and it was more about connection.

For a patient really coming into our practice, because we do things so differently, the first steps, the first encounters, are probably the most important for our patients. So by using orientation, especially in a group setting, using orientation in a group setting we are able to number one, set them up for what’s the expectation of you going forward as a patient. Group visits are a big part of what we do here and for the patient to come in with that knowledge, understanding the expectation, that transition, that journey as a patient, is so much easier. We use that orientation really as the launch point for our patients. They come in, not as just another patient. They come in seeing multiple faces that they already know from orientation. Knowing what the expectations are—both of them and from us—and they’re ready to make changes because it’s already been presented to them. This is what being a patient here entails.

James Maskell: Yeah. I love that. One of the things that I’ve heard from practices that have tried to implement group visits is that the hardest lift is from zero to one, right? Getting patients to do that first group visit. Once they do it once, once they get used to sharing and seeing that the other people in the group are just like them and have the same symptoms and are getting better with just the kind of protocols you’re using. Then it’s so easy for them to say “I want to do this more.” It seems very, very sensible if group visits are going to be part of your practice to bring people in as a group so that you can introduce them to more people and you could introduce them to some of the concepts. You mentioned the information that you gave them changed. Was there a change in the amount of information that you gave them versus information that they shared back to you now?

Keri Sutton: Yeah, I would say initially it was just a lot of practice information, if you will. Kind of a business overview, and what we turned that into is more personal information. So again, like Heather mentioned, the connection was really important. So I think that they realize then that they were not alone in their journey, that I had been through something similar so I could relate, but everybody else in the room can relate to what they’ve gone through as well. So we have incorporated into that, not just my story of how I got into functional medicine, but we use a lot of stories in that as well, which made it more personal. We use patient examples, how someone may have been improved from what we do and how that’s affected them. We use examples of how we’ve asked someone to change and what that looked like for them and then what the outcome was on the back end once they’d given up let’s say gluten or dairy or some of those things that are hard to do.

So I think that’s kind of more of what we share with them. Now, I know Heather, when she does it, is a little bit better than I am when I do it, about making them be more engaged in the orientation, than what I was doing. And that really does involve them quite a bit more and even makes them more comfortable than when I was giving them my information and my story. But when you actually had some interaction back and forth, I would think the patient level has been so much better.

Heather Haun: Absolutely. At the beginning of each of our orientations, before we even share Keri’s story, I always ask them to tell me why they’re here. What do you want to accomplish with functional medicine? And for a lot of patients, that’s the first time that they’ve been asked to give that kind of feedback or give that kind of information. Instead of tell me what your symptoms are, we want to know what they want to accomplish as a patient. So a lot of times our orientation ends up being patient-led, where it’s less of us sharing information and it’s more of us asking what do you want to know about us? Or what do you want to know about each other? Or where’s this going to go? You guys lead that conversation. That’s really powerful because that patient takes that empowerment and they use it throughout their entire journey. They know that’s the kind of relationship that we have, that they’re in the driver’s seat, we’re just there to help them get there.

Keri Sutton: Some of the other things that we concluded as well, I think were more specifics on what they could expect as far as testing goes. We didn’t do that in the beginning. So we kind of added more information about that. What would be out of pocket, what would be billed to insurance, because there’s always a lot of questions around that. So I think that was new that we’ve added maybe even the last year or so.

One of the other things that I always like to mention, from the provider perspective, is patients are way more prepared when they see me for their first visit, or our other providers. They have an idea of what they need to come in already thinking. So they’ve had some time to gather their story. We tell them we want to hear your story. We don’t discount stories. We think it’s a very valuable part of your healing. So they usually have things they have written down, they have notebooks or binders, and they’ve kind of compiled their journey to the point where they are today. They usually will have that ready to go when I meet with them. So there’s not a lot of time that we spend trying to gather those facts because it’s already been done ahead of time.

The other thing that I’ve noticed is that patients, since we’ve been doing that orientation, are way more open in their first visit. You’re doing a lot of investigating, a lot of questions, and any provider knows that. But what I have seen particularly is that they already know—these are the things I want to divulge, that I may not have shared with them had I not felt like there was some comfort level from the orientation that we do in the beginning.

James Maskell: Heather, what are some things that you do in that orientation to facilitate that because I think that is a really crucial piece. I think that a lot of times we’ve heard from people who run group visits is that they hear patients say things to other members of the group that they’d never told them clinically and that makes the case a lot easier to sort of open up and deal with. I just wanted to see if there are certain questions or certain prompts or certain structures that you’ve created to facilitate that?

Heather Haun: Oh, for sure. You only know so much from a patient based off of what they put on their paperwork. Typically, that’s pretty black-and-white. What I’ve found through looking at new patient paperwork, putting together different sets of paperwork and different versions of it, a lot of times our patients are used to filling out paperwork a certain way, right? Like your traditional system asks them very black and white—what are your symptoms, how many times a day X, Y, Z. We have redone our paperwork to ask more general questions, more personal questions, more relationship questions. Are you ready to make a change?

So before orientation even begins, I have already run through somebody’s paperwork. I make notes—Sally is here for these reasons, X, Y, Z. But I’m also asking her out loud, “Hey, Sally, what are you trying to accomplish today?” And if it matches, what’s on the paperwork, that’s awesome. Nine out of 10 times, though, it’s different from what they have listed on their paperwork. So I think that the patients appreciate the fact that we go a step further than just what’s on paper for them even initially. So, sometimes it’s why are you here? Sometimes it’s what are you trying to accomplish? Sometimes it’s who has done this in the past?

So again, when we look at the longevity of a patient for our practice by asking certain things at the beginning, they’re used to hearing that when they get to group visits down the road. They’re like, “Oh, I’ve already been in this situation. I kind of already know what to expect.” But we never leave anybody out. It’s always my expectation that if you’re at an orientation, or if you’re in a group visit, you participate as much as what you’re comfortable with. I typically try to push patients towards, “Hey, let’s share a little bit about yourself.” That’s the best way that they connect with other people, by being open and willing to share about themselves.

James Maskell: Yeah, I think what’s really interesting is I’m sure it simplifies the front desk piece as well, because it’s just like, “Hey, what’s, what’s the first step here. I’ve got all these questions.” “Okay, great. Here’s the first step. This is the appointment. This is when it is. This is where it is. This is where you start.” Because I know when I worked in a clinic, if you didn’t have something like that, first of all, it was very hard to train a front desk person to be able to deal with all the questions. And also if you had any turnover in the front desk, you’d have to start all over again and you’d have to be answering all those questions. And it just seems like it’s a nice, easy way to help people to say, “okay, here’s the first step and here’s the information questions.” You said Fridays, have you found consistently that’s the best time? What time of day do you do it? And how long did it take you to work out when the optimum time was for your practice?

Keri Sutton: We started with Fridays. We feel like our patient visits have always been more successful on Fridays. There seems to be more flexibility with scheduling. So we kind of rolled with 1:30 PM on Fridays and it’s been really successful, so we’ve stuck with that. Now this year, Heather has added an additional time on Wednesday. So we have added more times because the size of that group has grown so much that one hour once a week… We have the capacity of 10 to 12 patients and beyond that it’s crowded. So we’ve needed to add a second one.

Heather Haun: The other side of that, too, is we don’t schedule anybody’s provider visit until they go through orientation. So if we wait until Friday to see all these patients and we end up with cancellations in our schedule or gaps in our schedule, instead of calling people and rescheduling, making it available multiple times throughout the week gives us kind of an arsenal of people that we can say, “Hey, you went through orientation today, actually have an opening tomorrow. Can you make that work?” So it’s nice to give them options in that regard.

James Maskell: Okay, so let me just make a note. So I’m sure all of this was going beautifully well, and then suddenly group orientations weren’t really available once COVID hit and the lockdown happened. So I’d love to find out a little bit about how you adapted the orientation for the COVID years. And what did you learn from that process about the orientation and about the difference between online and in-person?

Heather Haun: I think we’ve all become more tech savvy in the past three months. When we looked at transitioning one-on-one appointments to telemedicine, we were doing a lot of group visits too, at the time when everything somewhat shut down. So for us, bigger picture was how do you take this entire practice and put it all on Zoom or whatever video platform that we were going to use at that point. So for group orientation, specifically, I was surprised because we really didn’t see a drop in numbers. In fact, if I had to look at numbers, I think that we’ve seen more people go through orientation in the past 10 weeks than we did the 10 weeks prior to that when we were doing them in person.

So I think that you can consider a lot of factors there. I think health is just on the front of people’s minds right now. They want to know what do I need to do to be healthy? Then somebody shares that they’re going to take Care Health and Wellness and I accomplished this. So, not only that, but people are at home. I mean, a lot of people are at home. So when we make it easy for the patient to attend orientation from their home, they still get the information that they need, still get the group experience, then it’s a win-win for both of us. It takes less staff to facilitate online orientations. It takes less time typically. We do a tour of our facility in person and I love that. I think that in-person definitely has its value, but in a mode of survival—how do we make it work—I can’t say enough good things about how we’ve transitioned over the past 10 weeks to make it work for us.

Keri Sutton: Initially, we took a couple of weeks off from orientation when COVID hit to kind of regroup and decide what we were going to do. And what we did was go back to scheduling every patient over the phone and that didn’t go well. We realized that we didn’t have enough information on patients to know how to schedule them appropriately. They came in very under-prepared, confused a lot of times as to why we’re not billing insurance or what their expectations were. So it was clear with that little break that we took of just a few weeks, that we needed the orientation back in place as quickly as possible. So that’s how Heather transitioned—

Heather Haun: Yeah, we’ll never go back. Never.

Keri Sutton: No.

James Maskell: It was almost like a kind of a glitch in the matrix that helped you see how successful the system that you had built was, and once it was taken away, you got to see starkly just how much value it was adding. Right?

Heather Haun: Yeah. And I think really, especially with group visits, sometimes even your staff members, it’s hard for you to get a hundred percent buy-in when you do something new and different. So when we started groups in general, there was I think an acclimation period for our staff members. So by backing off of doing group orientation for two or three weeks, whatever we did, that was just the cherry on top for all of our employees to be 100% bought into everything that’s happening here and that was really powerful.

James Maskell: Beautiful. I’m really excited to share this with our community because I feel like this is definitely a best practice. There is so much information to communicate for functional medicine. I think what you’re really doing is you’re really creating an opportunity to not have expectation mismatch. Which I feel like is really the thing that stops people from having a great experience with functional medicine, is that they just don’t know what to expect. Those expectations are not well communicated and therefore they could have a very similar appointment with you. Ten people could have the same appointment with you and leave with 10 different opinions as to what just happened based on their expectations and how well they were met. I think that’s really, really interesting.

Keri, is there one part of your story that you found that once told, really gets people engaged to want to be part of it? As you tried multiple different versions of that?

Keri Sutton: I think probably the journey of being sent to specialist after specialist after specialist and everyone kicking me back to my primary care doctor, saying we don’t know what’s wrong with you. Most people can relate to that. Having been sent to numerous different specialists and getting no answers. That’s a common theme in functional medicine – people want answers that no one has been able to provide them before. So, I think that’s probably—

Heather Haun: Yeah, and I would say that after we shared Keri’s story, a typical question that we would ask is who can relate to that? And the feedback that we get from patients, “Oh, I’ve been in that same spot” or “I was sent to multiple providers as well. I still can’t find answers.” So the story, the relationship between the patient and Keri’s story, I think it’s probably the most important piece of what we do at orientation. For the patients to make that connection and say “I’m bought in, it worked for her, I know it’s going to work for me.”

Keri Sutton: And we talk in there also transitioning my whole family. So it wasn’t just me, but it’s very relatable. My husband had to completely change his life. My children’s lives have been overhauled. It’s been a complete transition. Our staff, everybody here are completely different than what they were five years ago because of my personal experience with functional medicine and changing, everyone else has had to do the same.

I also think that one of the other cool parts that we have with orientation that we haven’t touched on yet is that we get so much, I said earlier, we get a lot of insight on the patient. So we actually get a really good feel for what that patient is going to be like, and then we determine how we schedule them. We haven’t really talked specifically about that. We don’t put anybody on the schedule until they’ve gone through orientation. And sometimes you see what’s on paper and Heather has mentioned as well, we get them to give us feedback as well and to interact with us. Once you’ve interacted with a patient, it only takes a few minutes to determine this is the type of patient they are going to be. Sometimes we have patients that have come through orientation that want to schedule and we choose not to schedule them based off what’s happened in orientation.

So there is some good information that you can ascertain from that and it really is helpful, particularly with scheduling and getting the right type of appointment scheduled. But also the length of times—we have all kinds of timing of appointments, we know this person is going to need more time. This patient is going to need a shorter appointment. This one’s appropriate for this provider. Whereas, someone else more complicated might be better suited for myself. Do you have anything else to add, Heather?

Heather Haun: Yeah. I mean, the point of orientation really is to make sure that it’s a good fit for the patient. So we’re very open about, “Hey, if this is not for you, we get it. And we’re not going to take that personally, but we want you to make that decision before you schedule an appointment or spend any money with us.” We want to do that as a courtesy, really, to the patients to make sure that they find a good fit provider-wise for them.

Keri Sutton: The orientation is free. We didn’t mention that. We don’t charge anything.

James Maskell: Yeah, no, that makes a lot of sense. Heather, is that something that you do? And let me just ask you this, how much do you enjoy that time of the week?

Heather Haun: I think orientation is probably one of my favorite times. I started as a receptionist in this practice and at that time I got to see all the new patients that came in. Through that experience by working up front, you fall in love with the type of patients who are looking for the type of care that we give. The ones who come in with very little hope, and we end up giving them a big dose of hope. So for me personally, just knowing that people are looking for what we offer them, that’s why I enjoy orientation.

I also am in a unique position where I see people before their journey and I see them during their journey. And I see them kind of in their maintenance phase as well, kind of like our providers. So when I hear of a patient who has kind of a crazy backstory and I get to talk to them through orientation and then see them three or six months later, and I hear of the progress that’s been made from their time with Keri or other providers, that is very motivating to me. That shows me that what we’re doing here is beyond what I ever could have imagined five, six years ago.

James Maskell: I love that. Keri, I just want to finish with this question. We’ve been trying to help practitioners move to start their own functional medicine practices here for six or seven years and years before that, too. When you look back at the trajectory from conventional medicine and insurance billing to functional medicine and cash, I would love to make that journey as smooth as possible for every practitioner. I know that there’s a lot of PTSD with conventional medicine and there’s a lot of PTSD with insurance billing too.

One of the things that I think is the hardest thing for people to do when they make that transition—for doctors, nurse practitioners, or whatever type of practice you have—is to get people to part with their cash, right? It’s a job to be able to work out how to do that. From your experience of starting with insurance and then phasing into other things, it seems like this might be kind of an emerging best practice. Which is get your feet wet with functional medicine, doing the insurance billing, build up a good reputation, start getting people well, and then make that transition. As we end here, I would just love for you to reflect on this journey for you and what advice you’d have for other practitioners who are making that journey.

Keri Sutton: I would say that you really have to be kind of brave to want to go through the transitions that we’ve gone through. It certainly is scary, the unknown is the scary part. What’s going to happen when I start telling people they have to pay cash. What we had to do in the beginning when we were traditional medicine and really primary care and billing, was take excellent care of people then. So we made sure we knew who they were. We knew their family. We remembered things that they had told us in their previous visits. We remembered birthdays, holidays. We celebrated things with them. Then as this transition came on, now we’re going to charge you a small fee for certain services, they were a little more open to that because they felt like we had a personal relationship or connection already. Then as things even expanded from there, I felt like the bar was raised even more for us and we have to do a better job of taking care of people.

I mean, they’re paying a premium to see our providers. I mean, it’s not something that people are used to doing, to pay for something they’re used to insurance covering it. So you really have to treat them really well all the way around. From their experience when they come in the building to the nurse that sees them. The nurse should remember them, the nurse should do a great job of responding to whatever questions or needs they have. And then the provider has to remember who they are, has to know exactly what’s going on with the patient and give them the time that they deserve.

Now we do bill based off time, so the longer the visit, the more they pay and they understand that. We explain that to them coming in. But it really takes doing every little small thing correctly. We send a card to every new patient, thanking them for joining our practice. We send cards when someone gets married or has a baby. We do personalized notes that are handwritten so that they know they’re not just a number. When you are a part of a functional medicine practice, you’re part of this family. You’re never going to be just someone that we see in five minutes and a number that we don’t even know anything about you.

That was one of the things that we tried to make sure that we did really well, so that when we moved into this arena of, okay, now we’re going to charge you cash and it might be $300 for your visit, that people were receptive to that. And it really has gone well. As long as they know. So, that’s the other thing that we encountered. If we tried to change things and people didn’t know, it never went well. But if we kind of set the stage, prepare people for it, and certainly then adding the orientation was kind of the slam dunk there, where people were way more receptive to the fee for service, the cash-based.

James Maskell: Beautiful. Well, I just want to acknowledge both of you for the journey that you’ve taken to get here. And I know that you have a lot of people still to get healthy and an exciting future ahead and just treading that path ahead of the curve and making it easier for other doctors and practitioners to tread where you’ve been. So thank you so much for leading that. We very much look forward to following the clinic and the progress and the journey. Thank you for agreeing to be part of the podcast.

Keri Sutton: Thank you.

Heather Haun: Thank you so much.

James Maskell: So this has been the Evolution of Medicine Podcast. This has been our practice marketing series. We’ve been here with Keri Sutton, who is a nurse practitioner, and we’re also here with Heather Haun. Together they are working at Kare Health. Thanks so much for being part of this series. We are coming from Springfield, Missouri, and we will catch you next time.

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