The Practice of Therapy

Gordon Brewer: Well, hello everyone and welcome again to the podcast and I'm really happy for you to get to know today, ​​Robyn Miller from Thera Closure. And I think you're gonna find this topic just really interesting, just about what we do if something were to happen to us. But ​​Robyn, as I start with everyone, tell folks a little more about yourself and how you've landed where you've landed.
​​Robyn Miller: Sure. So I am a psychologist and I have been in private practice for almost 25 years. And during the course of my work, I have had to step in for two very close colleagues who suffered untimely tragedies, both seemingly healthy in their forties. And through that process really learned how. Devastating.
Of course the impact is on our clients and the all that's required to take care of. Patients and referring them on and securing the medical records in compliance with the law. And you know, closing down a practice at the same time as I was grieving myself and wanting to help the family who had just faced this traumatic loss.
That it, it, it's a. A much bigger endeavor than, than people realize, and it is written in our ethics code. So having gone through that a couple times myself, I started writing about it and talking about it, and in reaction to people's surprise I, I figured we needed to have an easier solution, an easier way to approach this so that more people could actually get it done rather than having it hang over their heads.
Gordon Brewer: Yes. Yes. And, and you know, it's, it's interesting because that topic has come up for me. Just, you know, I, the people that follow this podcast know that I had to take some time off when I was going through my wife's she was in hospice care and then eventually died. And so we I had to go through all of that, and so it was real important.
And then I just thought. Those very things. You know, if something were to happen to me, what would happen to my practice? What would my daughter be left with? All of those kinds of things. And so I think it's just you know you really thinking ahead, you know, it, it planning for the worst as they say.
So it just makes a big, i I I think it makes a huge impact to, to do all of those things.
​​Robyn Miller: I'm so sorry for your loss, but you No. Well, thank you. Yes. How the family is impacted and so if the loss is of a, a therapist and the family is, is not in the field as well, I. Then they are left with having to contact patients and let them know they don't know how to do that.
They don't know how to find referrals. They don't know the ethics codes and legal responsibilities around the, the medical records in that situation. Sometimes records get. Put on the curb because the family's just getting rid of boxes that were kept in the basement mm-hmm. For 25 years, and they don't know any better.
There's a real risk in addition to the tremendous burden that is placed on a grieving family at, at that time. So planning, you know, I like to think about it not as being paranoid, that something. Mm-hmm. Happen. People often say, this is so morbid, or it's so depressing. I really think of it more as you said about being prepared and practicing in good faith, in compliance, and then with peace of mind, knowing you've done all that you can.
You've made your best effort to care for your patients and your family. And, and then you can live a long and healthy, hopefully life and practice. Right. Knowing that's, that's off your plate.
Gordon Brewer: Yes. And you, you know, I think you know, now that I've got a bit of gray hair and just knowing how life is I was having a conversation with someone earlier well last week just about this very topic about as you get older, you recognize the finality of life and, none of us are immune. That's not trying to be, like you said, not trying to be morbid, but just being realistic about things and just thinking about the impact it's gonna have on. Our loved ones in particular, but also if you're, if we're in a, you're in a group practice, colleagues, all of those kinds of things is gonna make a, a big impact on people.
So, but what's ​​Robyn, tell us a little bit about your process and more about their closure and how all of that works.
​​Robyn Miller: Sure. I'm happy to. I wanna add one more thing before we move Uhhuh to that, in to what you were saying. Sure. I want people to understand that this is in our ethics code for all disciplines saying that we will, we accept the responsibility to plan for the wellbeing of our patients, continuity of care, and for the medical records.
And if we think about it, you know, we. Use our alliance, our bond with our patients, no matter what orientation you have to the therapy and the work that you do. We all believe that alliance is really important and we can't, I. Only think the alliance is for good. The alliance is going to help the patient heal.
I think it is, and we all believe that, but then we have to understand the other side of it. If we have that much power to help people change in positive ways, we also have that much power to impact people with our sudden abandonment. Not that we would intend that, of course, and mm-hmm. Any kind of loss, but that's how patients experience it.
As a rejection, as an abandonment. As they are suddenly left not knowing what to do, they are sometimes not notified. They, I've had people tell me, you know, I thought my therapist just gave up on me. They, they didn't call me back two months, and then I found out that they died. People have been notified by text message, so part of our duty as a therapist.
Not only to plan, but again, we value our emotional. Tolerance of hard things. Mm-hmm. We talk about shame and anger and rage, all kinds of things that, you know, we, we use our training to be able to sit with, but mortality is one that even us as therapists, we, we don't wanna talk about, but we owe it to our patients to be able to do that hard work too.
And accept, as you're saying, kind of life, life is not predictable.
Gordon Brewer: Yes. Yes. It really, really isn't. And you know, I, I will just to, to kinda lead off our conversation a little bit with this, I know back when I was going through all the care of my wife and all of those things I remember, talking to a colleague of mine, a close friend of mine, Dr. I'll give a shout out here to Dr. David Hall. But he and I had this conversation. I said, okay, David, you're gonna be my person to know where everything is. And he run, he runs a similar practice to mine in another city. And so I said, okay, here's where all the passwords are, here are all the things.
And then I told my daughter. If something happens to me, David Hall's your go-to person. Now, I know that's not a complete kinda thing, but that that was a starting point for me. I.
​​Robyn Miller: A really good start a mm-hmm. A start. That's much better than most people make. Mm-hmm. Well either never think about it. Mm-hmm.
Or think tomorrow. I'll do it tomorrow. And it is so important I. To recognize the details, some of which you're referring to. So what we, what we do in fair closure to, to, to answer. Mm-hmm. Question is to address this as comprehensively as possible. To make it as easy as possible for practitioners to get it done.
So what does that mean? We meet with people for an hour consultation because we want to know you in a personal way. We wanna know what kind of therapist you are, what kind of practice you have, what kind of patients you see, what's important to you, how you relate to your patients. Really wanna understand so that.
If we need to step in to serve for you, we are doing it with the degree of compassion that I did it for my two closest friends. Mm-hmm. But we as people that are not in your intimate circle, we would have the benefit of. Some distance to be to provide the clinical care and assistance to your clients and take care of all the business without being.
Overwhelmed and personally devastated by the grief of, of a loved one. The way, it sounds like maybe even your, your good friend David Hall would be if something were to happen to you. Right, right. I've kind of come to this place where I think even though. The standard has been just as you did and just as I did with my friend so many years ago, to say to a colleague or a friend who knows you, Hey, would you do this for me?
If something were to happen? I've come to see that that's really not best practice because it burdens the person or who cares about us at, mm-hmm. At a time of loss, and the job is really much, much bigger than. People recognize. So let me go back and try and succinctly tell you what we do. Yeah. Okay. Now we get to know you.
In your practice, we take you through a whole series of questions of things you might not have thought about if something were to happen to you, what about your patients and who do you want them referred to and how do you want them notified? And who's going to take you know, if you have a testing practice, who's going to continue the, the work of the writing, the report, if.
You haven't completed it yet. If you have a group practice, who's going to notify your staff and which one of your staff is gonna step up to continue payroll and keeping the lights on until a time when your estate is able to decide what? Happens longer term to your practice? Mm-hmm. A million questions, including what are your boundaries?
Do you want patients to know in great detail your circumstance or your situation? Or do you want that kept more private? Do you want them to attend a service for you or do you want them told that that's private and for family only? All these things to think about. And then we also get into the weeds about how would we find that information?
Do you have an EHR? How do we get access to the passwords? If you have paper files, how are we going to get the information about your calendar, your patient contact list? How do we take custody later? We go through all of these questions. We put it in a legally approved. Professional will that names their closure as the practice executor.
So you don't need to burden a colleague or a friend. And then we are on retainer for you and we, you know, yearly renew that and we. Would if notified then that something happened to you, whether it's, you know, the, the ultimate a death mm-hmm. Or sometimes an incapacitation where the second person, you know, had an, an untimely accident and we didn't know if she was going to get better, and thankfully she did, but there was a period of time where her patient, mm-hmm.
Be notified and kind of held until that happened, and some wanted to be referred out rather than waiting. So for all of those circumstances, you can have the relief of just trusting that, that someone is ready to step in and then there would be no final cost. To your estate. Mm-hmm. You control those costs by paying it forward.
Kind of like car insurance. You hope nothing's gonna happen, but if it does, you're covered. Mm-hmm. Rather than the alternative, which is. Either nothing is in place mm-hmm. In a friend. And sometimes those agreements say, you know, my estate will pay you your hourly rate for the time it takes you to perform these duties.
And people think, sure, sure. At two or three hours my estate will be happy to pay you, but it's really like 40 hours of work. Mm-hmm. The state might get an unexpected $10,000 bill. Mm-hmm.
So. It's important to kind of think about what the alternatives are. As you know, we've tried to come up with the solutions that would keep everything really fail safe, so nothing falls through facts.
Gordon Brewer: Yeah, yeah. You know, I, I think one of the things too, just with everything being just kind of electronic, do you all have a way to you know, people, we update our passwords regularly and all of that sort of thing, and so I just wondered how you manage, manage those kinds of things.
​​Robyn Miller: Exactly. We tried to think through every obstacle.
So this one? Mm-hmm. By, we provide, if patients want to use it, we provide free a password manager, and you can use that on your computer to capture only your professional accounts. We ask. Mm-hmm. Only the things typically in EHR, maybe a website access or maybe your professional email accounts only the things that we would need, not your mm-hmm.
Personal. But that captures just like Google or just like, you know, apple password. It captures it and it's only on your computer. That and, and with that company on the, the cloud storage for them, and it updates automatically, but you name us as the emergency contact with. The password company so that if we were notified that something happened to you, we would initiate that emergency protocol by reaching out to the password company and saying, Hey, Gordon has told us we're the, the contact, here's our certification.
We need access. And they, through a particular secure process then. You know, release the passwords to us once they verified that, that they should indeed do that and have always the access to the most UpToDate passwords. But we don't have any patient, confidential patient, or protected health information at all until that time.
Mm-hmm. To worry about, you know, are, is there any confidentiality issue regarding your patients and their materials being secure? Because we, we don't have them until we were. Stepping in as the executor, and then we do take custody of them in a HIPAA compliant and a secure manner.
Gordon Brewer: Yeah, I was, I was curious as how that, how that works.
Because normally you, I, I guess in our regular way of thinking, we have to have a release from a patient to release any information. But in cases like this, how does that generally work? Is it just, yeah. 'cause you know, technically we're not even supposed to share who our patients are. And so all of those, those kind of things.
So how does that generally work? It's a great question. So
​​Robyn Miller: we suggest that people who use our service put in their informed consent. A a just a statement that I have arranged with a. A clinical service to take custody of my records and assist patients in the event of an unexpected practice closure, or you can say an incapacitation or death, and you can say, you know, they are the closure and you can list our contact number.
Mm-hmm. Or you can leave it more, you know, vague. But, but that way you've. Kind of done your duty to let them know that that possibility exists. But even if you haven't done that, we don't require consents because we have first the professional will that is a contract that names us. As the person responsible for stepping in for clinical care and records, we also have folks sign a business associates agreement so that you're covered for hipaa compliance, that you know, we are then an agent of your practice.
So we have that. Responsibility of, of, of notifying patients and, and we, you know, only access the minimal information required. And patients have then the right to request their records or to have their records transferred to a new therapist. And, and so it's also another advantage of having fair closure do it rather than, you know, someone in your.
Town or in your suite because you also don't know if that person may know one of your patients socially. And, and so, you know, there is that possibility of, of some sort of, you know, too close for comfort contact and, and we are so removed from, from your personal world that it is a more anonymous you know.
Option for, for patients.
Gordon Brewer: Right, right. Yeah. I, I guess one thing too that people maybe not don't think about is just I know a lot of folks, particularly in private practice, use social media to kind of market their practice and then, you know, all of those contexts in that, in that context I.
Them knowing or that sort of thing of things being posted that all of that.
​​Robyn Miller: So we offer again, totally comprehensive. We ask if you have social media, do you want us to close it down? Do you want us to change an auto reply from your professional email or on your voicemail? Or on your website saying the practice of let's say ​​Robyn Miller is now closed, please contact Thera Closure for more information regarding records and any assistance that you might need.
Mm-hmm. So we real, and we encourage people to leave, especially a phone and a website up for one year so people who are looking for you would know where to go for their records.
Gordon Brewer: Right, right. Yeah. That's a, yeah, that's another thing I think in particular for solo practitioners. You know, all your records.
You know, technically I think in most states you're supposed to keep records for five to seven years. And so being able to, and typically too with I think a lot of people now are using electronic health records systems, so it's available. And then being able to maintain the access to those records if someone should request something.
And I'm assuming that you all kind of manage all of that so that people can get access. Yeah.
​​Robyn Miller: Exactly the way we handle it is once we've notified the current patients, they're our first focus because they're the ones that are gonna be knocking on your door or waiting on your zoom and not knowing where you are and, and mm-hmm.
Depending on their needs, whether it's a crisis oriented need or whether, you know, they need just support to process this loss that is going to be shocking and, and destabilizing for them and, and then they need some help with referrals. For ongoing care, those taking care of them is our first priority.
But once that is. Done. Then we move into the business of the practice. So if you wanted us to, we could send out final statements through your EHR to collect outstanding payments so that your estate benefits from you getting paid for work that you have already done. We can. Close out auto pay for, you know, let's say your psychology today or your, you know, this account or that account so that they're notified, like your licensing, your malpractice, all of those things.
And then records, we take custody and responsibility. So all of the EHRs have their own procedures, but we can download. All of your files and then store them ourselves in our HIPAA compliant electronic vault so that we can close your elect, your, your EHR, so your estate doesn't need to keep paying for it for seven years.
Your estate, you know, for kids it's often until 18 plus seven. Mm-hmm. So if you. Seeing, you know, a 12-year-old, you're, you gotta keep those records for like 13 years. Mm-hmm. Until they're 25. You know, this is a long time. And so we take responsibility for that. And then if they were to need their records, we would be able to, you know, facilitate the transfer of
Gordon Brewer: that.
Wow. Wow. What a commitment for you all. Kudos to you. I mean, because that's a lot. A lot to take on there. I, I know one thing robbing people are gonna be curious about is the cost involved. Do you wanna say a little bit about that?
​​Robyn Miller: I am happy to. I know it is hard to think about why this makes sense. I want explain why it makes sense.
So, like I said a few minutes ago, you know, if, if you have an arrangement with a colleague and they have to step in to do this. Think about the time required to call all the patients to speak with them, not in a hurry, but to care for them as they're processing this shock. To call them back multiple times as you figure out who would be a good referral for them and who has openings, so that you can match them in a good way rather than, you know what happens sometimes people get a list of like three names, none of whom are available.
Mm-hmm. 30 patients in your practice gets those same three names. You know, they that that's no good. So we take a lot of time and care to make sure people don't slip through the cracks. And then the record retention and so forth, all of those things take hours. And so from my experience, I say if you have 20 patients per week, it's gonna take someone about 40 hours to do the work to close down your practice.
Mm-hmm. And if you are going to pay them. Their hourly rate times 40 hours, depending what that rate is, your estate. Is going to get a 10 or $15,000 bill. Mm-hmm. So that's gonna be a shocking hardship for your company at that time. It's a liability. So the way we have structured is we have clinicians who are on call to step in and do all of this.
We have already. You know, we used the attorneys and we consult with them regularly to create the legal document of the professional will. So even just that alone, if you were to go to a lawyer and say, I want to make a professional will, they're gonna charge you between 1500 and $3,000. To make a piece of paper that is legal but doesn't actually perform any service for you, doesn't call your patients, doesn't keep the records, and you have to burden a friend with that.
So these are all the costs that you need to think about if you don't want to use the closure. Some people download a template from the internet that's, you know, a good place to start to think about what you need to do, but it's not comprehensive, it's not tailored to your practice. So given that all of that, including the costs of the record retention for those years, we charge a four 50 a year.
So depending, again, it might be the cost of two. Sessions a year and the first year there's an additional $200 fee for that one hour consultation and the creation of the will.
Gordon Brewer: Mm-hmm.
​​Robyn Miller: And nearly it's four 50 to keep us on retainer. If we need to step in for you, there are no final costs for your estate.
Wow. None. Yeah. So all that clinical time mm-hmm. Records, that's all included and, and covered.
Gordon Brewer: Yeah, that's, that's good. I was gonna do some quick math here. Just yeah, that's, that's really only, you know, $38 a month to think about that. And that's even for a life insurance policy, you're gonna pay more than that for, for something like that.
And so to me that's, that's kind of a no brainer to think about it in that way.
​​Robyn Miller: Well, thank you. Yeah, we just really racked our brains trying to figure out how to solve each element of this. Stressful
Gordon Brewer: mm-hmm.
​​Robyn Miller: That people, you know, of course it's so overwhelming. So, you know, people don't, just don't do it.
And I, I did a survey and my survey said 69% of therapists do not have a professional will. Right. So I am hoping that by outsourcing this. You know, you, you, like we do with our EEHR or our billing person, or our accountant or our maybe social media person kind of say, I don't know about how to do this. I'm gonna pay someone who is an expert and it will be a burden lifted from my shoulders and I can, you know, not worry about it anymore.
We created this to, to be that service. Mm-hmm. Or professional wills.
Gordon Brewer: Oh, wow. Well, what a, what a gift for therapists and, and psychologists and social workers and all of us in this business. ​​Robyn, I've gotta be respectful of your time and I'm, I'm, I'm sure we'll have this conversation again, but tell folks how to find you, how to get in touch, how to get started with their closure and all of that.
​​Robyn Miller: Absolutely. Thank you so much. So you can find us at www thera closure, T-H-E-R-A-C-L-O-S-U-R e.com. If you go on there, you can give us your email and we will send you for free a. Comprehensive ultimate professional will checklist, so you can go through and really think about the issues at hand and how you wanna approach it.
If you do want to use their closure, you can schedule a free informational meeting with us. Whether, whether you do or not. Mm-hmm. You want to use us, you can schedule a free information. If you do want to use us, you can enroll right directly from our website and I would love to offer your listeners a 15% discount.
Oh, that's junior. By using the code Gordon, mm-hmm. For their, their first year enrollment. So I hope you will reach out. Yeah. Folks.
Gordon Brewer: Well, yes, and we'll, we'll have these links in the show summary, in the show notes for people to access it easily. Well, ​​Robyn, this has been a great conversation and hopefully those listening have found this really enlightening and this is such a valuable service.
I don't know of any other service like this, so this is, this is great.
​​Robyn Miller: Yeah. Thank you so much, Gordon. It's been a pleasure. You do such a great service by sharing so much information. Yes.
Gordon Brewer: Well, thank you. Take care.
​​Robyn Miller: Bye-bye.