There’s a common problem in the healthcare field; especially in the physical rehabilitation and therapy space. That problem falls under the category of not enough patients. The more clinic owners and managers I talk to and work with, the more often I notice this pattern: Owners and managers see falling numbers (revenue, referrals, appointments, etc.). They feel the pressure (to make payroll or hit their departmental numbers). They become desperate for more patients. This leads them to run to the only thing they believe will help them: lead generation.

OK, in the healthcare field, we call it drumming up referrals, but it’s the same thing. As I’ve written about here, referral problems (or “not-enough-patient-problems”) may actually be patient retention problems. Unfortunately, the best marketing plan in the world fails if it doesn’t consider the patient relationship cycle.

Managing Patient Relationships

Let’s take a look at what happens when census dips, or the clinic schedule becomes light:

Managers and clinic owners see lower revenue and dips in appointment scheduling as a referral problem. “If only we could get doctor X to refer a few more patients…” or “We really need to develop relationships with some other doctors…” These phrases usually precede the implementation of some sort of new, growth-hack related, marketing plan or system. And it works…for a little while. Referrals increase. Therapists end up with full schedules again, and all seems right in the world. Then, usually 6-12 months later, it happens again. Numbers start dipping. Schedules free up, and therapists are treating less.

What happened? The marketing plan worked. You saw an increase in referrals and appointments being scheduled. You may have even considered hiring another staff therapist to handle the new workload —and to treat the number of patients surely coming down the pipe. Within the year or two, you’re looking at the same problem. But why? It all stems from not understanding, or capitalizing on, how the patient relationship cycle works.

Patient Relationships

As in most service-based fields, healthcare ultimately revolves around relationships. Relationships between patients and their clinicians can impact everything from clinical outcomes to satisfaction ratings [1]. But what is a patient-clinician relationship?

Well, as in every other human relationship, patient-clinician relationships form through social interactions between the clinician and the patient. As I’ve written about here, communication plays a large role in developing these relationships. How a clinician speaks, asks questions, and displays body language impacts the trust and confidence that a patient feels.

Often times, this relationships forms “on the fly”. Clinics and clinicians don’t intentionally try and form strong patient relationships. People that tend to choose healthcare as a career are naturally skilled with interpersonal communication and relationship-building. This means that most of the time, clinicians are able to form relatively strong and meaningful relationships with their patients. The patients, in turn, trust their clinician and can actively engage in the planning, execution, and benchmarking throughout the course of treatment.

Sometimes however, clinicians are busy. They feel rushed. They’re under pressure to meet certain productivity metrics. They fall into a rhythm of “conveyor belt” therapy. They treat patient appointments like checkboxes that need to be ticked in order to do their job, make their boss happy, and get paid. If you think about it, it’s not their fault. They’re in an environment where time-based productivity runs the show. Especially for those of us who come from the outpatient rehab world, it can feel that your whole day consists of trying to treat patients enough to get results, get your documentation done, and meet productivity. In environments like that, it becomes more important to intentionally cultivate strong patient relationships.

Cultivating Strong Patient Relationships

So if strong patient-clinician relationships are important, how do we go about developing them? Ultimately, relationships between clinicians and patients develop in the daily & routine interactions between them. How a clinician greets a new patient, or how that clinician conducts the initial assessment or interview sets the tone for the relationship. The patient receives subtle cues from the clinician during these initial interactions: What information are they focused on? What do they care about? Are they looking more at their watch or computer screen than me? We may not be aware of it, but all of those little things can either build or detract from a strong patient relationship.

Depending on your setting, population, and area of specialty, patient relationships can be difficult to form. For example, I once worked covering some acute care caseload. I saw patients for an initial assessment, made some discharge recommendations, and then they left the hospital in the next day or two. While you can still develop good working patient-clinician relationships under those circumstances it can be challenging.

Ultimately, our aim as clinicians should be to communicate to our patients an attitude of care, empathy, and sincerity. We want our patients to know that we don’t merely see them as a number (or 4 billable units), but as a real person experiencing a real dysfunction or limitation. We want to cultivate an environment of safety, trust, and collaboration. While we need to check certain boxes and gather important information to do our job properly, we also need to be aware of the social and emotional role we as clinicians play in the healthcare process. Patient education & counseling, responding to patient emotions, and even simply providing an empathetic ear or sounding board plays just as important a role in healthcare as gathering accurate ROM, MMT, or other diagnostic data.

The Patient Relationship Cycle

Understanding the importance of cultivating strong patient-clinician relationships leads to some questions. One of these questions revolves around the cycle of patient-clinician interaction. Patients start off as new referrals or prospective patients and, through their interactions with us and our clinics, develop relationships with clinicians, staff members, and even our organization. Understanding where patients may be on this cycle helps clinics and organizations intentionally build strong relationships with their patients. Enter what I call the patient relationship cycle.

This cycle (pictured below) represents the typical lifecycle of a patient’s interaction and relationship with your clinic. It begins with a new referral —or in some cases, a piece of marketing— and ends with (hopefully) a returning patient who actively refers friends, relatives and neighbors to your clinic. Your  communication and interaction with a patient should correspond to the stage that they are in.

Patient Relationship Cycle

New Referral

Whether a patient is referred to your clinic by another medical provider, or if they hear about you through your marketing, odds are that most of your prospective patients in the area (your ideal patients) start they’re relationship with you before you even see them. Your reputation —usually conveyed by the referring provider— influences the patient’s perception of you, your clinic, and the quality of your services. Likewise, your marketing & messaging subtly communicates to your prospective clients about the same things. These patients and prospective patients begin forming an idea in their mind about you, your clinic, and your services —all without even meeting you.

When these patients show up at your clinic for an initial appointment, free consultation, or evaluation, they bring with them these perceptions and preconceived ideas. That means when patients are in this stage of their relationship with you and your clinic, you need to be proactive and intentional in your communication with them. This may mean providing referral sources with information or “talking points” about you. Sometimes, having brochures available in the offices of your major referral sources also helps. When crafting marketing messages, be sure that those messages communicate what you want to those prospective patients. This may be the value you bring to the table, social proof by way of testimonies, or the fact that you are experts in your specialization, etc.

Then, when this patient walks into your clinic for their first appointment, you need to make good on those promises you’ve made in your message and marketing. Your front-office staff should also be involved in this, as they are likely the first people your patients see, talk to, and interact with. As I’ve written about here, often times the process of care (on-boarding, new patient paperwork) influences patient engagement and experience as much as the actual care they receive.

Current Patient

Once a patient takes the step to schedule a follow-up appointment the communication and interaction changes again. These patients are no longer “prospects”. You don’t need to convince them to schedule that first appointment or interaction (you’re over that hill), but you do need to provide them reasons to become engaged in treatment. Active patient engagement & participation positively impacts both clinical outcomes and patient satisfaction scores. So how do you get a patient actively engaged in the treatment process?

Hopefully, at the first appointment, you or your clinician(s) took time to listen to the patient, to validate their experiences, and to answer their questions in a way that communicated empathy, understanding, and competence. After that, the next step is to seek input from the patient in the treatment planning process. Focusing on goals and objectives that are meaningful to the patient leads to greater engagement and experience. That may mean regular “check-in” conversations between the clinician and the patient. Sometimes, even the clinic owner or manager can take a random stroll through the clinic and waiting area and ask patients “Are we doing everything that you expect or desire to help your recovery?” or “Is there anything we can do to better help you meet your goals?” Taking the time to ask these questions really makes an impact on patients’ perspectives of the clinic.

It is also important to note that, just because a patient schedules a follow-up visit (or two or three) doesn’t mean you’re out of the woods. As our last article outlines many patients never make it out of this stage. They go from current patients to “where-did-they-go” patients. Often times, a low patient retention rate may result from a breakdown in the patient’s relationship —either with the clinician or the clinic/organization. We need to make sure that we never take our current patients for granted. We must always take steps to ensure that they’re engaged and satisfied (and if not, figure out how to fix it).

Retained Patient

So a patient has stuck with you past the first few follow-up appointments, now what? At this point in the patient relationship, the clinic & clinician needs to focus on engagement. Up to this point, your patient was exposed to your message or reputation. They’ve interacted with your staff and clinicians. And —hopefully— they’ve participated in developing their treatment plan, desired goals, and expressed their aspirations for treatment. Now, you and your clinic needs to use that information and integrate it into that patient’s treatment and appointments.

Take the time to gauge how the patient feels about the progress of treatment, the relevance of treatment, and their progress towards their desired goals. Use that information to inform treatments appointments. It’s one thing to ask a patient about how they feel about treatment. But you take it to a whole new level when you actually act on the information and feedback the patient provides. When the patient feels valued, heard, listened to, and feels like a partner in their treatment plan, they naturally become more motivated and engaged in treatment.

That leads to course of care retention (retaining a patient through to completing their plan of care). This should be one of the few key metrics that you focus on regularly, as it shows the level of patient engagement & satisfaction with your clinic and services. Patients that are engaged and are having good experiences in your clinic are more likely to finish their course of care. If you notice low numbers with plan of care completion, take a closure look at patient engagement and experience.

Returning & Referring Patient

Aside from course of care retention, another form of retention is just as important: clinic retention. This type of retention leads to repeat patients. These patients may have come to your clinic for shoulder pain. They had a great experience, felt engaged in treatment, met their goals, and completed their plan of care. Now, perhaps they have elbow pain or hand pain. They choose to return to you clinic (because they had such a great experience the last time). Now, obviously, we hope that our patients complete their plan of care in our clinics then go on to live a long, pain-free life. But, if they’re in a position where they need services again, we want them to think of us first, right?

Another side benefit of getting a patient to this stage of the patient relationship cycle impacts business growth: word-of-mouth referrals. Often times, patients that choose to return to your clinic feel so good about the services & treatment you provide, that they tell their friends, neighbors, and relatives about your clinic. They become advocates —and in some cases, fans— of your clinicians and your clinic. If they were referred to you by another healthcare provider, they’ll go back to that provider and talk about the great experience they had in your clinic. This may influence that provider’s choice to send more referrals your way.

Often times, I notice that clinics simply hope, pray, and trust that their patients will come back to their clinic in the future. They know these patients had great experiences, realized their goals, and left happy. But they still wonder whether these patients will come back to their clinic if they need services in the future. This typically results from not having a good method for follow-up and engagement for these patients. Whether it be via social media, email marketing, or phone calls (yes, people still talk on the phone), you need to have some way of both following-up with former patients and maintaining that relationship.


It’s easy to see falling numbers, fewer appointments, and less patients as a lead generation (or referral) problem. In some cases, you may be right. Often times, however, you need to take a look at metrics and data that speaks to patient engagement & retention. Low numbers in the areas of plan of care completion, returning patients, and cancelled appointments/no-shows indicate problems in the patient relationship cycle. Understanding this cycle is the key for any clinic owner or manager to increase retention, engagement, and returning patients.

If you go and spend thousands of dollars on marketing campaigns aimed at boosting referrals and new appointments, you will see an increase in new appointments and referrals. You’ll notice revenue increases. What you may not notice is the slow, continuous leak of patients not coming back, finishing their plans of care, or referring friends to your clinic. At the end of the day, lead generation (or drumming up referrals) covers up problems with patient experience, engagement, and retention. Basically, if you’re spending money to fill up a leaky bucket, you’ll find out that your bucket ends up empty at the end of the day.

Does your clinic understand the patient relationship cycle? Do you have plans and systems in place to engage patients at each stage of the patient relationship cycle? Share any additional resources that you found helpful in the comments below!

For more informational reads, check out our Blog to see all the articles we’ve published to date. Click here to head over to our resources section and check out our variety of clinical and professional resources aimed at increasing your knowledge and skills. If you’d like to make some changes in your clinic or health center, and would like some help, check out our consulting and advisement services or contact us to see how we can help you break out of the norm and provide a truly impactful patient experience.



[1] Kelley, J. M., Kraft-Todd, G., Schapira, L., Kossowsky, J., & Riess, H. (2014). The influence of the patient-clinician relationship on healthcare outcomes: a systematic review and meta-analysis of randomized controlled trials. PloS one, 9(4), e94207. doi:10.1371/journal.pone.0094207


Rafael E. Salazar II, MHS, OTR/L is the president and CEO of Rehab U Practice Solutions. He has experience in a variety of rehab settings, working with patients recovering from a variety of injuries and surgeries. He worked as the lead clinician in an outpatient specialty clinic at his local VA Medical center. He also has experience as an adjunct faculty instructor at Augusta University’s Occupational Therapy Program, as a Licensed Board Member on the GA State OT Board, has served on several committees for the national OT Board (NBCOT), and as a consultant working for the State of Georgia’s DBHDD. He is also on the Board of Directors for NBCOT. He works to help healthcare clinics and organizations deliver uniquely impactful patient experiences by improving service delivery through training & advisement.

Read his full bio Here. Read about Rehab U Here.

Schedule a call with him Here.

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