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Episode 139 | Making Hard Decisions with Stephanie Rosado

Episode 139 |  Making Hard Decisions with Stephanie Rosado

WITH Stephanie Rosado

  • Episode 139 | Making Hard Decisions with Stephanie Rosado 00:00


Making Hard Decisions as a Leader with Stephanie Rosado

Hi Group Practice Listeners! In this coaching episode, I’m talking with Stephanie Rosado all about making hard decisions as a leader in your group practice.

In this episode we cover:

  • leader decisions regarding growth
  • deciding when to hire
  • deciding when to expand
  • making decisions re: leadership roles in your practice

This episode is sponsored by TherapyNotes. TherapyNotes is an EHR software that helps behavioral health professionals manage their practice with confidence and efficiency. I use TherapyNotes in my own group practice and love its amazing support team, billing features, and scheduling capabilities. It serves us well as a large group practice owner.

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Maureen Werrbach

Maureen Werrbach

Hey, everyone, welcome to another episode. In this episode, I am doing a coaching session with an Exchange member Stephanie Rosado, and we’ll be talking about how to make difficult decisions as a leader.

You know, all of the difficult decisions! She’ll be talking about one specifically that she’s working on. But really there’s a theme to just having to lead and make difficult decisions and how we do that as business owners. So enjoy.

Stephanie Rosado

I think that the biggest one that I’m sort of in the midst of making–and I’m just, I think I’m terrified–but also just one that I think probably some people will relate to, because I’ve seen questions pop up about it on on different on the different Facebook groups. But essentially, looking at moving into office space. And I have currently one office location that is just me renting an office and a suite. And I was in the process of expanding. I had hired two people at the start of 2020. And within, you know, two months, three months, we were in shutdown. So at that point, we were all sharing the office and it was working great. And I didn’t know how quickly I was going to scale. I sort of had an idea of where I wanted to be at the end of the day in terms of my business plan. But I didn’t know how quickly I was going to kind of see what that­–just trying all all of it on. So that pushed everything into fast gear is essentially–a fast and slow gear because of year.

So I had those two employees. Since then I’ve hired three more. So now we’re a team of six.

And obviously cannot go back to sharing one office with six people inside a suite. And the suite that I’m in is amazing. We share it with a bunch of psychiatrists, and it’s wonderful. But that’s just not going to work. So the question I’m sort of struggling with is how big do I go, because the offices I’m looking at are eight to ten offices. Which, my goal was to have 10 full time, and then have maybe a littering of, you know, some part time people to sort of fill the gaps and kind of make the team a little bit more rounded out. So maybe 15-17 total. And that’s that’s kind of where I think I’d like to stop. At this point. That’s my plan. So that said, 10 seems both like a good number, because it’ll allow me to be there. But it’s scary, because we’re in San Diego, and it’s huge. I mean, the markets crazy here, the spaces are so expensive, and it just feels big. So one question is, am I making the right decision by going back big? Or should I just get an office for the number of staff that I currently have? Which sort of seems silly, but then that’s where I’m like, what’s the fear?

Maureen Werrbach

Yeah, I mean, your business plan seems to support the larger space. And I’ll say that most of the decisions that I see group practice owners making, a lot of it hinges on their their risk level. Plus what income they have to support, whatever amount of time that office space won’t be utilized. So I don’t know if you’ve done any sort of calculations on because it sounds like had 10 office space isn’t far off from what you’re hoping to grow into. Which is a good sign and looking at it!

When I work with other people who are like I’m not sure yet how big I want to get a 10 office space, I would say is not something to jump into because you might decide at five people you’re good.

But you are at six, which doesn’t leave a ten office space completely unused, which is good. We still have a little bit of time to grow before you would be using that office space.

The second thing that I would think about is the financial piece, because that’s obviously the scariest part of it. Do you have enough funds? How long does it take a clinician to fill? How many clinicians do you expect to hire? I would say through 2021, right, we’re in the beginning of when do you plan up? When would you have planned on getting that one?

Stephanie Rosado

Yeah, I mean, right now, there’s a lot of TI’s in this couple of spaces that we’ve been looking at. Soundproofing has been a huge factor in those but we’ve set like June to be kind of the goal.

Maureen Werrbach

Okay, perfect. So I would look at what is your expectation? How are you forecasting what between now and June looks like in terms of how many clinicians, extra clinicians, you’re hiring? An subtracting what that 10 office spaces from what you’re expecting to forecast between now and June, plus the six people that you have. Would you be I mean, I can envision you being at capacity already by June. And not even needing to forecast a second. Because I was gonna say, and then you have to forecast June to, let’s say, the end of the year, because that’s when you’re actually paying the rent. And how many clinicians can you get to cover the costs of that rent by the end of the year? That’s how I always look at it. Yeah, I’m expanding into a new space, where I don’t yet have the people for it. But you’re planning pretty healthily ahead of time that you can potentially make it work so that your 10 office space is full by the time the 10 office space is actually ready.

Stephanie Rosado

Yeah, that’s that’s what I’m thinking. The other factor in this I think that’s made it challenging has been–I’m sure you’ve heard the concerns about hiring. I mean, I felt I waited, I didn’t just hire anybody that came to the door, I was definitely very choosy about who I was bringing on and looking for certain qualities and mostly culture and fit was really important to me. And then skills, you know, are really important, but I think those can be grown and and groomed. Anyway, the hiring was really it was slow. But I mean, one was word of mouth from another clinician. And then the other two were through like traditional Indeed, or one of them was just found us on our website, which is wonderful.

But the hiring, I don’t say drought, but slow process makes it a little.

And then the to add to that we are only credentialed with our two insurance companies really, we only take two. One of them is very minimal and but the other one is our main insurance, TRICARE. And as we serve the military population here in San Diego heavily, we have sort of specialties in those areas with working with combat stress and trauma.

So long story short is on that we have people not in the pipeline, and I’m worried about like, okay, these two are the last two I hired, other three are full, the last two I hired are waiting on credentialing still. That’s what’s the pipeline sort of does. They’re doing admin tasks for me, and one is creating a group that’s gonna launch probably in the next two weeks to do some private pay groups and whatnot until she’s credentialed. But it sort of makes this whole thing a little scary as far as like you hired Do I go ahead and start putting out now and hiring for that timeline, so that they’re credentialed and starting to see patients by June?

Maureen Werrbach

How long does it take to get into TRICARE?

Stephanie Rosado

Oh, God, it used to take 45 days now it’s taking like 90 to 120. I did just invest in some new marketing, which I’ve never marketed so I’ve never really like done a Google ad, or anything like that. And all my clinicians have been full via word of mouth and referrals from other, you know, providers in the community, and then the insurance company, the one insurance company, essentially, so I’m feeling good about the ability to fill them. But I just feel worried that to have four people maybe I would hire two at a time because it’s just so much easier to onboard them together. Having them be sitting there not seeing patients for like four months, and then paying admin time, just all of those factors kind of go into it.

Maureen Werrbach

So when I hire clinicians, they aren’t their start date. They’re not hired until their first client is scheduled, technically, or they’re hired but their start date isn’t until their first client is scheduled. So we don’t have them do any sort of admin time. Okay.

Stephanie Rosado

Even even, like attend meetings or anything like that?

Maureen Werrbach

Nope, not until they start when they are officially onboarded. That is when that’s when they start attending meetings and all that. Okay.

Stephanie Rosado

Interesting. Yeah. I mean, I think one of the things I struggled with these two was, my bleeding heart therapists came out saying these people are like really struggling and they have families and you know, they were looking for work and also thought that they were a great fit for the practice. And it kind of worked in both regards, because one of them was had a lot of administrative experience prior manager or program director, and also clinician. So she was like, “I would love to do and take screenings and like do admin stuff behind the scenes and tell them up to par, if that’s something you’d be interested in,” that sort of piqued my interest. Just because then I wouldn’t have to necessarily hire an admin person yet. And then I thought she could train my new admin person down the line.

Maureen Werrbach

That’s a smart move.

Stephanie Rosado

Yeah. And then the other one, she wanted to create the group. So in California, we have to pay for all time work. So I’m paying her those 10 hours a week, essentially, to work on getting the group up and running, doing research. And she’s done a few other little admin tasks that were helpful for me. So it’s kind of worked in my favor, because not paying an admin person right now. But down the line, I can, it’s good to hear that people do hire and then just kind of hold off completely. I thought maybe having attend meetings was a thing.

Maureen Werrbach

No, I mean, we have it set up so that they start attending meetings once they are fully on boarded and have their first client scheduled. That’s when they’re considered, like, fully employed, and expected to attend any meetings that we have. I see the benefit in being able to pay people ahead of time so that they can start attending meetings and be a part of the culture. Yeah, but in reality, in our industry, it can be hard for practice owners to do that, just because if there’s no income coming in, and it takes up to 190 days, or whatever it is, yeah, it’s it’s just not feasible. And so I, you know, with workplace culture, there’s only so much that can be done by having them attend a meeting here and there, when they’re not really invested yet in the work, they’re not a provider yet. So I see that as like a small price to pay to potentially have them just wait on, you know, administrative tasks.

Obviously, the two people that you brought on to do admin work, it sounds like there’s a benefit for it.

But if you’re just trying to find admin things for them to do future people, just to have them, you know, ready to see clients I don’t think that’s necessarily needed, and maybe a little cost prohibitive. Sure, as you’re trying to expand a new space and save, save on costs for that.

That being said, you are in a perfect time, right now, if you’re able to timeline it out where that space opens in June, to start interviewing people, because you’re right, most practice owners are in this drought phase right now of having a hard time finding a quality clinician to hire, to start. Just let them know, the onboarding time, you know, typically takes a handful of months just because we’re credentialed with Tricare, but we’re looking to hire people that can start, you know, May/June.

If they can start working remotely in May, let’s say you find someone this month, and it takes them a couple months and they’re ready by, you know, April or May, I would have them start at that point via telehealth, just as they build their caseload up so that once June hits they’re able to kind of cover some of those extra costs of the added space that you haven’t been paying for this whole time.

Stephanie Rosado

Sure. That makes sense. Yeah. That’s what I was sort of hinting on. The question is, am I being too, like, you know, I’ve heard you talk a lot about I’ve read a lot about people scaling too fast, and then it becoming kind of a little bit problematic.

So I didn’t want to become, you know, that balance of like, being too eager to capitalize on this time, that seems kind of idle, then like a good time to do some of these things.

But also the thought of okay, they’re full time caseload is 30. So that’s 120 patients I need to fill. So I did invest, like I said, I invested in marketing. And we should be starting where we bookkeeping, all of our content, and we’re starting a blog and we’re doing all that stuff. So I’m hopeful that that will start to draw in even, not just the insurance and more out of network and more private pay. We have a pretty good percentage, but even more to fill those other people so we can litter them in with a couple clients here and there starting up until June, but I didn’t want to be too zealous about I’ve just hired these two. I just got them on boarded. They don’t even have patients yet. I’m gonna hire two more. And I was like, that feels weird, I guess but I don’t know if that’s how it’s done.

Maureen Werrbach

Yeah, I mean, you have six right in total?

Stephanie Rosado

Myself plus five.

Maureen Werrbach

Yeah. Okay. So the other three, are they full? They’re full. And how long did it take them?

Stephanie Rosado

I mean, that’s who I hired in January 2020. We were full before the pandemic hit. And then the other one I hired in May and she was, well she was part time, I should say so, but then she went to full time in December and she’s been full. Now, the only reason we’re picking up a couple patients here and there is because some of our patients went on unemployment and stuff like that. But generally, they’re pretty full. They can, one of them can’t take any of the other can take one or two here and there, depending upon their where their clients are with me. So yeah, pretty quickly, we feel I would say they could get an average of four to five and takes a week.

Maureen Werrbach

Okay. And then the two that you just brought on that don’t have anyone yet. When are they ready to start? You’re waiting for them?

Stephanie Rosado

Yeah, one of them should be by the by beginning of February, or mid February, and then the other won’t be till like mid March, probably.

Maureen Werrbach

And so even if you were to hire someone now, they’re likely not going to based off of your history so far that I’m hearing, it’s very unlikely that anyone you hire now that once they are you get them credentialed, or you start the credentialing process, and they actually get credentialed, your current two people who will be full. Right?

Stephanie Rosado

I think so. Yeah,

Maureen Werrbach

It sounds like it takes just a couple of months for them to get completely full. And I feel good, generally bringing on people when my existing newer staff are around that 75% mark. So even if they’re not 100%, full, when I was, you know, a newer practice or had less clinicians, that was kind of the metric I used for bringing on new people. I wanted my existing people to be around 75%. Because the idea was, and it worked out in my favor in this way was that by the time that new person I hired, got on boarded, went through the credentialing process and could actually see clients, so people that were at 75%, were likely closer to 90 100% full. And so it sounds a little deceiving. For those that don’t take insurance to hear you say that you don’t have anyone there that two people don’t have any clinicians. But this is kind of the norm for insurance practices that take insurance that have to, you know, wait this longer amount of time. And like you said, you’re also investing now in this private pay, and just getting front and center with private pay clients. I don’t see it being an issue. It sounds like your business plan is to be a slightly larger practice 10, you know, plus clinicians.

And so it boils down to, it sounds like you have a system in place for hiring and onboarding and getting them filled up.

The main question is really, do you have the funds to cover the cost of whatever the difference is between your one office space and now this 10 office space? Do you have the funds to cover probably six to eight months of rent, while you’re building that caseload? And that’s on the safe side.

Because we think about it. You have all this time through June, to hire people, we’re making the assumption that it’s going to take eight months past June for you to fill that space up, which is very unlikely. Do you have the funds to cover through December and June through December in the office space? While you’re building the case, loads of the people that are there. And now if it feels like oh, I have to have three more full time people fully filled to cover the rent, otherwise, I don’t have it, then I would say not, then find a five office space that has a right of first refusal that allows you to build out once you’re ready.

Stephanie Rosado

Or even maybe like somewhere between five and 10, like a seven or eight. Yeah, something like that. So that we could all each kind of have our own offices and then still building. I know, I keep going back and forth. One of the offices, they have the option of building into additional offices within it that wouldn’t really cost us extra, and it would make it like a 10 office. It’s already currently an eight office.

Maureen Werrbach

Is the rent, like and that’s the other thing to think about. I’ve had spaces that I was looking at where the eight office space costs, barely less than than the 10 office, you know, that is there, is it proportionately less to have eight offices versus the 10 office space. Because if you’ve been building out a wall, it’s gonna it’s gonna cost money, it doesn’t cost nothing, you know? So yeah, I know, that’s the office space, you’re saying you could build you know, break to the rooms up and make it into a 10 office space.

Stephanie Rosado

Right. You said they will Yeah, we put it in our TI request so they would have them do it. Yeah, they would do it because the soundproofing is the number one the major issue, and so many of these buildings, we’re looking at the soundproofing. So we’re we’re asking them to do TIs, including sound specialist soundproofing. In which case, they could build those two in our offices. And the space needs to be built that way so that we have a waiting room. So we asked for that.

But there to answer your question, no, in this area, this is not significantly less.

Because we looked at another eight office suite and it was like we’re talking maybe less than $1,000 difference a month and so that’s not significant. But the price per square foot here is decent. I don’t know about where you guys are but it’s decent. Compared to California market, it’s not the highest, but it’s high. It’s high.

It’s like, you know, you get it, you get a 4000 square foot office and you’re pushing a $10,000 rent money. Yeah. So it’s pretty pricey here. But I don’t again, I know that is like New York and Chicago and other places the same. But that’s good to hear that if I felt like I needed three more, I think that’s what we’ve done the math, the numbers, has been fine finance guy, and he essentially was like, it’s the margins aren’t going to be good at first, like, you’re gonna have to really buckle up and get some more clinicians in there to make the margins feel good.

Maureen Werrbach

Yeah. And, and that’s how it normally is, initially, the margins aren’t good. And it’s just a matter of knowing, based off of how you lead and how your business works, how quickly you can get for it to be profitable. So I mean, unless you’re looking for a space that fits exactly what you have, obviously, then it’ll be perfect. Because then it’ll be profitable, because you are setting it up. You’re not setting up a space for expansion, you’re setting up a space that fits what your virtual space right now is, you know? But in most cases, if we take COVID, and all this weird virtual work that everyone’s doing away, whenever we grow, that’s the risk that we’re taking. It’s that we’re, you know, bringing out a space or taking out a space that’s larger than the space we have now so that we can support the growth of a couple more clinicians. So that byproduct is that the profit margins dip, because you’re paying more rent than what you have clinicians bringing income in for. But that’s where the fun work comes in with you of making that space filled.

Stephanie Rosado

Right, yeah, that’s helpful. Yeah.

Maureen Werrbach

I mean, I guess, if you’re thinking about eight, between the eight office and ten office space, I would be looking at long term: am I going to need to build out the eight office space rather quickly? And is the 8 office space, going to save me the amount of money that like whatever the 10 office space is? If the eight office space is $9,000 and the ten office space is $10,000, I likely would just take the 10 office space, because I’m actually saving money in the long term.

If I know that I’m going to want to have enough clinicians to cover all that space, it just makes more sense.

But if it like works out in a way, where it’s 10,000, for 10, offices and 8000 for eight, then yeah, you know, if you want to take a little less of a risk, but still have enough space to grow. The thing I hate is moving into a space, that doesn’t allow for growth. If that was the case, I would say that’s not a smart move. If you are wanting to grow, you want to have the ability to grow. So if an eight office space would allow you to grow, then that might be worth it. If the pricing is so that it’s you know, far enough away from the 10 office space.

Stephanie Rosado

Sure. Okay. That makes sense. Yeah.

Maureen Werrbach

What are the hard leader questions are coming up for you?

Stephanie Rosado

So the next one is a guess, related to hiring with me not promoting within it. I don’t know why I can’t­–I’m trying to do some work on it myself, in my own sort of therapy, and just leadership stuff is like, what is it about that that feels challenging for me? And I don’t know if it’s because I wind up feeling like there’s certain clinicians, I gravitate towards the way that they I see certain things in them. And then I say, wow, that’s really great. But then I fear that it will come across as like, favoritism or me grooming. So you know, I really am trying to navigate that piece, because I see potential in some of my clinicians there. I’ve asked them if there’s things that you want, step up and talk to me about it. But I feel a little stuck with that for some reason.

Maureen Werrbach

I like to go the route of seeing who is presenting leadership at me. When I first started, I would like look for it in people, you know, I would try to see who who seems like someone that would could lead well, and then kind of like what you were saying, start the process of like, teaching them how to lead. And I’ve really shifted that over the years. In realizing feel you could be disappointed if you’re bringing on someone who you can see potential in as a leader, but maybe who really can’t lead and the whole idea of like the superstar and the rock star. Yeah, yeah.

And so I shifted a few years ago. I look at hiring, leadership for leadership as those who are showing me that they are a leader now.

And I’m essentially giving them a leadership position that they are almost living in some ways without the title versus, like trying to lift someone up into it. You know? And I think that helped me with the question that you’re asking now of favoritism. That is that this person is clearly showing that they’re stepping up and leading without my initiation, without me asking. And so it only felt natural to honor that work that they’re doing by creating a leadership space for them to, you know, actually have a title that goes with what they’ve been doing. So that was helpful for me,

Stephanie Rosado

Yeah, I like that. I like that spin. It definitely helps break away from the fears of the team perceiving something. And I have to kind of keep that mindset that it’s not about worrying about just what they perceive, necessarily, but that my motivation for doing that, that goes with shedding the whole like, being liked and and all of those sort of little, you know, stuff that comes with leadership. But essentially just remembering that, you know, that I’m seeing something and there’s a reason I’m seeing something. Or that they’re presenting it to me and shifting away from trying to hold it in them. Because that does feel it also creates like I don’t say a burden.

But in a way, it almost feels like I become sort of this mentor for a role that I really need them to be the leader in.

Maureen Werrbach

Yeah, yep. And that’s the issue I’ve seen just myself, as I’ve grown as a leader and brought people into leadership was initially having leadership that I had to train and teach how to even lead which put a lot of the outcomes of their leadership pulling back on me and truly, you own the outcome. And if I’m hiring someone to leave something, I want them to own the outcome of all the work that they’re doing, and independently be able to see where they need to make some some shifts have difficult conversations, without me managing them.

And you know, that happens a lot with business owners who bring their employees up into leadership versus hire someone out and bring someone you know, who is a CEO of a past business, have them be a CEO of your business, or CFO, whatever.

It’s very a very different field, when you bring someone who’s led a team, in as a leader.

There’s a lot of things that they don’t have to like, shed, that an employee would have to in terms of like peer relationships, and shifting from being a peer to now being someone’s no leader, and all of those things. So there are some dynamics that come with bringing someone up from employee to leadership.

I prefer that despite all of that I like you know, part of how I have my business run is that I want it there to be a space for upward movement. So I don’t hire leadership teams from outside, it always comes from within.

But everyone knows, and this might be where I can help you with the transparency pieces, I’m pretty transparent, and say, you know, all leadership positions are come by people who practice what they preach and are leading, and I see it. I’m not unsure if you’re a good leader, I’m not asking people to lead, I see them leading. And I want to honor that by providing a position for them to officially lead in. And it’s helped for people who, you know, I think everyone kind of wants to lead in terms of like, ego stuff, you know, it’s just natural thing, even though not everyone is meant to lead. In the past I would  have people that were like, Oh, I didn’t realize you were looking for a supervisor like I might, you know, I would have been interested. And then having that conversation.

And now they know this, but that was where I learned, okay, I need to be transparent and say those people who are leading are doing so because they’ve shown it to me, and I don’t have to worry that they can or can’t lead. You haven’t shown it I didn’t realize you would want to lead; show me something together. If you are showing me that you can lead that you’re doing it well that you’re, you know, providing something positive to the community and to our business, yeah, sure as heck, I’m going to find something. I’m going to find a way for you to lead. And it’s really shown those people that like maybe in theory want to lead because it would be nice to have a title and it’s just, you know, this ego boost that we before they realized like shoot, it doesn’t come natural for me to lead you to do some work around how to grow that piece of me.

Stephanie Rosado

That makes sense that would be like that. I like that. That’s good. Very helpful.

Maureen Werrbach

it’s been nice talking to you. I feel like I haven’t seen you on Facebook.

Stephanie Rosado

I have been on but I’m not on as much as I used to be but we lost our childcare in December. So we’re doing a lot of juggling we have jack in the family. It’s just been a lot of a lot of juggling. So I get on to like look for certain things, but I definitely look forward to our childcare resuming in March. Hopefully then I or school, one of the two, and then I will be able to do more.

Maureen Werrbach

Yeah well keep me posted on what you decide the eight and 10 office space.

Stephanie Rosado

Yes. Thank you so much. I really appreciate this opportunity. And I hope that your house is it’s not like rotten milk.

Maureen Werrbach

Literally, another podcast in one minute. I’m going to go run and see how bad the kitchen smells.

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Meet your host


Maureen Werrbach is a psychotherapist, group practice owner and group practice coach. Learn more about her coaching services here:


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Episodes are structured into categories: coaching sessions where I coach a group practice owner on a specific topic, tips of the day by yours truly, real talk where you get to be a fly on the wall while an established group practice owner and I talk about the highs and lows of ownership, and trainings done by experts in the field.

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* The content of this post is intended to serve as general advice and information. It is not to be taken as legal advice and may not account for all rules and regulations in every jurisdiction. For legal advice, please contact an attorney.

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