How healthy is your practice, really?

To measure practice health, look at five connected areas: client outcomes, financial health, practice operations, clinician well-being, and client experience. That’s the model from Ensora Health’s 2026 Practice Success℠ Report, a survey of 1,124 licensed therapists across mental health, behavioral health, and rehab therapy. Almost everyone agrees with the model. Far fewer can see how their own practice is doing in each area, and that visibility is what set thriving practices apart.

“How healthy is my practice, really?” was the question behind the first episode of Ensora’s Unlocking Practice Success webinar series. Casey Openshaw, OTR/L, an occupational therapist who owns The Openshaw Spot, a pediatric therapy practice in rural Down East Maine that serves children from birth to age 21, joined Ensora product leaders Cory Polonetsky and Lynn Carroll to walk through how she checks on each domain. Below, you’ll find her routines alongside what the research found.

How do you measure practice health?

You measure practice health by checking all five domains, because they affect each other. When a clinician is stretched thin, they have less to give in each session, so outcomes and client experience can slip. A family that feels unheard may stop coming. That empty slot is lost revenue, which puts more pressure on everyone who’s left.

“One weak domain pulls on the other four,” Lynn said during the webinar. The same chain works in your favor: when you strengthen your weakest domain, the others tend to improve with it. For a full breakdown of what each domain covers, read the five domains of Practice Success, explained.

Why most practices can’t see how they’re doing

Ensora’s research found a 77-point gap between what therapists agree success takes (95%) and how many say their practice is thriving (18%). Thriving and struggling practices agreed on what matters. What thriving practices also had was enough data in each domain to notice when something slipped, plus a routine for what to do next.

Most practices don’t have that view yet. Only 7% track all five domains. The widest blind spot is client experience: practices rank it first in importance and first in how well they think they’re doing, but only 19% track it. Among practices that call client experience a clear strength, just 28% measure it.

Client outcomes: Make progress visible across your caseload

“I think client outcomes is the most important part of owning a practice, because that’s why they’re there.”

– Casey Openshaw, OTR/L. 

Client outcomes are why most clinicians got into this work, and every other domain feeds into them. Yet only 21% of clinicians in Ensora’s research have a steady, reliable way to see how clients are progressing across their caseload. Thriving practices were far more likely to have that view: 40%, compared with 23% of struggling practices.

Research on routine outcome monitoring points the same way. A 2023 review in Psychotherapy Research found that regular progress feedback helps most for clients who aren’t on track, especially when clinicians have tools that flag who needs attention. In rehab therapy, the American Physical Therapy Association describes standardized outcome measures as a common language for judging whether interventions are working.

For Casey, that view lives in each client’s chart. She opens a goal graph to see whether progress is trending up. When there’s a dip, she clicks that date to see what happened, like a hard day or a different therapist that week. A graph shows patterns across a full caseload that are hard to hold in your head between sessions.

“I think client outcomes is the most important part of owning a practice, because that’s why they’re there,” Casey says.

The biggest barrier is time. Nearly four in 10 clinicians in the research named competing administrative demands as the top obstacle to tracking progress. Casey sees this in pediatrics, where tight margins push many practices to require notes at the point of service. “Sometimes they’re just putting in what they did for activities and rarely tracking the data as much as they should be, just because of stress and decreased amount of time,” she says.

Her first recommendation is an EHR that tracks client outcomes, so progress data sits with your notes. If you’re comparing options, see how Fusion by Ensora Health tracks goals for SLP, PT, and OT practices and how TheraNest® by Ensora Health supports mental and behavioral health practices.

Your 15-minute first step: Choose one short outcome measure and decide when your clients will complete it. This guide to starting measurement-based care without the overwhelm walks through how to begin.

Financial health: Know a few numbers well

“Sometimes I’ll bill a client and I won’t get paid for six months, or even know if [I’m] going to get paid on that claim.”

– Casey Openshaw, OTR/L.  

Financial health is where practice owners feel least confident. Only 9% say it’s a clear strength, the lowest of any domain. And 59% of practices feel financial stress when their numbers are unclear, even when the practice may be doing fine. 

Training is part of the reason. Clinical programs prepare you to work with clients, but as the American Psychological Association notes, that training “often does not address the realities of running a practice.” Casey’s degree required statistics and economics and nothing else on the business side. She did have a head start: both of her parents ran their own businesses, and her grandfather owned the town grocery store, which is now her office building.

Therapy billing was still a new kind of hard. “Sometimes I’ll bill a client and I won’t get paid for six months, or even know if [I’m] going to get paid on that claim,” she says. She’s not the only one dealing with this. In the APA’s 2024 Practitioner Pulse Survey, psychologists who left or never joined insurance networks named low reimbursement, administrative hurdles like preauthorization, and unreliable payment as their main reasons.

You can’t control how fast a payer pays, but you can control how clearly you see your numbers. Cory shared that in Ensora’s research, practices that measure their finances report less financial stress, whatever the numbers show. “Just knowing is better than not knowing,” he said.

Casey now calls financial health her practice’s strongest domain. Every two weeks, when she runs payroll, she checks these numbers for each clinician and for the practice as a whole: 

• Available appointments per clinician

• Three revenue numbers per clinician: what they could bring in, what she’d like them to bring in to support their pay, and the point where she needs to step in

• Revenue compared with payroll cost: what each clinician brought in over two weeks next to what they cost in payroll

When a number drops, she looks for the reason, like a flu going around, a run of no-shows, or the first week of school. The same numbers help her decide when she can afford to hire. Her other advice for new owners: talk to a tax professional early.

Your 15-minute first step: Pick one financial number, like days to get paid, and write down what good looks like for your practice. These therapy practice financial benchmarks by practice size can help you set a target.

Practice operations: Fix the problem that hurts most

Most practices know exactly where operations hurt. In the research, 47% named no-shows and late cancellations as their top operational headache, but only about 20% have a defined process to get ahead of them. Most react after the slot is already empty. Thriving practices were less likely to name no-shows as a top concern: 33%, compared with 52% of struggling practices.

No-shows affect care as well as revenue. In a 2024 study of outpatient physical therapy clinics in JOSPT Open, the average no-show rate was 17%, and clients who missed more visits were more likely to stop coming before they were discharged.

Casey’s practice uses a flex schedule list for two things.

First, it fills open time. Families with unpredictable schedules, like shift work or a sibling’s sports season, join the list instead of holding a standing weekly time. When a time opens up, or someone cancels that morning, her team reaches out to families on the flex list first.

Second, it backs up her cancellation policy:

1. After two cancellations or no-shows in a six-month plan of care, the family gets a warning.
2. A third moves the client to the flex list, and they give up their standing time.
3. The same pattern repeats on the flex list, with another warning before discharge.

That adds up to about six chances, which Casey calls lenient compared with practices that allow three. If you adopt a similar policy, share it in writing at intake and check it against your professional code of ethics and your payer contracts. The no-show playbook covers how to enforce a policy without straining client relationships.

Your 15-minute first step: Name the operational problem that hurts most, write down one follow-up step or metric, and check it on a regular schedule.

Clinician well-being: Follow through on the policies you set

Clinicians need to be well to do their best work, and Ensora’s research found a gap between what practice owners believe is in place and what their clinicians experience. Among owners, 58% say their practice has a formal after-hours policy, but only 37% of employed clinicians say the same. You can see the full findings on the clinician well-being domain page.

Casey thinks the gap comes from follow-through. Owners put policies in place, and if nobody holds the team to them, they fade. Her own policy is simple: at 6:00 PM, unfinished documentation waits until tomorrow. She set it after noticing clinicians regularly staying until 8:00 or 9:00 PM. “You guys can’t be doing this. You need to go home to your family,” she remembers telling them.

A few of her most dedicated clinicians used to text her ideas late at night so they wouldn’t forget them. Now they add those thoughts to a shared Google Doc to discuss later, which also protects coworkers’ evenings.

Work after hours is common across the field. In ASHA’s 2023 survey of speech-language pathologists in health care settings, 22% said they work off the clock every day. A 2024 review in Counselling Psychology Quarterly found that smaller caseloads and firm boundaries may help most with emotional exhaustion.

Thriving practices were also more likely to hold regular workload reviews: 48%, compared with 34% of struggling practices. Casey says the right caseload depends on the clinician. Some want a full schedule, and others want a smaller group of clients they see every week. She asks each clinician what success looks like to them and is clear about how caseload connects to pay. She also holds weekly one-on-ones through her team leads and a weekly meeting in each office about what each client needs.

If you practice solo, set your own end-of-day cutoff and check each month whether your caseload still fits your life.

Your 15-minute first step: Ask each clinician, or yourself, how manageable their caseload feels right now. These common reasons therapists burn out can help you spot other early warning signs.

Client experience: Ask before there’s a problem

“If there’s a problem and a parent’s unhappy, you’re going to be the first to know. But if they’re happy, most of the time they’re in and out.”

– Casey Openshaw, OTR/L. 

Client experience ranked first in importance in the research, yet only about one in five practices track it. Casey says the hard part is getting responses. Parents are in and out of the waiting room, running errands, or taking a quiet minute while their child is in session.

“If there’s a problem and a parent’s unhappy, you’re going to be the first to know,” she says. “But if they’re happy, most of the time they’re in and out.”

Her practice sends a satisfaction survey by email, posts QR codes in the waiting room, and asks therapists to mention it. The latest survey drew 30 responses from about 400 active clients. Casey aims for roughly a 10% response rate and shares results at team meetings. One theme matched what she’d noticed herself: chaos in the waiting room, which her team is now working to calm.

Asking clients for feedback is linked to keeping them in care. A 2021 meta-analysis in Clinical Psychology Review found that collecting progress feedback from clients reduced dropout. Thriving practices in Ensora’s research were also more likely to follow up when a client leaves treatment early: 44%, compared with 26% of struggling practices.

In pediatric practices, Casey points out, there are two clients in every visit: the child in session and the parent who decides whether to keep coming. Her practice offers parent coaching so families can carry strategies home. “It’s hard for kids to make progress in one hour a week if our techniques and our advice [aren’t] being followed through at home,” she says. The American Speech-Language-Hearing Association notes that families and caregivers “play a pivotal role in treatment outcomes.”

Your 15-minute first step: Write a three-question client survey and decide when clients will get it, such as by email after their fourth visit.

Where to start this week

You don’t have to fix everything at once. Because the five domains are connected, improving your weakest one tends to lift the others. Thriving practices in Ensora’s research got there by seeing clearly and acting on one thing at a time.

To find your weakest domain, take the free Practice Success Assessment. It takes about five minutes and gives you a personalized action plan across all five domains. Then download the 2026 Practice Success Report for the full findings and a 15-minute action for every domain.