Building a Mobile FEES Empire: Stuart Bradley and Kristen Waltman on Scaling Carolina Speech Pathology

Stuart Bradley was told it couldn't be done. Take endoscopy equipment portable? Build a private practice around mobile FEES evaluations? The big equipment companies said no. Stuart said watch me.

That was 1996. Today, Carolina Speech Pathology operates in 13 states with 30 employees, including 15 speech-language pathologists who drive their own routes, carry their own equipment, and bring swallowing assessments directly to nursing home patients who can't get to a hospital.

Stuart and his colleague Kristen Waltman joined Clinic Chats to talk about how they built and scaled a mobile FEES company, what it actually costs, and why putting the patient first is the only business strategy that works long-term.

From Trauma Hospital to Portable Endoscopy

Stuart's path to mobile FEES started in acute care. He began practicing in the early '90s, working brain injury rehab in a trauma hospital where he learned to perform FEES on patients too critically ill to be transported for modified barium swallow studies.

When he moved into geriatrics as a rehab manager in a nursing home, something clicked. He saw how institutionalized patients missed out on services they needed, especially around dysphagia and quality of life. That's what turned him into an advocate for nursing home patients and eventually pushed him toward private practice.

When he approached Olympus and Pentax about building a portable system, they told him it wasn't possible. But Stuart had a background in television production from his pre-college days working in cable TV. He figured if he could watch HBO on a telephone pole, he could make a FEES image portable. So he bought a light source, a scope, two high-definition VCRs, and a television, and built his first system himself.

He's been building endoscopy systems ever since. The equipment Carolina Speech Pathology uses today comes from EndoHD, a company Stuart started. It's all FDA-approved, and each unit runs about $20,000 to build in-house.

Kristen's route was different but landed in the same place. She started doing FEES in grad school under a mentor who was passionate about the procedure and went straight into it during her CFY. After years in inpatient brain injury rehab, she hit burnout, took time with her kids, and eventually found Carolina Speech Pathology. The flexibility and the focus on geriatric dysphagia care turned into a second career passion.

How a 13-State FEES Operation Actually Works

Running a mobile practice across 13 states is a different animal than a local clinic. Every clinician at Carolina Speech Pathology is a full-time, salaried employee with health insurance and vacation. They work from home, get reimbursed for car use, and carry company equipment to their assigned facilities.

On a typical day, a clinician completes about three FEES evaluations and drives anywhere from 200 to 400 miles. The scheduling is handled by a central coordinator who manages inbound calls, texts, and emails for every geography. A separate person handles invoicing.

Geographic growth is intentional. Kristen, who runs operations, insists on contiguous states. Hopping over six states to launch in Oregon creates real problems when equipment breaks or a clinician gets quarantined. Sister states let them cross-cover and shift resources quickly.

Their biggest growth lever has been corporate nursing home chains. Landing a large chain in Georgia or Florida gives them a beachhead in a new state, and then they build out the rest of the client base from there. Their sales team, modeled after pharmaceutical sales, focuses on building relationships with prescribers, which in this case means fellow speech therapists who can refer patients for FEES.

The Business Side Nobody Warns You About

Carolina Speech Pathology bills facilities, not insurance companies. Under the Medicare program, vendors providing therapy must bill the nursing home directly. The facility then handles Medicare Part A, Part B, Medicaid, or whatever applies. That simplifies things considerably for Stuart and Kristen, but it creates its own headache: getting paid.

Nursing homes are notorious for slow-paying their vendors. Cash flow becomes a real challenge because employees get paid on schedule whether or not the customer has settled their invoice.

Payroll is contracted out through a payroll company. Their chief finance person coordinates with Kristen to run it every two weeks. Most other functions have been slowly brought in-house over the years: IT, scheduling, and administration. Marketing is one of the few things still outsourced.

Stuart's number one piece of advice? Avoid debt at all costs. And when he talks about risk, he reframes it. Entrepreneurs don't just take risks. They rule out risks, methodically, until what looks like a gamble is actually close to a foregone conclusion. The failures still happen, and they're expensive, but the question is always about scale: how much expense can you afford to learn from?

Why Patient-First Thinking Is the Real Growth Strategy

When you ask Stuart and Kristen about competition, they don't spend much time on it. Local hospitals can do FEES. Small independent practitioners can do FEES. A couple of companies have some scale. But Carolina Speech Pathology focuses on its own identity and lets the chips fall.

Their niche started as mobile FEES when hardly anyone was doing it. Now it's their ability to serve large corporate chains across a massive footprint. If you're a chain with buildings in 10 states, Carolina Speech Pathology can cover almost all of them.

But underneath the growth strategy is a simpler principle. Put the patient first and the business follows. Some days they drive 400 miles for a single patient in a rural community and don't make money. They do it anyway, because serving underserved populations is the whole point. The business works out over time, even if not as fast as you'd like.

Kristen puts it this way: you have to be forward-thinking, find a need, and really believe you're helping somebody. Stuart adds the practical side: be passionate about what you do, put care first, and the money will always follow.

Finding Your Niche and Running With It

Stuart and Kristen's story is a reminder that the best private practices are built on specificity. They didn't try to be everything to everyone. They found one procedure, one setting, one patient population, and went deeper than anyone else was willing to go.

They built their own EMR equipment. They created a pharmaceutical-style sales model for therapy referrals. They insisted on full-time salaried employees when the industry norm was contractors. Every decision reinforced their identity.

For SLPs considering private practice, the takeaway isn't that you need to build a 30-person company in 13 states. It's that having a clear niche, understanding your market, and being willing to do the hard operational work is what separates practices that grow from ones that stall.

Running a multi-state therapy operation means juggling scheduling, documentation, and billing across dozens of clinicians. ClinicNote is a HIPAA-compliant EMR built specifically for private practices and university clinics, keeping everything in one place so you can focus on patient care instead of paperwork. See how ClinicNote works.

Transcript

Kadie: You are listening to Clinic Chats, the speech therapist's private practice podcast, a podcast full of personal journeys where we not only talk about success stories, but also real life struggles of small business startups. Clinic Chats is sponsored by ClinicNote, a HIPAA-compliant, cloud-based EMR platform used specifically by private practice owners and university clinics. I'm your host, Kadie Jackstadt, and thank you for joining me today.

Kadie: So on today's episode of Clinic Chats, I have two guests. They are the owners of Carolina Speech Pathology, LLC. We've got Stuart Bradley and Kristen Waltman. Hello, and welcome to Clinic Chats.

Stuart: Hello. Thanks for having us.

Kristen: Yes. Thanks for having us.

Kadie: You all are my very first private practice company who specializes in FEES. So super excited to dive into that. I'd like to backtrack a little bit and find out where your experience first began and how that transpired into private practice.

Stuart: All right. Well, why don't I start that off? First experience. So I've been practicing since, let's see, I had my season end of '91, beginning in '92, and worked in acute care hospitals doing brain injury rehab. In so doing, I learned about dysphagia. I had some dysphagia classes or a dysphagia class in grad school and exposure to dysphagia, but not really until I started working in a trauma hospital. And that's where I learned FEES, and we were doing FEES on patients who were too critically ill to be transported for doing modified. So we're doing it on fairly significantly injured patients.

Stuart: Now, the other part of the question about swerving into private practice, that was always kind of been in my head as a goal to do, was always to have my own business and get a private practice started. And so in so doing, I launched the first iteration of Carolina Speech Pathology back in 1996, contracting FEES to nursing homes. FEES is something that has been very near and dear to me for quite a few years.

Kadie: Yes. And whenever you first began in '91 in the acute setting, once you got trained in your first experience with FEES, did you kind of know that that was your passion?

Stuart: I didn't at that point. I knew brain injury, and then I knew brain injury was my initial thing, and then started... Oh, I know what triggered geriatrics. So I got really into geriatrics by being a rehab manager in a nursing home as my first job after getting my Cs. That's where I saw that the system itself, the institutionalization of geriatric patients, causes them to miss out on services that they really need, and dysphagia and quality of life being a huge one. That's really where I got into being an advocate for patients in nursing homes.

Kadie: And Kristen, what was your background out of grad school, and how did you get involved in FEES?

Kristen: Sure. I actually started doing FEES in grad school. One of my mentors was very big into FEES, so that was a really cool experience. And then jumping into my CFY, I started doing FEES. So I really have only done FEES for swallowing assessment. I shouldn't say only, but that's been my primary focus. And much like Stu, my initial focus was very much brain injury. That was kind of my passion, inpatient rehab, brain injury.

Kristen: And then you kind of get burnt out, honestly. It's really heavy. And so I kind of just took a pause and had little ones for a while, and was not at home, but just didn't want to be in that setting necessarily anymore. And Stu and I actually know each other from before this job, and was looking, kind of what you said, Kadie, for flexibility. And this job is really flexible, and it was a great fit. And so I just completely dove into FEES.

Kristen: And just to also bounce off of what Stu said, doing FEES in our setting, I have found to really love geriatrics, and realized that this is such a huge portion of dysphagia care in the setting, and have kind of found my second career passion, I guess.

Kadie: Okay. So backtracking, Stu, you started doing it yourself on the side in 1995, when I was four years old.

Stuart: Yes. When you were four. Yes.

Kadie: Oh, my gosh. Thanks for that. I appreciate that. So whenever you first began, did you purchase your own equipment?

Stuart: Interesting you should say that. I first went to the big endoscopy companies, at the time it was Olympus and Pentax, and said, this is what I want to do, I want to do this on a portable basis. And they made the mistake of telling me it can't be done. And I'm the guy, if you tell me it can't be done, I'll try to prove you wrong.

Stuart: And so I basically bought the equipment necessary, a light source, a scope, and a couple high definition VCRs and a television. And I put together my first system myself.

Kadie: Wow.

Stuart: And did that because prior to going to college, I had a background in television production. I worked in cable TV. And I learned back in the '80s, that if I can be on a telephone pole and watch television and watch HBO on a telephone pole, I certainly can make a FEES television image portable.

Kadie: Yeah. So that's how we came about equipment. And frankly, I have been building endoscopy systems ever since.

Stuart: Oh, my gosh. Well, I feel like it's just like you're destined then with your experience and where it all led you. And now you're literally built it yourself.

Stuart: Yes. The equipment that we use today is EndoHD, which is a company that I started. And that's basically we supply our own equipment.

Kadie: Wow. And do you outsource it or sell any of your equipment?

Stuart: We did for a number of years under a company called AlteraVision. And it was something that, again, that was somebody said that it can't be done to start a medical device company on your own. And so said, well, screw it, let's do it anyway. And Kristen was working the clinical side and directing the clinical side of our business while I was working on the medical device side of the business for a number of years. We ended up shuttering that business for a number of financial reasons, though.

Kadie: Yeah, that was kind of my brutally honest next question, was to dive into a private practice. I mean, it's a risk. And so I was just curious, at what point did you kind of decide that this risk is worth it? It sounds so easy to say I'm going to prove these people wrong, but it does take a lot of thought and a big risk.

Stuart: Yes. So it's interesting that people say entrepreneurs take risk. And honestly, I look at things, and Kristen and I have many conversations about business where what we're doing is we're weighing the risk and we're ruling out a lot of risk to where when we make a decision to go forward with a project or in this case, a company or start a company, it's really we've ruled out most of the risk. And it seems pretty much like a foregone conclusion at that point.

Kadie: And Kristen, are you an employee at this point or are you co-owner?

Kristen: No, I am an employee as well. I was one of Stu's first employees. And I think that Stu and I both share the same philosophy, like you have to... there is risk involved, absolutely. But you also have the reward. And so unless you kind of want to stay in the middle and just ebb and flow a tiny bit, you really do have to go forward, I feel like, to get the reward on the other side. And that can sometimes backfire, to be honest, but I think more times than not, it doesn't backfire.

Stuart: Yeah, we have plenty of examples of where the risk does backfire. Plenty of examples, and they're expensive, but they're worth learning. And it just becomes a question of scale. And how much expense can you afford to learn?

Kadie: When you're first beginning, or if you think back of how you began working with these nursing homes or whatever clientele that are seeking a FEES evaluation, how does that first look? Are you going into several locations and spreading the word that you have that capability?

Stuart: Initially? Yeah, it was, I was basically the head salesman for the company. And it was just going to nursing homes and saying, this is what we have available. How'd you like to contract with us?

Kadie: And does that, time pay out by patient, by evaluation? And then they charge the insurance, or are you charging the patient's insurance?

Stuart: We bill the facility. So under the Medicare program, the law is written such that vendors that provide therapy must by law bill a nursing home. And so they pay out of the daily rate that they get. Now they can bill insurance, they can bill Medicare Part B, they can bill Medicaid, and they also deal with Medicare Part A.

Kadie: But you don't have to.

Stuart: No, thank goodness.

Kadie: That's amazing. I'd say that is a sweet deal. You can leave it pretty straightforward then with your bill to the facility. So to everybody listening who has to use the fee schedule, I feel for you. We negotiate our prices on an individual contract basis.

Kadie: And now I heard Kristen reference other employees. How many total employees do you have at this time?

Kristen: I think we're about up to 30. At one point pre-COVID, we were higher than that, but we've obviously had to kind of pivot, and I hate that word, it's so commonly used now. But yeah, we're about at 30 right now.

Kadie: Holy moly, okay. So you're not just in Carolina, are you?

Stuart: We go all the way up from, let's see, Pennsylvania to Florida out to, our furthest west is Texas, but we are in, I believe, 13 states.

Kadie: Wow, so tell me the structure of that. Pretend like you're looking for someone new in California or whatever. How does that process look?

Kristen: I like geographic growth, and geographic growth is hard to do. And so would it be fair to say that, Kristen, you're not always the biggest fan of geographic growth?

Kristen: I like contiguous states. I don't like to hop over, because I have to think about it from an operations standpoint, and it's really hard to, say, hop over six states and launch out in, say, Oregon or something, because should something happen with equipment or an employee out there, it's really difficult just to keep things moving. Whereas if I have South Carolina, North Carolina, Virginia, it's so easy, we just shift, and then we can cross-cover. Because it's so different than, say, the hospital. You don't just have this great pool of staff. We're all mobile and hundreds of miles apart. So to me, just to keep the process going, it just helps to have sister states, if you will.

Stuart: And so we have expanded out of North Carolina into those states and a bit west, Texas being the furthest west. Dallas forward, yeah.

Kadie: And so you provide your speech therapists with the equipment they need?

Stuart: Correct. Yes. They get the equipment they need. They get to work from home, and we reimburse for the use of the car and all that kind of normal stuff.

Kadie: So they are contract employees, would you say?

Stuart: Nope, they're full-blown employees. Full-blown salaried employees, absolutely. Salary, health insurance, vacation.

Kadie: Wow, okay. And how many evaluations would you say typically makes up a full-time schedule in a week?

Kristen: Again, pre-COVID, things are a little bit different now and we're trying to adjust. But on a typical eight hour day, we would do about three exams and drive anywhere from, I'd say a pretty decent day of driving 200 miles and a heavy day is like 400 miles of driving.

Kadie: Wow. So you have about 30 employees now, full-time and part-time, or all full-time?

Kristen: We have three part-time right now, and then the rest are full-time, and they're not all speech pathologists. We have 15, if you include Stu and I, 15 speech pathologists. And then we have a sales force and some admin, an IT fella. So with all of us together, 30.

Kadie: So tell me a little bit about your need for the other employees as far as IT, sales, whoever else you might utilize.

Stuart: So sales is our next largest employee group. Well, administrative is right now, but that's again, because of COVID. But normally sales is something that I brought into doing because I mentioned multiple iterations of Carolina Speech Pathology. I took a break at one point and worked as a pharmaceutical sales rep. Quite enjoyed it. That was over 20 years ago when it was still a fun gig.

Stuart: But what I've done is we've tried to kind of model our sales process to how pharmaceutical sales works. In other words, our sales people are to develop relationships with the prescriber, and the prescriber being our fellow speech pathologists, basically. And so that's how they go about driving new business by getting contracts. Asking clinicians to refer patients to us for doing FEES. And that's how we've expanded fairly significantly is through the use of sales reps.

Kadie: When would you say was the biggest growth in the current company as far as expansion?

Kristen: It's definitely this last five years. I would say in particular, we picked up one large customer and that was probably our biggest expansion just by default in the Georgia area. And that's probably, gosh, maybe six or seven years ago, just if not looking numbers to numbers necessarily, Kadie, but if I'm just looking at the trajectory of our growth, like the percentage of growth year over year, I would say then.

Kristen: And then after that point, it really is picking up new customers within the territory, getting a big corporate chain helps us. And then the corporate chains also help us launch into a new territory. Like for example, we secured a large corporate chain in Florida, which really allowed us to spring dive into Florida then. That gave us a reason to go to Florida. And then we built the rest of the client base up from there.

Kadie: How would you say you find your SLPs that you feel are qualified? That's gotta be challenging. I think FEES sounds amazing, but I've got zero experience and that has to be tough to make sure someone knows what they're doing.

Kristen: It takes me a really long time. That's kind of my gig. Would you say, Stu?

Stuart: Absolutely, you're a savant when it comes to that.

Kristen: I love recruiting. It's really fun to me because I get to meet new people, but I look at a couple of different things. They've got to be in the right location. As unfun as that sounds, if you're not in the right place for this job, it doesn't work. So I look at that. I definitely look at personality because it is a little bit of a salesy job. You're going in with customers and they need to like you. So you've got to be outgoing, friendly, likable.

Kristen: And then clinical experience is a big deal as well, of course. And it's great if I can get someone who's been trained, but sometimes we don't, not very frequently, and then we will do a full-blown residency program. But I would say 99% of our folks come to us with a whole lot of experience and then we do about a month onboarding process. So it just takes a lot of networking.

Kadie: And how close of communication would you say you all have with all 30 employees?

Kristen: Multiple group chats all the way to, we have an annual party once a year where everybody is flown into location and we do that as well.

Stuart: So it ranges. Daily communication happens within the clinical staff, happens within the sales staff, happens within the administrative staff, but we try to... it's very difficult when everybody's working from home and somebody's in Pittsburgh and another person's in Tampa to really maintain that. So there's a lot of electronic communication that goes on.

Kristen: And I think just too, Stu, as much as this has kind of shocked everyone's world by working remotely, our therapists are mobile, so they're not working from home, but we are very used to using technology to connect with one another. So don't get me wrong, this is definitely different, but as far as the need for tech and really being kind of intentional with your communication, we're pretty used to it at this company because you don't bump into someone down the hallway.

Stuart: Right. But difficult when you're spending time on the road to maintain that communication.

Kadie: Any details or information you could give just on challenges running the actual business, whether it's tax side or payroll side? All of that takes work. Do you all do that or hire that out?

Stuart: Let's see. So there's many business side challenges to doing this. Payroll, we contract out through a payroll company. We have a chief finance person who coordinates that. Kristen and she coordinate doing payroll to make sure everything lines up, especially now within our COVID era where we've had to change some statuses. It becomes more challenging to generate the payroll every two weeks.

Stuart: Other challenges are as simple as getting paid by our customers. We do the work and then we invoice. So it's not like we can take the product back if they don't pay. And nursing homes are notorious for not paying their vendors. So that's a challenge. So cash flow becomes a really big challenge because our employees want to get paid and they should get paid and they do get paid whether or not the customer pays us.

Kadie: What else, Kristen?

Kristen: I'm trying to think. Everything else we keep pretty much in-house. It's been a slow transformation from contracting it out to bringing it in-house. But we have an internal scheduling team. Our IT is now, we outsource that before we brought that in. We have some marketing that's outsourced. But other than that, we have mostly everything internal at this point.

Stuart: Yeah, we really do.

Kadie: Your company. Yeah, it's just really amazing and unique. Are there other FEES competitors that you are super aware of? Or do you feel like you're one of the leading options?

Stuart: Well, we think we're the best option, of course.

Kadie: Of course.

Stuart: Yeah, you are. The best and the leading option. Of course, there's competition and it ranges from, we compete with the local hospital, frankly, because the local hospital can do FEES. The local hospital can do fluoro. But they can't take it to the facility, correct? That's correct. And there are small independent practitioners who do FEES as well. And there are a couple companies that have a little bit of scale. Honestly, we don't look at our competition that much. We really just focus on our own business and let the chips fall where they may.

Kristen: I think the thing too, kind of just going off of what Stu said, I think you have to have kind of your own identity when you're having a private practice. You have to have a niche of sort, right? And so I feel like our niche maybe started out as just mobile FEES because it was relatively unheard of, Stu, right?

Stuart: Right.

Kristen: And now I feel like our niche is that we really can cater to a very large footprint. So if you are that large corporate chain, we can serve almost all your buildings. So that's kind of our new niche. And we do some continuing education too, which is another piece of our company that helps our current customers as well. So I think it's really just finding, how do you stand out?

Kadie: And you don't make your own endoscopies anymore, right? You're purchasing, or did you say you do?

Stuart: Oh, the equipment? Yeah, it is still. Yeah. And it's all FDA approved equipment. So I took it through the FDA a number of years ago.

Kadie: What kind of expense does that look like per user? Per SLP that you send one to?

Stuart: I don't know how much it costs us for equipment these days. I mean, we're talking, I don't know, $20,000 worth of equipment easily. Does that sound right?

Kristen: Yeah, that sounds right. It does. $20,000 to build in-house.

Kadie: One unit, correct?

Stuart: One, yes.

Kristen: Which is why the coverage is so hard. I mean, because you can't just put this equipment in a hundred people's hands, and that's why we have to drive so much. It's because you really have to have the density to make it, to get that return on investment on the piece of equipment.

Stuart: And it's a value proposition to our customers because frankly, our customers could go out and buy equipment for themselves, but the return on investment would take so long that the person would end up retiring.

Kadie: Well, I think you all are geniuses for making this happen and the growth that you've been able to do. Where do you see it going in the future? Continued growth? Are you happy with where you're at?

Stuart: I always want more growth.

Kristen: I would like to expand to, I don't know, like the Caribbean maybe. That would be really amazing.

Kadie: Do you all do the FEES anymore? Are you pretty much the business side?

Kristen: If you asked me that in February, I would have said business side. When you're asking me that now, I'm on the road one to two days a week seeing patients now to help out.

Stuart: And I'm less, but I still get out and see patients also. Yeah, with COVID, we have people quarantined and just like, it's been really difficult to staff appropriately because the volume's up and down and you just, you don't know where you're going every day. So we've definitely pulled in a lot more.

Kadie: So typically at this point, are you guys getting the calls from the relationships that you've established through your sales team? They call you or the employee that's nearest and that's how they set all of that up?

Stuart: We have a central person who handles all the scheduling for all the geographies. And she takes the inbound calls, inbound text messages, emails, and coordinates the entire thing.

Kadie: And does she do the invoicing there as well or is that a different person?

Stuart: It's a different person. Yes.

Kadie: Well, is there anything, any tips and tricks that you'd like to tell our audience or things to avoid? Anything that comes to mind?

Stuart: I have my usual. What do you have, Kristen? What's your usual?

Kristen: I don't think I knew this one.

Stuart: Oh, my usual is avoid debt at all costs.

Kristen: Well, and I think, Stu, you're underestimating yourself a little bit. Stu has this really awesome knack. He really is a visionary in that he sees a need. He can kind of forward think. I'm not as good at that. I can, if he gives me an idea, I can run with it and make it happen. But I really do think that you have to be forward thinking and find, like I said, a niche, find a need, and really believe that you're helping somebody.

Kristen: And we always say put the patient's needs first and the business comes second. This will follow.

Stuart: Yep. And it really does. It always does. So if we do drive 400 miles for one patient, yeah, we probably didn't make money that day. But if we serve the rural community or serve those kind of folks, the business just works out.

Kristen: Yep, absolutely. It's got to be something you're passionate about. But if you put that care and the patient first, money will always follow. It may not follow as fast as you like, but it will always follow.

Kadie: Well, that's really great insight. Thank you both so much for taking the time to come on the podcast. Really appreciate it.

Stuart: Oh, well, thank you. Appreciate it.

Kristen: Appreciate it.

Kadie: Thank you for joining me and listening to Clinic Chats, the speech therapist's private practice podcast. If you have a moment, please leave a five-star review for Clinic Chats to help other SLPs find our podcast. If you'd like to share your own personal journey through private practice, please email me at kadie@clinicnote.com. That's K-A-I-D-E at clinicnote.com. Thank you.