From Three Unemployed SLPs to 23 Staff: Elizabeth Morrison on Building a Practice in Rural Arizona

Elizabeth Morrison and her two business partners were all unemployed. The private practice they'd been working for was going out of business, and there weren't many SLP positions in Northern Arizona that let them do the kind of work they actually wanted to do. So they started their own.

Elizabeth wanted to focus on AAC. One partner wanted school-based work. The other wanted home health. They pooled their licenses, split the tasks by personality, and launched Dynamic Interventions of Arizona in 2008. Elizabeth conducted her first employee interview at her kitchen table with her infant daughter in a bouncy seat on the floor.

Twelve years later, they have 23 clinical staff across two regions of Arizona, including a brick-and-mortar clinic in a medically underserved county they'd been dreaming about for five years.

Three Partners, Three Strengths, One Business

The reason this partnership works, according to Elizabeth, is that the three founders think differently and attack problems from different angles. Instead of fighting over who does what, they looked at their natural strengths and divided the business side accordingly.

One partner manages the DDD (Division of Developmental Disabilities) liaison work: emails, calls, authorizations. Another partner has a head for numbers ("which is kind of rare for SLPs," Elizabeth laughs), so she handles bookkeeping and the accountant relationship. Elizabeth handles marketing and HR.

"I say all the time, there's no way I could have done this on my own. It's really been this collective effort of the three of us that has made this business so successful."

They were slow to delegate beyond the three of them. Even after 12 years, bringing on an office manager just this past summer was hard. Letting go of intake calls, scheduling, and documentation tasks felt risky. But at a certain point, the volume made it unavoidable.

Scaling Into Underserved Communities

Dynamic Interventions started in Flagstaff, but Northern Arizona is massive. It covers roughly half the state, with large stretches of rural land and communities designated as medically underserved areas and healthcare professional shortage areas.

In August 2019, the team opened their first brick-and-mortar clinic in Mojave County. It had been a five-year goal. Between Flagstaff and Mojave County, they now run school contracts, home health services, and clinic-based care. Their staff includes 14 SLPs, an OT, two COTAs, five SLPAs, a school psychologist, a full-time billing specialist, a part-time billing specialist, and a part-time office manager.

"Our mission is just to continue to grow and to serve the communities that we serve and to reach even more communities and patients in those really rural areas of Arizona."

The growth wasn't forced. In fact, Elizabeth says they've done minimal marketing. Northern Arizona's need for therapy services has always outpaced what they could provide. They've almost always had more referrals than staff to fill them.

AAC Through Teletherapy: An Unexpected Win

When COVID pushed everything to teletherapy, Elizabeth was nervous about her AAC caseload. Could kids who rely on augmentative communication devices really make progress through a screen?

The answer surprised her. Not only did it work, it worked better in some ways.

In person, Elizabeth was quick to jump in, model directly on the device, and help a student navigate to the right icon. Over teletherapy, she couldn't do that. Instead, she'd describe the sequence of icons and ask: "Where do you think that word might be? Is it under the umbrella? Is it under the shoe?"

The kids had to figure it out themselves. And their skills improved significantly because of it.

"I am amazed at how well they've adapted and how much more independent they've become."

She uses screen sharing to model on PRC software from her computer, pulls up YouTube videos to prompt conversations, and lets the students drive their own devices. The independence that teletherapy forced turned out to be exactly what her AAC students needed.

Teaching in the Field Instead of the Classroom

Elizabeth has been a clinical educator at Northern Arizona University for about 15 years. She used to teach their AAC course in the classroom, but the business got too busy for that. So she shifted to mentoring graduate student clinicians in the field.

It's her other passion alongside AAC. She gets up early, packs her days wall to wall, and somehow fits it all in.

"I'm very passionate about our field, about the field of CSD. And I want to do whatever I can to really impact the future of our profession. I feel like educating and mentoring grad students is really the way that I can pay it forward."

Just Jump In and Do It

Elizabeth's advice for anyone thinking about starting a practice: stop waiting for the perfect moment. It doesn't exist.

She started Dynamic Interventions in her second trimester of pregnancy. One of her partners had three young children at home. None of them had other jobs to fall back on. They jumped in feet first and figured it out as they went.

"It's a lot of hard work. It's a lot of late nights and long hours, and a lot of mistakes that you're going to make along the way. But you'll learn from those mistakes and then you just have to keep going."

The first year is the hardest. The learning curve is steep: registering with the corporation commission, opening a business banking account, learning to write RFPs for school bids, figuring out insurance coding and billing. Elizabeth compares it to drinking from a fire hose.

But they called their SLP friends when they needed help. The first two clinicians they hired still work for them today. And the practice that started with three people working out of a home office now serves communities across half of Arizona.

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Transcript

Kadie: You are listening to Clinic Chats. Clinic Chats is a multidisciplinary therapy podcast that was created for students, professionals, clinic directors, and supervisors. Clinic Chats is bridging the gap between graduate programs and professionals, sharing personal journeys of the smallest of private practice startups, large and expanding practices, as well as university clinic triumphs and tribulations. We hope you'll find our podcast informative and helpful in your career endeavors. Clinic Chats is sponsored by ClinicNote, an electronic medical record company for private practice and university clinics. ClinicNote was designed to make scheduling, documentation, report writing, and billing effective, efficient, and HIPAA compliant.

Kadie: I'm super excited for this podcast episode. Today I have Elizabeth Morrison, who's an SLP and co-founder of her own private practice called Dynamic Interventions of Arizona. Hi, how are you, Elizabeth?

Elizabeth: I'm great, Kadie. How are you?

Kadie: Doing well. It's been a little bit since I've recorded a podcast, honestly, so I'm super excited for today.

Elizabeth: Oh, that's great. I'm super excited, too.

Kadie: So, I'm sure that you have a lot to share. I know you also have experience in being a clinical educator at Northern Arizona University. We will be kind of meshing both of your experience at this time. Does that sound good?

Elizabeth: That sounds great.

Kadie: All right. So, if you want to give me a rundown, I know you mentioned you have your doctorate, and I'm curious on how you've used that to implement your knowledge into your private practice. So, if you want to start from the beginning, I'd love it.

Elizabeth: Oh, gosh. So, I've been practicing for 18 years. I started out, actually, I got my bachelor's degree and my master's degree at Northern Arizona University here in Flagstaff, where I live, and I worked my way through graduate school as an SLPA. So, I started at the very ground point of our profession and then worked my way through graduate school. I worked in a school-based setting as an SLPA in a preschool program for children with hearing impairments, and I was also on the assistive technology team.

Elizabeth: And so, I was incredibly lucky to be mentored by two assistive technology specialists. One was an OT and one was an SLP. They were amazing, and they taught me so much about assistive technology and AAC, and that's really where I developed my passion for AT and AAC. That really developed before I even graduated with my master's.

Elizabeth: And so, I graduated from my master's program, and I started off, I was a CF in a private practice, and then I went and worked for a grant program, a grant project through Southwest Human Development and then NAU, and it was the Assistive Technology Training Project. I did that program, that grant ended after about three years, and then I went back into private practice, a different private practice for about two years, and then two of my colleagues, we started up our private practice 12 years ago.

Kadie: It sounds like AAC is really your passion and experience. Is that what you have focused your business on, or does your business kind of entail all pediatrics?

Elizabeth: I see all patients, so all ages. There's just a ton of diversity in our private practice. In the beginning, I started out as an AAC specialist in a school-based setting in our practice, but my business partners were both very general, generalist SLPs.

Kadie: Okay, so you mentioned school-based, so back to starting your practice, did it start out with seeing patients one by one, or did you contract with schools, you and your business partner?

Elizabeth: So I have two business partners, both are SLPs. Oh gosh, it's such an interesting story, but in the beginning, we started up our business because there wasn't a lot of opportunity for SLP positions here in Northern Arizona to do the kind of work that we wanted to do, that the three of us really wanted to do.

Elizabeth: And so we really started up our private practice just as a way for us to do the work that we wanted to do. I wanted to do AAC, one of my business partners wanted to do school-based work, one of my partners wanted to do home health. And so really, we started up the business just so that we could do the work that we wanted to do, and that's how it started. And then it just kind of snowballed.

Elizabeth: Very quickly, we found ourselves in the position of having more work than the three of us could do, so it just kind of snowballed, and we had to start hiring independent contractors pretty quickly. But really in the beginning, we were just flying by the seat of our pants.

Kadie: That's awesome, so clearly there was a need, and you guys just ran with it.

Elizabeth: Exactly, yeah.

Kadie: And so what year did you say that was?

Elizabeth: So that was in 2008.

Kadie: Where has the business gone since that time?

Elizabeth: Oh my gosh, it has grown so much. We are located in Northern Arizona, so we are based here in Flagstaff, that's where I am and my two business partners are. But Northern Arizona is huge, it encompasses basically half of the state of Arizona.

Elizabeth: And so we also just last, not this past summer, but a year ago, August, we opened up our first brick and mortar clinic over in Mojave County. Mojave County, that's been a dream of ours for about five years. We've been wanting to open up a clinic in Mojave County, because Mojave County is both a medically underserved area and a healthcare professional shortage area. And so there's a huge need in that area, and so that was a dream that we finally realized just a little over a year ago.

Elizabeth: So we do, in Flagstaff, we do school-based work, we do home health work. And in Mojave County, we have our clinic, we also do home health, and we also do school-based work, we have school contracts in that area as well.

Kadie: Oh my goodness.

Elizabeth: So currently, I mean, we have 23 clinical staff. We have 14 SLPs, an OT, two COTAs, five SLPAs, and a school psych. And then we have three office staff. We have a full-time billing specialist, a part-time billing specialist, and a part-time office manager. So our business has grown significantly since it was just the three of us working out of my home office.

Kadie: Absolutely. Okay, you're definitely one of the larger business owners that I've had on the podcast, and I think it's so great for you to share this. So your manager, are they the ones taking the intake calls, distributing that paperwork, inputting it, all of that?

Elizabeth: Correct, yes. And that's a very new person. We just hired that, we've needed to hire that person for a long time, but it was difficult for the three of us to kind of let go. Even though it's been 12 years, we have had a hard time sort of letting go and letting other people do things. We've all been incredibly hands-on with the business from the very beginning. And so we just hired an office manager just this past summer.

Kadie: Yeah, that's so hard. That's the first person that your new patients will come across, but if you find the right person, it's worth it.

Elizabeth: So that was kind of, we've known for a long time we needed to do that, and then we finally, we just got to a point where we said we absolutely have to, we cannot manage this on our own anymore.

Kadie: What at this point does your role entail?

Elizabeth: So I work clinically three days a week. I am in a school-based setting, yeah. So I maintain a caseload of about 25 patients a week in three days. And so I do two days of school-based work, and of course I'm a teletherapist now, right? And everybody is a teletherapist now.

Kadie: Yeah, how's that going for you?

Elizabeth: Yeah, it's great. I love it. It's been absolutely pretty seamless and amazing. My patients have been remarkable transitioning to teletherapy. They are fantastic. So it's actually been really wonderful. So I do two days of school-based work, teletherapy, and I do one day of home health. But all of my home health patients are now teletherapy patients as well. And those patients use AAC. So that's where I get to do my AAC piece.

Kadie: Wow, so you're doing AAC through teletherapy right now with your home health patients?

Elizabeth: Yes, yes.

Kadie: And how is that going? Please describe that.

Elizabeth: It's going really well, actually. I was nervous about that. I didn't really worry about my school-based kiddos. I knew they were going to be great. I was really curious in the beginning how teletherapy with AAC was going to work. And it's exceeded any of my expectations.

Elizabeth: The biggest thing that I've noticed is when I'm in person with my patients, I'm fairly quick to jump in and help them and model for them directly on their AAC system. When I'm in teletherapy, I can sort of describe for them the sequence of icons. And I'll say, where do you think that word might be? Do you think it's going to be under the umbrella? If we're using a PRC system, is it going to be under the umbrella? Is it going to be under the shoe? Let's think about where those pictures take us.

Elizabeth: And so they have to be a lot more independent now. And their skills have significantly improved because I'm not there to bail them out all the time. So they're having to really be a lot more independent with their communication, whereas before they could always kind of fall back on me and they knew I would sort of help them out of a tough spot.

Elizabeth: So now I just kind of have to pause and wait for them to think about it and think, where does that belong? Or where does that word, where am I going to find that word? So it's been fantastic, actually. I am amazed at how well they've adapted and how much more independent they've become.

Elizabeth: YouTube videos where we'll just kind of watch some clips of a video and then just talk about it. Or my patients are asking me, I want to watch a video about volcanoes, and then we'll talk about volcanoes. I have the PRC new voice or PASS software on my computer and so I pull that up and screen share. And so that's how I model for them on their device because everybody uses a PRC system on my caseload right now.

Kadie: As far as the paperwork and business side of all of these different avenues, home health, school contracts, the clinic, how can you all manage to juggle that or have you split it?

Elizabeth: So we've split it and it's amazing. The three of us, we all think really differently and we all approach problems differently and just look at things from different angles. And I think that's been really advantageous for us. What we've done in terms of the business aspects is we've kind of all looked at, okay, what are our strengths? Just what are our innate strengths as people? And then we've capitalized on them and translated those into business tasks.

Elizabeth: One of my partners, she kind of is the liaison with DDD, so she sort of manages the emails and the calls and the authorizations for services and she sort of manages that. And then my other business partner, she has a head for numbers, which is kind of rare for SLPs, right? Like we're not math whizzes, right?

Elizabeth: So she has a head for numbers, so she does all the bookkeeping and deals with our accountant and does all of that stuff that just, I would be so horrible at that. And then I'm sort of the marketing HR person because that's kind of where my strengths lie. So we've divided and conquered all of those tasks for the business, which is amazing.

Elizabeth: I say all the time, there's no way I could have done this on my own. It's really been this collective effort of the three of us that has made this business so successful.

Kadie: Well, there's so many hats to wear, so it's nice to divide those.

Elizabeth: Oh, absolutely.

Kadie: So with your marketing expertise now, what has been the process? Maybe earlier on in your business, there might've been a little bit more, or has it not let up and changed?

Elizabeth: So marketing has been really interesting. Northern Arizona is a really high need area. We have a lot of areas in Northern Arizona that are medically underserved areas and that are healthcare professional shortage areas. A lot of Northern Arizona is very, very rural. So we haven't had to do a ton of marketing.

Elizabeth: Early on, we kind of got a Facebook page, we created a Facebook page, right? We push out content through our Facebook page and then we got a website. And so then we started looking at ways to sort of optimize the search engine. So the SEO aspect of it. We've done little things, we've taken little postcards to physician's offices, we've made flyers, we've gone to, at one point there were these sort of special needs parent fair things through children's rehabilitative services where we would go and set up a booth and parents and families would come through.

Elizabeth: And so we would do just little things like that, but we haven't dedicated a ton of time and energy to marketing because we really haven't had to. We've been in business for so long and in the beginning it was just the three of us. And so we only needed enough work for the three of us and we immediately had enough work for the three of us. And then we started getting more work than we could handle and so we had to start hiring people or hiring staff.

Elizabeth: So we've almost always had more work than we could manage. And so we've done a little bit of marketing here and there where we've reached out to school districts, we've sent them information, we call and request to be put on their bidders list if we're interested in bidding on that school district. But really it's been fairly minimal.

Kadie: That's nice. So it's really the area that has served you all well.

Elizabeth: It has. It really has. Like I said, we constantly have more work than we can fulfill.

Kadie: So do you have a waiting list or where does that work go?

Elizabeth: So with our DDD contract, we're not allowed to maintain a waiting list. With private clients, we can maintain a waiting list. We never have very many patients on a waiting list. I think right now we have two or three. But with DDD, we cannot maintain a waiting list. So if we can't see one of the DDD patients, we have to just say we can't see them. And then they go back into the DDD system to find another provider.

Kadie: I see. Well, that all is just such an amazing story. And it sounds like it's not slowing down anytime soon. So how are you juggling also being a clinical supervisor?

Elizabeth: Well, I've been a clinical supervisor or a clinical educator at NAU, I think for about 15 years. So it's something I love. Teaching. I taught in the classroom at NAU for just a little bit. I taught their AAC course for a little bit until the business got too busy and then I couldn't do that anymore.

Elizabeth: So I love teaching. I love teaching in the classroom. I don't really have time to do that anymore. So I teach in the field instead. So I love mentoring and educating graduate student clinicians in the field. It's my other passion aside from AAC.

Elizabeth: So I don't really know how I manage everything. Everybody asks me that all the time. I don't really know. I get up really early and my days are completely packed. And I don't know, I just somehow manage to get it all done.

Kadie: But both are your passions. So they're not going anywhere.

Elizabeth: Exactly. I'm just, I'm very passionate about our field, about the field of CSD. And I want to do whatever I can to really impact the future of our profession. And I feel like educating and mentoring grad students is really the way that I can pay it forward in our profession.

Kadie: Well, we typically wrap up our episodes with any points of advice for our listeners who may be considering starting their own business. So what would you like to tell our listeners?

Elizabeth: It was so interesting. So, Jenna Castro-Olson, I know that she was on your podcast not too long ago. And she interviewed me on her podcast, Private Practice Success Stories. I think she's amazing. I think she has just the best advice out there for anybody who wants to start up their private practice. And a lot of the things that she, I follow her on Facebook and all of her Facebook groups. And she has her growth Facebook page for private practice, who want to grow their private practice. And then she has the one for private practice beginners. And so I'm in both of those.

Elizabeth: And I think one of the things that she says is that everybody thinks they have to wait and they're always waiting for this perfect opportunity or this perfect time to open up their private practice. And I don't think there is ever a perfect time.

Elizabeth: I was in my second trimester of pregnancy. And my other business partner had three little babies at home. And so I don't think there's ever a perfect time. I think that you just have to jump in and do it. I think that you just have to decide that that's what you're going to do and you're going to do it.

Elizabeth: We didn't at the time, the three of us, we didn't have other jobs. So we didn't start with half private practice and then half our regular jobs. The three of us were unemployed at the time. The private practice that we had been working for was going out of business. And so we didn't have jobs. So we all jumped in feet first and made it happen.

Elizabeth: And it's a lot of hard work. It's a lot of late nights and long hours, and a lot of mistakes that you're going to make along the way. But you'll learn from those mistakes and then you just have to keep going.

Kadie: Exactly. What was the hardest or most challenging year? This could be the one, but looking back, what would be the most challenging year?

Elizabeth: I would say the very first year of practice is the absolute hardest because the learning curve is incredibly steep. You are learning everything.

Elizabeth: We had to learn how to register with the corporation commission, open up a business banking account, get an accountant, apply for our vendor contract, learn how to write RFPs for school bids, learn how to write contracts for our school contracts, everything. I mean, it feels like drinking from a water hose in the very beginning because there's so much that you don't know. Dealing with insurance, learning how to bill insurance, all of the coding, all of, I mean, it's just absolute madness in the beginning.

Kadie: And hiring your employees.

Elizabeth: Oh yeah. And we were lucky in the beginning because we had all practiced for a while in this community and so we had SLP friends. And so when we needed to start hiring people, we just started calling our friends. We started calling our friends and saying, do you need a little extra work? Do you want three clients in the evening? Do you want a day of school-based work?

Elizabeth: And so we were really fortunate and the two SLPs that we hired in the very beginning still work for us. But yeah, hiring staff, how do we do that? I conducted my first interview at my kitchen table with my daughter, my infant daughter in like one of those little bouncy seats on the floor. So it was, we really bootstrapped ourselves from the very beginning.

Kadie: So I think that's what's hard for a lot of people to envision. You want to come across as professional and look like you have it together. You probably won't that first year.

Elizabeth: You won't. Absolutely. There's no way that you can. I don't think.

Kadie: Right. Exactly. And it all has came together so well for you guys.

Elizabeth: It really, really has. We're so fortunate in this business because healthcare is not an easy business to be in. There's a lot of ups and downs and there's lean years and there's plentiful years. We're just really riding it out and our mission is just to continue to grow and to serve the communities that we serve and to reach even more communities and patients in those really rural areas of Arizona.

Kadie: So amazing. Well, thank you so much for taking the time to come on to the Clinic Chats podcast. I appreciate it.

Elizabeth: Thank you so much, Kadie. This was great. I really appreciate your time.

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 kadie at clinicnote.com, that's K-A-I-D-E at clinicnote.com.