So You Want to Practice? In the Country? If you want to live and work in a rural area, take some advice from a 20-year veteran of small-town life. In Private Practice
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In Private Practice  |   February 01, 2016
So You Want to Practice? In the Country?
Author Notes
  • Claudia Ellis, MA, CCC-SLP, is the owner of Mettowee Valley Speech Therapy Services in Granville, New York, and is the president of the American Academy of Private Practice in Speech Pathology and Audiology. She is an affiliate of ASHA Special Interest Groups 1, Language Learning and Education; and 18, Telepractice. cellisslp@gmail.com
    Claudia Ellis, MA, CCC-SLP, is the owner of Mettowee Valley Speech Therapy Services in Granville, New York, and is the president of the American Academy of Private Practice in Speech Pathology and Audiology. She is an affiliate of ASHA Special Interest Groups 1, Language Learning and Education; and 18, Telepractice. cellisslp@gmail.com×
Article Information
Speech, Voice & Prosodic Disorders / Special Populations / Older Adults & Aging / Early Identification & Intervention / School-Based Settings / Healthcare Settings / Practice Management / Professional Issues & Training / In Private Practice
In Private Practice   |   February 01, 2016
So You Want to Practice? In the Country?
The ASHA Leader, February 2016, Vol. 21, 34-36. doi:10.1044/leader.IPP.21022016.34
The ASHA Leader, February 2016, Vol. 21, 34-36. doi:10.1044/leader.IPP.21022016.34
In 1990, two years out of graduate school, I was living in a small town in upstate New York and working in the public schools in Manchester, Vermont. But after six years, I felt that the challenges of school-based work were outweighing the joys and I decided to take control of my life and career. I left my secure position to pursue a private practice in my town of Granville.
I had been getting my feet wet in the health care arena by working with some home health care patients and early intervention clients. So, I took a leap of faith to join the minority of audiologists and health-care speech-language pathologists who work in rural settings: 13 percent and 19 percent, respectively.
Rural SLPs and audiologists are likely to have different experiences from our city and suburban counterparts. The village of Granville, for example, has a population of 2,543 and the town of Granville adds another 4,100. We have one grocery store, one drug store, one gas station, one health care facility, one nursing home (one other in North Granville), one speech-language pathology practice, no audiologists and one traffic light. The nearest hospital, theaters and shopping are 45 minutes away.
If you want rehabilitation services, you must drive 45 to 60 minutes or live in a nursing home that provides them. Some home health care services are available, but mostly occupational and physical therapy. With Medicare limits on the number of rehabilitation sessions allowed, patients often don’t pursue speech-language treatment.
Getting started was difficult; my husband and I were concerned that my business would not generate income equal to my school salary. But those fears quickly disappeared as I discovered the intense need for services in our small community and surrounding areas.
Here’s what I have learned in my 20 years of rural practice.
You need to seek out contracts. I got my start by contracting with home health providers, early intervention programs and schools to provide speech-language services. Much of my business today is still based on these contracts.

I got my start by contracting with home health providers, early intervention programs and schools to provide speech-language services. Much of my business today is still based on these contracts.

You will spend a lot of time in your car. Travel to schools and patients’ homes is a necessity. Travel—sometimes 60 to 100 miles in a day—cuts into available service time.
Home visits can be an adventure. If you stop to ask directions, you’re likely to find that people know the names of the neighbors on the corner or on the farm up the road, but not the names of the streets. In upstate New York, ice and snow add to the transportation trials. One family lived at the top of a steep, poorly maintained, private dirt road. My car got stuck on ice at the top, and I needed roadside assistance to inch my way down. After that, I walked up the hill with crampons strapped to my boots.
As your business grows, you may need dedicated space. For the first five years I worked out of my home, but it became too intrusive on my family life. We decided to purchase a two-family home, renovate the downstairs for my office and rent out the second-floor apartment.
Specialization and private pay are not options. Rural clinicians cannot specialize in one particular area—there just aren’t enough people—or operate a private-pay practice. Most families cannot afford treatment on their own, so accepting insurance is a necessity. I became a Medicare provider when I started getting calls from people looking for post-stroke rehabilitation services in town. I took more training and began providing aphasia treatment.
You can’t be everything to everyone. Often there are treatments or programs that I would like to offer to my patients, but I can’t—overhead and equipment costs are too high when I can’t predict how many people would benefit from them.
Confidentiality poses challenges. In a small town, everyone knows everyone else. Every time I go to the store or a restaurant, I see a grandparent, aunt, uncle, cousin or friend asking me how a certain child is doing. I simply have to say, “He/she is a great kid.” You have to be very careful to comply with privacy laws outside the office as well as in.

Every time I go to the store or a restaurant, I see a grandparent, aunt, uncle, cousin or friend asking me how a certain child is doing.

Staff can be hard to come by. Hiring clinicians to work in my office has been difficult. A small rural community is not attractive to young clinicians who want easy access to shopping and entertainment and a vibrant social life.
You may feel isolated. I missed regular contact with professional colleagues. It took some time but I eventually connected with physical and occupational therapists, but not SLPs. At one ASHA meeting I stopped by a booth for the American Academy of Private Practice in Speech Pathology and Audiology and signed up. It was the missing link I needed to stay in contact with SLPs and audiologists in similar circumstances.
But there are upsides, too. I have grown as a professional and an individual. I have developed long-term relationships with families, children and personnel in schools and nursing homes. I have met wonderful families who are committed to meeting their child’s or loved one’s needs. I see the results of my early work with children when family members I see in the grocery store tell me about their successes or when a young adult comes up to me and says, “Hi, Mrs. Ellis, remember me?” I read about my students in the local newspaper and see their accomplishments in academics, the arts and sports.
It’s been hard work that requires creative thinking and self-sufficiency, but there’s nothing else I would rather do.
1 Comment
February 2, 2016
Tanya Lujan
Rural towns need more SLPs
This is exactly what I needed to read! The past few months I have been contemplating driving out to some of our rural towns in desperate need of services. Getting contracts is a great way to get started, I never thought about that. I was dissuaded by the thought of having to rent office spaces and set up a clinic. Thanks for this article!
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February 2016
Volume 21, Issue 2