Establishing an Independent Family Practice

I always knew I wanted to work in family practice. So, it was a natural fit for me to fill in at a family practice in Londonderry, New Hampshire, while working as a registered nurse (RN) in the Boston area. The temporary position provided one of those pivotal points in your life that may not be recognized or appreciated at the time. The practice was owned by a female physician who became a close friend. When I decided to study to become a nurse practitioner (NP), I was able to do some of my clinicals with this same physician. Traveling to other sites allowed me to gain a different perspective. In 1997, very soon after completing my family NP program, my physician friend confided that she had been diagnosed with cancer and asked me to join her practice in Londonderry. The offer was made at the perfect time since I had just passed my boards and had begun putting out feelers for an NP position.

Over, the next 5 years, the practice increased and the staff was expanded to include two NPs and a physician’s assistant. This growth was in spite of the doctor’s failing health and inability to work full time following surgery. I had always been comfortable and in agreement with the prevailing philosophy of the practice, which was that patients were allowed to choose a particular healthcare provider (HCP), who would follow them over time. I believe that the building of a relationship between patient and a particular HCP is essential to providing optimum care. Although my employer and I initially shared this vision, she shifted her philosophy during her long illness. She wanted to feel that the practice and the patients were hers, and she changed the policy in the practice so that patients did not see the same HCP on their visits. This would have freed up my calendar since I had a large patient base, but I would not be able to follow-up on patients I had seen for years. I had to evaluate my situation. She was very ill, and I could conceivably find myself unemployed at age 50.

Starting an Independent Practice

I have the advantage of living in New Hampshire, one of the states in which NPs have full scope of practice and do not have to collaborate with or be supervised by a physician. The change in the way my employer wanted things done gave me a good reason to start my own practice. Although she supported my independent practice, she was unhappy about the patients who chose to follow me.

But where to start? I first wrote a business plan based on information in books. I used an Excel spreadsheet to graph out 1- and 3-year projections for patient load and income, which turned out to be surprisingly accurate. I originally had an NP partner. Although the arrangement seemed like a logical choice at the time, our ideas on how responsibilities should be shared did not work as well as we had anticipated.An important axiom in business is to change what does not work; we decided to part ways, and the practice has prospered under single ownership.

I had always thought that the purpose of the US Small Business Administration (SBA) was to help small businesses. I was surprised to find out that the SBA would not provide start-up funds; a loan application could be made only after the practice had been successful for 10 months. I somehow had to get my own start-up money, and the SBA might provide additional financing down the road. I had heard of an NP who sought money from a source funding women’s companies in New Hampshire, but I ultimately obtained the $50,000 to $75,000 start-up money from investments by family members.

My first office space was located near the old practice since my patient population lived in that general area. The building was close to a highway, and my clinic was on the ground floor, making it easy for patients to park and walk inside. It is important to consider location and ease of access when choosing a clinic space. This first location was about 1100 square feet. My family helped me transform what had been a small dentist’s office into the first home of Landmark Family Healthcare, which opened its doors in 2002.

The original staff was limited. In addition to the other NP, who was there for a while, and myself, we had a medical assistant and my daughter Jennifer, who wore several hats as our receptionist/office manager/billing clerk. The start-up financing went for rent, equipment, and salaries for the two staff members. The other NP and I were not salaried at first. I probably made about $10,000 the first year. We had the advantage of 500 patients on my panel when we opened the doors; Jennifer scheduled patients from the very first day. I recall that we received out first insurance check 3 weeks after opening, which is a rapid turnaround.

Finances were challenging the first few years; it took about 5 years for the practice to become really profitable. There were ups and downs in patient load and income. We learned to save ahead for the large expenses, such as malpractice insurance, that come due at the end of the year when insurance companies closing out their books tend to pay more slowly. There were times in those early years when I had to dip into my personal savings to cover these expenses. Fortunately, that is not the case today.

Prospective business owners usually want to know about marketing. Although the practice did start out with a sizeable patient population, I bought a 1-year ad in the Yellow Pages the first year. I also took out weekly ads for 2 months in the two local newspapers, which allowed old patients to find me and new ones to learn about the practice. I have used word-of-mouth since then.

Growing a Practice

After a couple of years, we moved the practice to approximately 1800 square feet in a building across the street from the location where I had first worked in Londonderry. Since the building was new, I was able to design the whole space. At the time, the area seemed ample, but the practice continued to grow. Landmark Family Healthcare remained at this location for about 5 years. Meanwhile, my dear friend, who had remained in touch over the years, passed away in 2007. A year or so later, I moved Landmark Family Healthcare to the offices where I first started my career as an NP. Going back into this larger space, which consists of about 2500 square feet, seemed like coming home.

The staff has also expanded, currently consisting of 13 full- or part-time members. We have three full-time family NPs—my daughter Joanne Romboli-Hill, MSN, APRN; Jennifer Cremone, MSN, APRN; and myself. An NP who works 1 day a week with us also runs a cardiacpulmonary rehabilitation unit, making her a wonderful resource. We also recently gave a contract for a 24-hour position to an NP student who worked at the practice for 2 semesters. To round out the staff, we have an RN, three medical assistants, three receptionists, and a billing coordinator/office manager.

It can be difficult in family practice to know exactly how many patients you have at any one time. Patients who change HCPs may or may not request the transfer of their medical records. In any spare time, we try and identify those patients who have not contacted the practice in the recent past. We currently have between 5500 and 7000 patients.

We recently initiated a practice website, which is not currently being used for marketing. I see it as a place where patients can access a health library with certified sites, read announcements, and see pictures of the staff. It is hoped that down the line, patients will be able to use the website to contact their HCP, make an appointment, and pay a bill online.

Following Your Bliss…

Strangely enough, I never doubted that my independent practice would succeed. Undoubtedly, the large financial commitment and long hours can be daunting. However, establishing an independent practice in a state providing full scope of practice has allowed me to do it “my way.” I have been able to schedule appointment times the way I want them to be and plan for longer visits when they are needed. Being the “boss” has allowed me to implement my ideal of continuity of care from the front door to the examining room and to hire staff members who share the same philosophy. I have been fortunate in having wonderful relationships with local physicians and hospitals.

My philosophy was and continues to be that all staff member have their own patient population. Patients have the right to be treated by the HCP who makes them feel comfortable and with whom they have established a rapport. Our patient-oriented approach has led to a situation in which we interact like a functional family. We keep in close contact with our patient population, and they invite us to weddings, baby showers, graduations, and other happy events; we also go to funerals.  Our low patient turnover emphasizes that the philosophy of letting patients be followed by one HCP has worked well in this practice. Following my bliss has resulted in my dream being very successful indeed.