Many psychiatry practices reach a point where medication management and therapy referrals cover most patients well, yet a group of people with treatment-resistant depression keep coming back with the same question: what else is there? Spravato (esketamine nasal spray) is one of the options those patients ask about, and offering it in-house can let a practice keep that care close to the provider who already knows the patient.

Adding Spravato is an operational project as much as a clinical one. The medication is given in the office, under observation, on a set schedule, and inside a federal safety program. That changes how a room is used, how a day is scheduled, who answers the phone, and how records are kept. This guide walks through the planning in the order most practices meet it: the rules, the space, the people, the workflow, and the systems that hold it all together.

Why Spravato Changes How a Practice Runs Day to Day

Most outpatient psychiatry runs on short visits. A medication check or follow-up appointment fills a slot, the patient leaves, and the next one arrives. Spravato works differently. The patient self-administers the nasal spray in the clinic under the direct observation of a healthcare provider, then stays for monitoring. According to the prescribing information and the Spravato REMS program, patients must be monitored by a healthcare provider for at least two hours after each dose, including pulse oximetry, followed by an assessment of whether the patient is ready to leave.

That single requirement shapes almost everything else. A treatment session occupies a chair and a staff member’s attention for a much longer block than a standard visit. Patients cannot drive themselves home after treatment, so transportation becomes part of scheduling. Treatment courses also involve repeated visits over weeks and months, which means the practice is managing an ongoing program rather than a one-time appointment.

Thinking of Spravato as a new service line, with its own space, staff roles and processes, tends to work better than trying to squeeze it into the existing appointment template. Practices that plan it this way usually find the launch smoother and the program easier to grow later.

Getting Familiar With the REMS Requirements First

Spravato is only available through a Risk Evaluation and Mitigation Strategy (REMS) program. Healthcare settings must be certified in the program before they can receive and administer the medication. Certification requires the setting to confirm it can meet the program’s conditions, including direct observation of administration and post-dose monitoring by a healthcare provider.

Before anyone measures a room or posts a job listing, a good first step is to read the current REMS materials and the prescribing information directly from the manufacturer’s healthcare provider resources. Requirements for documentation, monitoring and reporting are spelled out there, and they can be updated over time. Having one person in the practice own this reading, and keep track of updates, helps avoid confusion later.

It also helps to map each REMS requirement to a concrete question for your practice. Who will observe administration? Where will vital signs be recorded? Who completes and submits required forms, and when? Writing these answers down early turns a regulatory document into a practical checklist that guides every other planning decision.

Planning the Treatment Space

Space is often the first physical constraint. Patients need somewhere comfortable to sit or recline for the full monitoring period, with enough privacy to feel at ease. Some patients experience dissociation, sedation or changes in perception after a dose, so a calm, quiet setting matters. Comfortable seating, adjustable lighting, a blanket, and a little distance from the busy front desk all help.

Practices handle the layout in different ways. Some convert an underused office into a single treatment room. Others set up a larger room with several stations separated by curtains or partitions, which lets one staff member observe more than one patient at a time within whatever ratio the practice’s clinical leadership decides is safe. Either way, staff need a clear line of sight to patients, and patients need an easy way to call for help.

Equipment belongs in the plan too. Blood pressure has to be checked before and after dosing, and pulse oximetry is part of the monitoring, so the right devices should be within reach of every station. Secure, compliant storage for the medication itself also needs a home, along with a place for staff to document in real time without leaving the patient’s side. Walking the route a patient will take, from the waiting area to the chair to the exit, often reveals small fixes before opening day.

Thinking Through Capacity and the Treatment Calendar

Because each session is long, capacity is driven by chairs and observation hours. A practice with one chair can only run a handful of sessions per day, and the number depends on how many hours the treatment area is open. Adding a second or third station increases capacity, but only if there are enough staff to observe safely.

The treatment course itself also affects the calendar. Patients typically start with an induction phase of more frequent visits and then move to a maintenance phase with less frequent sessions, as described in the prescribing information. A new patient therefore takes up more slots in the first weeks than an established one. When planning capacity, it helps to model how many patients can be in induction at once without crowding out maintenance patients who rely on consistent appointment times.

Many practices start with a modest number of sessions per week, learn how the flow feels in practice, and then expand. Blocking dedicated Spravato days or half-days, instead of scattering sessions throughout the week, often makes staffing simpler and gives the team a predictable rhythm.

Building the Right Team Around the Program

A Spravato program touches nearly every role in a practice. Prescribers evaluate candidates and make treatment decisions. Clinical staff, such as nurses or medical assistants, handle check-in, vital signs, observation and discharge assessments. Front desk and intake staff answer questions, schedule sessions and manage insurance steps. Someone also has to keep REMS documentation complete and on time.

Practices adding Spravato often discover that the intake side grows faster than expected. Patients and families have many questions before they book: how treatment works, what a session looks like, whether insurance covers it, and how to arrange a ride home. Those conversations take time and a good grasp of the treatment. Some clinics build this skill in-house, while others bring in outside help. Options such as psychiatry staffing solutions focused on outsourced intake can supply coordinators who specialize in interventional treatments and handle outreach, patient education, pre-screening and scheduling, while treatment decisions stay with the clinic’s providers.

Whatever mix you choose, write down who owns each step. Clear ownership helps close gaps such as a patient who was approved but never scheduled, or a session that happened but was not documented. Cross-training at least two people for each critical role also keeps the program running during vacations and sick days.

Training Staff Before the First Patient Arrives

Training should cover both the clinical and the human side of treatment. Staff observing sessions need to know what to watch for, how to record vital signs and observations, when to escalate a concern to a provider, and how to judge readiness for discharge according to the practice’s protocol. Running through a few practice sessions with a colleague playing the patient builds confidence quickly.

Front-line staff benefit from training as well. They should be comfortable explaining what a visit involves, why patients need a ride home, and why sessions last as long as they do. Clear, kind explanations help patients arrive prepared and reduce last-minute cancellations.

Finally, train everyone on the documentation flow. When each person knows where information is entered, which forms are required, and what “complete” looks like for a session, the end of the day gets much calmer. A short written guide kept near the treatment area is a useful reference for the first few months.

Designing the Patient Journey From First Call to Ongoing Care

It helps to sketch the whole patient journey on a single page. A typical path might look like this: an inquiry comes in, intake gathers basic information and answers questions, a provider evaluates whether Spravato is appropriate, insurance and benefits are reviewed, the patient is enrolled and scheduled, induction sessions take place, and then maintenance sessions continue with regular reassessment.

Each handoff in that path is a place where a patient can stall. Someone may wait days for a call back, an evaluation might be booked but not confirmed, or a prior authorization might sit unfinished. Assigning a clear next step and a responsible person at every stage keeps patients moving and reduces frustration on both sides.

Existing patients deserve a dedicated path too. Many practices find that some of their best candidates for Spravato are already in their care. A simple internal process, such as a way for prescribers to flag possible candidates during routine visits, helps those patients learn about the option without needing to search elsewhere.

Handling Insurance and Benefits Verification

Coverage questions are often the biggest source of delay. Spravato involves both the medication itself and the in-office services around it, and payers may handle these differently. Prior authorization is common, and requirements vary by plan.

Building a repeatable process saves a great deal of time. A checklist for each payer your practice commonly sees, a template for gathering the clinical history payers ask for, and a tracking method that shows where every authorization stands all reduce back-and-forth. Patients also appreciate being told early what the process involves and roughly how long it usually takes at your practice.

Keep an eye on reauthorization dates as well. Patients moving from induction into maintenance can run into gaps if renewals are missed. A simple reminder system that flags upcoming expirations protects continuity of care.

Choosing Systems That Fit Treatment Workflows

Spravato adds layers of information that general scheduling tools may not track well: dose history, observation periods, vital signs, assessments, REMS documentation and transportation notes. Many practices start with spreadsheets and paper logs, then find those become hard to manage as the patient count grows.

The electronic health record remains the home for clinical notes, but practices often need another layer to manage the patient journey around treatment, from inquiry and intake to scheduling and follow-up. A patient relationship platform built for behavioral health can track where each person is in that journey, send reminders and preparation instructions, and show which steps are pending. Tools such as Rise4’s healthcare CRM are designed around this kind of infrastructure, linking patient acquisition, intake, communication and treatment tracking for clinics that offer TMS, ketamine and Spravato, and connecting with the EHR and practice management tools a clinic already uses.

For practices focused on this treatment specifically, a CRM built for Spravato treatment practices can add workflows for documenting REMS safety steps, tracking dose history, timing observation periods and organizing pre- and post-treatment assessments within the patient record. Whatever you choose, look for HIPAA-compliant handling of patient information, clear reporting, and a setup that matches how your team actually works. Asking for a walkthrough of a full treatment day, from check-in to discharge, is a good way to judge fit.

Communicating Clearly With Patients and Families

Good preparation shapes the patient experience. Before the first session, patients should know how long they will be at the clinic, what to bring, why they need someone to drive them home, and what they might feel during monitoring. Written instructions sent ahead of time, plus a quick phone call, help people arrive calm and ready.

Families and support people are often part of the picture, especially when they are the ones providing transportation. Giving them clear pickup times and a contact number reduces confusion at the end of a session. A comfortable spot for them to wait, or a reliable way to reach them when the patient is ready, is a thoughtful touch.

After each session, consistent follow-up keeps patients connected to the program. Reminders for the next appointment, a check-in about how they felt, and a simple way to reach the clinic with questions all support adherence over a multi-week treatment course.

Spreading the Word Responsibly

Once the program is ready, people need to know it exists. Internal awareness is a natural starting point: prescribers and therapists within the practice can mention the option to patients who may be candidates. Updating the practice website with a clear, accurate page about the service helps patients and referring providers find the details they need.

External referral relationships often follow. Primary care providers, therapists and other psychiatrists in the area may have patients who could be candidates but do not offer the treatment themselves. A short, factual overview of your program, how to refer, and how you communicate back with referring providers makes it easy for them to send patients your way.

Any marketing should stay accurate and measured. Describe what the treatment is, who it may be appropriate for, and how the process works, and encourage people to speak with a provider about whether it fits their situation. Clear, honest information builds trust with both patients and the professional community.

Tracking How the Program Is Doing

A few simple measures show whether the program is running well. How many inquiries turn into evaluations? How long does it take from evaluation to the first session? How many patients complete induction and continue into maintenance? Where do patients most often drop out? These operational questions reveal bottlenecks long before they become serious problems.

Reviewing these numbers monthly with the team turns them into practical improvements. If authorizations are slowing starts, the insurance workflow might need more attention. If sessions are fully booked weeks ahead, it may be time to look at adding a station or extending treatment hours.

Patient feedback belongs in the review as well. Short surveys or informal conversations about comfort, communication and scheduling can surface small changes that make a real difference, such as better seating, clearer directions or more flexible appointment times.

Preparing to Grow Once the Program Is Stable

After the first few months, many practices see where expansion makes sense. Common next steps include adding treatment chairs, opening additional days, hiring or cross-training more clinical staff, or offering Spravato at a second location. Each step carries the same planning questions about space, people, REMS certification and workflow, so the groundwork from the first launch becomes a template.

Documenting what worked, and what you adjusted along the way, is one of the most valuable things a practice can do during its first year. That record turns a one-time launch into a repeatable process that new staff and new locations can follow.

Adding Spravato to an existing psychiatry practice takes careful planning, but each piece is manageable when it is handled in order. Start with the REMS requirements, design a calm and well-equipped space, build a team with clear roles, map the patient journey, and choose systems that support the way your clinic works. With that foundation in place, a practice can offer another option to patients who need it, and grow the program at a steady, sustainable pace.