The “What I Wish I Knew” series of articles is a service of AAPP’s Resident and New Practitioner Committee. Articles are intended to provide advice from experts for students, residents, and new practitioners. Articles are not intended to provide in-depth disease state or pharmacotherapy information nor replace any peer-reviewed educational materials. We hope you benefit from this “field guide” discussing approaches to unique problems and situations.

Kelly N. Gable, PharmD, BCPP
Professor and Director of Well-being and Resilience
SIUE School of Pharmacy
Psychiatric Care Provider
Family Care Health Center

Dr. Kelly Gable is a Professor in the Department of Pharmacy Practice at SIUE School of Pharmacy. She received her Pharm.D. from the University of Mississippi, and subsequently completed a specialty residency in psychiatric pharmacy practice at the University of Southern California. Dr. Gable’s clinical appointment is with Family Care Health Center in St. Louis, where she works collaboratively with psychiatry as part of a behavioral health team focused on the integration of primary and behavioral health care. She is the first psychiatric clinical pharmacist to be recognized as a provider by the Missouri Department of Mental Health. After spending years working as a psychiatric care provider on Assertive Community Treatment (ACT) teams at Places for People, she now acts as an ACT team consultant, focused on psychiatric medication management for individuals with serious mental illnesses.

Are you exploring the development of a new clinical practice site? This concise review will provide you with a few considerations as you address the “where, when, and how” questions surrounding setting up your own  new practice. I have had the opportunity to develop and expand upon clinical pharmacy services in several different treatment settings through the years. As you navigate your own challenges and successes during this exciting process, I encourage you to think about the following questions:

  1. What practice environment gives you the most job satisfaction? Below is a non-exhaustive list of potential new practice environments. As you begin to envision what your ideal practice site might look like, consider which of the following descriptions matches your personal and professional interests best.

Inpatient Psychiatry/Neurology:

  • You enjoy drug therapy monitoring
  • You are quick to identify and resolve drug therapy problems 
  • You value being part of an integrated team-approach to care
  • You find leading patient education groups to be of interest
  • Long-term follow-up to patient care is less desirable to you

Emergency Department Triage/Consult: 

  • You find a fast-paced clinical environment to be exciting
  • You work well under pressure
  • You are not easily overwhelmed by intense or acute psychiatric emergencies
  • You enjoy toxicology and assessment of laboratory values in relation to medical treatment  
  • You are comfortable talking with patients about their medications and performing medication reconciliation  

Outpatient Mental Health Organizations:

  • You enjoy building more long-term relationships with your patients
  • You are interested in exploring ways to enhance your communication skills and non-pharmacotherapy focused treatment knowledge (e.g.- MI, DBT, trauma-informed care)
  • You partner well with psychologists, social workers, and counselors
  • You have the opportunity to develop a collaborative practice agreement with a psychiatrist
  • You are further interested in the treatment of serious mental illnesses 
  • You appreciate the impact and value of treatments that may improve adherence (e.g.,- long-acting injectable antipsychotics)

Outpatient Integrated Care (Primary Care Clinics/Federally Qualified Health Centers (FQHCs):

  • You enjoy focusing on both primary care and psychiatric/neurologic patient care and are interested in collaborating with both behavioral health and primary care-focused providers 
  • You can envision offering a clinical pharmacy consult service to non-psychiatric/neurologic trained providers
  • You value a patient-centered medical home model of care
  • You are further interested in the treatment of depression, anxiety disorders, and substance use disorders
  • You are interested in exploring ways to enhance your communication skills and non-pharmacotherapy focused treatment knowledge (e.g.- MI, DBT, trauma-informed care)
  • You are interested in expanding patient access to behavioral health / psychiatric pharmacy, especially in underserved communities

Consult and Liaison:

  • You enjoy problem-solving and thinking on the fly
  • You value a team approach to care and prefer to not be limited to a specific hospital unit
  • You are interested in providing education to non-psychiatric/neurologic providers
  • You have the flexibility to maintain involvement in walking/rotating rounds
  • The medical aspect of psychiatric and neurologic conditions is of greater interest to you

Government Supported Programs (e.g.- VA, state facilities):

  • You wish to become involved in system-based care
  • You are interested in the process of medication formulary review
  • You prefer a work environment with continuity between inpatient and outpatient settings
  • You are further interested in the treatment of PTSD and substance use disorders
  • You are seeking out greater autonomy in collaborative practice prescriptive authority
  1. Do you have a physician champion? While this is not a necessity for all practice settings, if you plan to have some level of prescriptive authority and pursue the development of a collaborative practice agreement, you will need to identify a physician partner. If your focus and interest is the treatment of psychiatric disorders, your collaboration should be with a board-certified psychiatrist. Be sure to review your specific state guidelines with regard to collaborative practice agreement development, as this will dictate the level of autonomy you will be offered in your partnership. Be aware of any restrictions or limitations placed on the number of advanced level practitioners that a physician can join in a collaborative agreement within your state. Be cognizant of how often your agreement must be renewed or updated (often annually) per state guidelines as well.
  2. Will teaching be a part of your new practice site? If teaching is of importance to you as you develop a successful career, look for practice sites that have partnerships with pharmacy and medical schools, residency programs, or other experiential learning programs. If you hope to integrate advanced practice pharmacy students into your practice site, ensure that there is room for student involvement. It is wise to request an identified space for you at the practice site and also an established and separate space for your students. Determine how many students per rotation and per year that the practice site can comfortably welcome as a learning experience. It is standard to precept two pharmacy students per advance practice pharmacy experience (APPE); however, you may choose to take more or less depending upon your practice site capacity. If you aspire to also teach other healthcare students, residents, and providers, ensure that there is opportunity for interprofessional teaching and learning. Try to be respectful of patient needs as you navigate experiential teaching, as too many student learners at once may be overwhelming or even triggering to patients within behavioral health care settings. 
  3. Have you met with administrators at the potential practice site? Prior to making your final decision, make sure to set up a time to meet with administrative staff and/or clinical and medical directors. A good working relationship and partnership with administrative personnel can dramatically enhance your job satisfaction and personal investment in your clinical service. From the start of the collaboration, begin to explore financial compensation and reimbursement opportunities for your service at the site. Clearly determine and define who will fund your position (e.g.- University/college, federal or local grant funding, provider-service reimbursement system). If you have an interest in grant writing, explore opportunities within the practice site structure that would allow for integration of your clinical pharmacy service into current or future funding sources. For administrators who are less familiar with specialized pharmacy roles, take time to provide education on the process of becoming a Board Certified Psychiatric Pharmacist. 
  4. How will you document your new service? No matter the practice location, take the time to determine the most effective and user-friendly method of documentation. Most practice sites will utilize an electronic medical record. Learn what credentialing process is necessary to allow for a clinical pharmacist to document within their system. You may be tasked with developing your own documentation template, or you may have the opportunity to integrate into an already established system. In a widely utilized system such as Epic, ensure that you are credentialed to function and document as a clinical psychiatric pharmacist, and not a dispensing pharmacist. As you learn the electronic database, determine if the system will allow for a more global evaluation of the treatment interventions you provide. An ongoing review of your interventions will provide you the opportunity to assess your clinical impact at the new site.
  5. How are you performing at your new practice site? Once you become established in your new role, ensure that there is opportunity for routine peer and performance assessment. For some practice settings, this process may be led by a pharmacy director or clinical program director. For practice sites without a significant pharmacy presence, clinical review may be conducted by your collaborating physician or medical director. If time allows, request a direct observation and evaluation of your clinical service with patients. This encourages professional clinical growth and demonstrates overall personal investment in the quality of care you provide. A quarterly to yearly peer evaluation of your documentation of patient care within the EHR can also be requested and is encouraged.
  6. I’ve started at my new practice site, now what? Always take the time to reflect upon what aspects are working well at the site and what feels less professionally rewarding. In many practice settings, non-pharmacy clinicians may be less familiar with the role and function of a psychiatric pharmacist. Remember, you bring a unique and wonderful clinical perspective to your new colleagues that is of great value to overall patient care. In an inviting and engaging manner, take the time to educate others on your extensive training and expertise. Throughout the exploration of your new practice setting, try to maintain a level of creative energy, innovation, and passion for what you do!