'Mental health is health': How Sanford is addressing patients' needs across its massive footprint

Sanford Health is the largest rural health system in the United States, offering physical and behavioral health services to 1.5 million residents across Iowa, Minnesota, North Dakota and South Dakota. 

Becker's recently connected with Sarah Prenger, Sanford's system executive director of primary care and behavioral health, to learn more about how the system is addressing the  behavioral health needs of the communities it serves.

Editor's note: Responses have been lightly edited for clarity and brevity.

Question: What is the overall mission of behavioral health services at Sanford Health? 

Sarah Prenger: At Sanford, we work from the philosophy that mental health is health; it's just as important as your physical health. We've tried really hard to integrate behavioral health services across our footprint. As the largest rural health system in the country, we serve 1.5 million patients across an area of 250,000 square miles. … We know that people who live in rural America face unique challenges and access to care is probably one of the most significant that they face and it is also a major determinant of their health. 

When I say that mental health is health, every bit as important as physical health, it may even be more so in some instances. When we think about the rural nature of our footprint, it's particularly difficult for our patients, the rural residents of these communities to access mental healthcare. Not only is our geographic area so large, but almost the entirety of our footprint is federally designated as a mental health provider shortage area, so our efforts have to be unique and creative to reach our folks. 

Q: How are patients coming to Sanford to receive behavioral health support? 

SP: Recently, we've had a big push to bolster our virtual care. We received a very large gift from our benefactor to invest $350 million into virtual care, and one of the very first service lines that we stood up is behavioral health. We recently launched an online scheduling option for mental health appointments. If a patient is sitting at home, struggling, they can go online and request an appointment with a Sanford provider for therapy or psychiatry, [and] just that step of having some sort of help scheduled can be very reassuring. … Based on the patient response and numbers of appointments scheduled, we know that people are looking for help. 

We have traditional specialty clinics and offer inpatient care for behavioral health needs, but we also have 50 integrated behavioral health therapists. These are master's-prepared counselors and social workers that work inside our primary care clinics. A patient may be seeing their primary care doctor [and] mention some signs or symptoms of depression. We're able to pull integrated health therapists into that same visit versus having the patient come back for care. It also helps reduce the effect that stigma can have on the ability to seek care. In a small farming community, everyone knows who drives that one red Ford truck, which can prevent a patient from making an appointment at the mental health provider's office. 

Q: What is the role of virtual behavioral health care at Sanford, and how has it developed in the wake of the pandemic?

SP: One of the few silver linings of COVID is that virtual care was established as an absolutely legitimate way to reach our patients, especially in behavioral health. Across the country, the most common service that is provided virtually is behavioral health. There's significant evidence now that demonstrates it is as good, as effective as in-person care for most patients. We have definitely taken that to heart at Sanford. Today, 1 in 5 behavioral health appointments that are scheduled with a Sanford provider are virtual. 

Q: What are the behavioral health initiatives Sanford is working on? 

SP: We are working to continually bolster our virtual services. We have an internal goal that we would like to ultimately be able to serve our patients within 24 hours of them requesting a virtual behavioral health appointment. We'd also like to expand the reach of our integrated health therapists. Today, our integrated health therapists serve in about 65 primary care clinics across our rural footprint either in-person or through virtual care platforms.

We recently launched a text-based remote patient monitoring program that proactively contacts patients that have been identified as having a diagnosis of depression. It'll check in with the patient routinely, asking them questions about their mood and suicidality, for example. We have Sanford care managers on the other side of that platform who are monitoring those alerts who are proactively reaching out to patients who might be escalating in symptoms. If a patient indicates that they are having suicidal thoughts, the National Suicide Hotline will contact those patients within minutes versus the patient having to proactively reach out to the hotline. 

Our Sanford Traumatic Stress Treatment Center in Fargo, North Dakota, is focused on studying how to provide better assessments and treatments to children who are experiencing or have experienced severe trauma. We also have patients come from all over the country to receive services for eating disorders from Sanford providers in Fargo. We offer outpatient and inpatient care.  

We are focused on building a pipeline of the next generation of behavioral health providers. This past year we launched a pre-doctoral psychology internship, and now we're working on developing a formal psychology residency. We continue to teach adult psychiatry residents. When we talk about poor access, the professionals just simply aren't here and we're not alone, but it is more difficult in rural settings. 

We have developed a Sanford-created curriculum designed to help teach the learner to identify and respond to another individual in a behavioral health crisis. It's called the BHEARD — which stands for Behavioral Health, Education, Awareness and Response Development. So far, we've educated about 1,000 individuals and we're currently working on a strategy to bring that education to all Sanford leaders. These are skills that you could use if a co-worker is struggling, if a patient in a waiting room is struggling, if you have a family member at home. It gives you the skills to ask the tough questions. 

Last year, we opened an EmPATH unit in Bemidji, Minnesota. EmPATH stands for Emergency Psychiatric Assessment, Treatment and Healing. We are providing urgent mental healthcare and treatment for people that are in crisis in a supportive calming environment rather than a traditional, perhaps chaotic emergency room. We serve adults and children within our EmPATH unit. We also have spaces for cultural and spiritual healing, designed particularly for Indigenous patients. 

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