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  • Sue Gehling

Iowa nurse creates virtual mental health service with focus on rural schools

This article was originally published in the the Iowa City Press-Citizen by Cleo Krejci.

Tricia McGregor remembers the 40-minute drive from her home in Albert City, Iowa, to the neighboring town of Spencer.

It was the closest available option where her children could get mental health appointments.

"I would end up having to take pretty much a half day off from work, because I'd have to go pick them up from school, drive them to Spencer and take them back to school," she said. "It's just back and forth, and it takes a lot of time."

Her two boys, ages 15 and 13, and two girls ages 9 and 7 all get the same type of services today — but during school hours, in a school building. They don't like missing school, McGregor said.

"They just get pulled out of class for maybe 45 minutes at the most, and they just go down the hall, and right back to class again," she said. "It's been very beneficial for them; they're definitely working on improving coping skills, lessening anxiety."

They signed-on to the idea of using telehealth mental health services when they became available within the Albert City-Truesdale district in fall 2020. Albert City-Truesdale is one of four districts in Iowa trying out a new telehealth platform, called Classroom Clinic, that provides psychiatric evaluations and diagnosis, medication management and therapy.

Sue Gehling, a psychiatric nurse practitioner, hopes to scale-up the company's services to more schools, with a focus on rural areas — districts of about 1,000 — where she sees the biggest gap in services, she said. She decided to develop Classroom Clinic after realizing how frequently she would get questions from patients and their families in Carroll, where he works, about mental health.

"Here I am, as a provider in rural Iowa, trying to help families, listening to the despair and the despondency and the frustrations that they've had," she said. "And listening to the schools, and the frustrations and the despondency that they're dealing with (too). And then suddenly realizing one night ... the cavalry is not coming here to rural Iowa to help us.

"I'm not trying to be arrogant, or mean, or anything like that. It's just the reality of it."

Gehling ended up working with her local small business development corporation, the Iowa State University Startup Factory and the Goldman Sachs 10,000 Small Businesses program via Des Moines Area Community College. She was recently appointed to Iowa's Mental Health & Disability Services Commission.

She also worked with a graduate student at Mount Mercy University to create a statewide survey about mental health support for public schools. When it came to telehealth, 55% of the about 600 people who answered — superintendents, principals, school counselors and nurses — said their districts are not accessing it.

Throughout the startup process, she's received $150,000 from the Coronavirus Aid, Relief and Economic Security Act and $25,000 from the Iowa Economic Development Authority. She interviewed more than 75 educators statewide about the state of mental health as she developed the business.

"We all know there's a student mental health crisis," she said in those interviews. "Tell me, from your perspective, what are the biggest pain points and what would be a solution to fix that?"

'A big magnifying glass on the problem we already had': Need for mental health services predated pandemic

Pat Hamilton is like many educators in Iowa: He's anecdotally noticed a recent increase in kids dealing with anxiety, depression and other mental health issues.

"The natural reaction is to say that that was COVID," Hamilton said. "But we had seen that coming prior to COVID. COVID just put a big magnifying glass on the problem we already had."

Hamilton works for the Spencer Community School District, which serves about 2,000 students in northwestern Iowa. As director of student services, he oversees "pretty much everything outside of the general education realm," like English as a second language, special education, support for at-risk students and equity.

The district already had a nurse and guidance counselor in each school, but added Classroom Clinic in September 2021 for additional support. As of late last month, 75 students had used the service across 235 appointments. They access the appointments in private rooms at school, fit with monitors and microphones.

Hamilton said there are other services in town that students can use for appointments.

"It wasn't that we disliked the supports we got from those agencies," he said. "It was just that, you know, they're full. It's hard for a parent that wants to get their child help; it might take months to get into see somebody. You might have to go to Des Moines, Sioux Falls."

It's a similar story in Jefferson, Iowa. When the local district there began using Classroom Clinic in October 2019, Superintendent Tim Christensen said there was a "total lack" of nearby options where students could get medication management.

"If somebody felt that student 'X' needed to be on medication, their parents struggled with taking them to Des Moines, Ames, Iowa City, in order to be seen by medical personnel that can prescribe medication," he said.

That's changed. Still, the Greene County Community School District designates Tuesday afternoons for telehealth mental health appointments. Student needs will continue to "grow and grow and grow," Christensen said, so "the more avenues we have to address those is better."

COVID pandemic spurs telehealth, mental health funding

There's long been a recognition that telehealth can provide access to care for people living in rural areas, said Bill Menner, executive director of the Iowa Rural Health Association.

He also said the pandemic expanded its access. In Iowa, there was already a shortage of mental health providers, he said — especially in rural towns where, "chances are, there's no especially licensed mental health provider."

According to 2022 data from the Rural Health Information Hub, 92 of the 99 counties in Iowa are considered a "shortage area" for mental health services.

The idea of bringing telehealth specifically to schools in rural areas is also unique based on Menner's experience. The idea hits on a "niche within a niche," because it targets mental health and rural schools at the same time, he said.

Sixty-four school districts, out of 327 statewide, received money for mental health resources from the Governor's Emergency Education Relief Fund (GEER II). The $8.6 spread out across Iowa schools came from federal coronavirus relief dollars. About a third of districts that applied for the money were not chosen to receive it; 196 didn't apply.

Spencer will use the $100,000 it received from GEER II toward Classroom Clinic as well as adding behavioral support worker.

Greene County schools have gotten help paying for the telehealth services from its local area education agency. The district has also used Elementary and Secondary School Emergency Relief dollars to pay for the program, Christensen said, which is another source of federal pandemic relief funding.

Hamilton has sent letters to state legislators about mental health in Iowa schools. Changes to the system won't happen overnight, but the problem is also not going anywhere, he said.

"I would say we're an island out there doing this," he said. "I just wish it was available to all schools."

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