With high blood pressure and mental health problems that kept her from getting healthy, Diana was facing a hard road to better health. But she had a clear idea of something that would help.
“If we could give you any tool in the world to get healthy, what would that tool be?” Karin Underwood asked her. As part of a Center for Social Innovation-funded Impact Design Immersion Fellowship, Underwood was exploring ways to better serve people with chronic health problems during the summer between her first and second year at Stanford.
“A friend,” answered Diana, whose name has been changed to preserve her privacy.
Her answer surprised Underwood, but she learned what Diana meant: She wanted someone to talk to, who would know her name when she called. Someone to whom she would be accountable and who would understand the challenges she faced.
That moment encapsulates Underwood’s vision for CoachMe, a six-month, text-based coaching program for low-income people who are enrolled in Medicaid and who have chronic health conditions.
Medicaid is the federal-state health insurance program for people with low income. It covers one in five low-income Americans, including many who need complex and costly care and lack access to other affordable health insurance.
NPR recently reported on the rising gap between rich and poor Americans’ health, the core of the problem CoachMe is looking to address. People with Medicaid use the emergency room as a source of care more often, representing 62% of all emergency room visits in 2015. Each emergency room visit costs thousands of unnecessary dollars, and because the emergency room isn’t a good place to deliver regular and preventative care, ER visits do not provide the ongoing support needed for chronic health conditions, such as diabetes and obesity. Those with chronic conditions are more likely to have a co-occurring mental illness, like Diana does. Underwood believes CoachMe can help address these challenges.
The Novel Idea
CoachMe combines two innovative ideas that have been shown to work — text-based coaching and proven primary care interventions — extending them to a population often overlooked by health technology innovators.
Underwood’s proposed model includes an in-person first visit where the coach and patient tie health goals to life goals. People will set goals like: “I want to lose 20 pounds and not be so dependent on my meds.”
After the first visit, health coaches will follow up with supportive check-ins and helpful advice delivered by text messages and phone calls. Most coaching will focus on supporting behavioral changes that have the biggest impact on health and life expectancy — weight loss, diet change, exercise, and medication adherence — while adapting proven health coaching protocols to the context and challenges faced by low-income people.
Underwood was accepted into the 2019 cohort of a San Francisco-area tech nonprofit accelerator, Fast Forward, and she aims to have one paid pilot with 40-50 people, as well as an enterprise client in the first year. She’ll market the service first to health clinics, who will help identify high-risk patients who would benefit most from tech-supported peer health coaching.
She has engaged advisors with clinical, technology, and mobile health expertise and is planning for her first hire to be a peer health coach. Eventually, Underwood hopes to draw all of CoachMe’s peer coaches from the Medicaid population, offering 36 to 48 hours of training and paying a competitive wage. “The people we interviewed while designing CoachMe could be incredibly good at this job,” she says. “There is this desire … people who are on Medicaid, and who are low-income, want to help others.” [CoachMe initially served female clients; it has since expanded its pool to include all adults on Medicaid.]
The biggest challenge she faces at the moment is developing the right revenue model — and she believes that will follow once she has a proof-of-concept showing that CoachMe improves patient outcomes, including weight loss, lower blood pressure, fewer emergency room visits, and less smoking. As CoachMe generates positive health results that reduce costly ER visits, she aims to monetize the service.
“One of the huge advantages of the Stanford Innovation Fellowship for me is that it will support me to extend proven tactics like peer health coaching and text-based interventions to a market that most people overlook: low-income people who struggle with chronic health disease,” Underwood says. “I can listen to patients, adapt these tools to best meet their needs, and learn from what does and doesn’t work. The year-long fellowship provides the time and support so that I can focus on executing, operating, and learning.”
Underwood grew up in West Chester, Pennsylvania, the youngest daughter of two professionals who worked for the same health IT company their entire careers and believed in creating change from within the health system.
After getting an undergraduate degree at Washington University in St. Louis, Underwood spent two years at mProve Health, a mobile technology startup facilitating patient engagement and data collection for clinical research studies. Underwood then went to work at One Acre Fund in Kenya, a nonprofit social enterprise using asset-based financing and agricultural training for smallholder farmers to reduce hunger and poverty. She also worked in Myanmar at KoeKoeTech, helping build the first mobile app to spread critical maternal health messages to new mothers. She learned how important implementation is: “Abroad, I saw how the simplest solutions, like a reusable sanitary pad, could have massive impact if delivered in the right way.”
But Underwood wanted to live in the United States and to live where she worked. “Every decision you make has so many assumptions built-in,” she says. “It’s really hard to create the necessary feedback loops if you’re not in the community you are working with.”
She decided to go to business school after she realized the challenges of running a large team at One Acre Fund. “I was dealing with challenging strategic and people management issues pretty much every day,” she said. “I realized I had more to learn to be the best leader I could be.”
She applied to Stanford GSB. When she didn’t get in the first time, she resolved to reapply, worked to get more experience, and improved her essays. The second time around, she got in.
Once at Stanford GSB, Underwood reacquainted herself with the U.S. healthcare system, thinking about how to use tech innovation to benefit the millions of low-income Americans who receive care through Medicaid.
“The biggest difference I can make is doing the unsexy hard work to scale proven solutions,” she says. “I came into business school excited about spreading innovation to where it’s most needed.”
— Elizabeth MacBride