 And welcome to this session, Meet the Pioneers, tackling the mental health crisis. I'm very pleased to be able to moderate this session and to introduce Robin McIntosh, who is one half of two team of pioneers. And we hope that Robin, you'll be able to speak to the fantastic work that you're doing today. So I just wanted to open the session by asking Robin to tell us a bit about your journey to developing this app. And it's been a journey for you, I know. So it'd be wonderful to hear a little bit about that. Yes, of course. Well, thank you so much. We really, really appreciate it. And I'm really excited to talk to you today, Elena. So my name is Robin McIntosh, of course, and I am a co-founder, co-CEO of Work at Health. And Work at Health is a digital intervention for addiction treatment. So think of us as a virtual hospital. We do everything that a traditional treatment center would do without, of course, the in-person component. I started work it back in 2015 in the Bay Area in the United States with my co-founder, Lisa McLaughlin. We had known each other for quite some time. She was actually the first person, the first person that I met in the Bay Area at NAEI meeting. We were sitting side-by-side and back in 2009. So we had talked about doing something together and, you know, very Bay Area story, doing something in the addiction capacity for a long, long time before we actually did. But really our inflection point, our pivotal moment was kind of a breaking point. It was right before the opioid epidemic hit the news and we had a lot of friends who were relapsing and passing away. I felt that the 12-step groups that we were a part of weren't as sticky as they could have been. And there were a lot of wait lists, I remember that, especially in California and Oakland where I lived. There were a lot of wait lists at all the local treatment centers. So we decided to pair together and do something. And what we did was we really dug into the problem and the problem of addiction in America. And we found that, we found really that although 20 million Americans are diagnosed with a substance use disorder, nine out of 10 don't receive the treatment that they need, which is just abysmal. And considering that almost nobody gets diagnosed, right? They're sort of scratching the surface and it's a tip of the iceberg issue. So we dug into the problem and really our research showed that it was an issue of accessibility, one and affordability. And Elina and I are going to talk about this a little bit, but in America we have a very complex and somewhat dysfunctional healthcare system as the world knows. So affordability rehab costs a lot of money. So an average inpatient's day for 30 days might be, anywhere from $30,000 to $45,000 on the high end and insurance up until the Affordable Care Act didn't cover it, right? And largely, and even now, largely most insurances don't cover the whole portion. And when you think about that, even 10%, even 5% of a $30,000 bill is way past what a normative person could afford, right? Like somebody even fairly well-off. And then accessibility, you know, I think you can't talk about this problem without understanding the context in which we have to seek wellness and seek recovery. Accessibility, when you think about it, you know, we're asking our most vulnerable population, one of our most vulnerable populations to sort of assume of their life and say, you know, hand up, I'm an addict, here's my scarlet letter, I'm going away for 30 to 45 days, shit me away, you know, and I'll come back and I'll be renewed, right? It's a very cyclical process and the process of recovery and people commonly relapse. It's, I don't know anyone that hasn't had, you know, an episodic nature of addiction over the long haul in the lifespan. So, you know, it's tricky. It's tricky what we ask people to do. So we set out to solve that problem with work at health. I think the road has been incredible. We've made incredible strides, but we could do so much better. So I come at that with a lot of humility and I'm excited to chat with you today. Thank you, that's quite an extraordinary story, Robin, and thinking about how you're taking on not only, you know, your own individual challenges, but also these structural challenges, as you say, in the American healthcare context, but you know, some of those challenges are certainly replicated around the world. I suppose we've, you know, during COVID in particular, but even before that, we've seen this explosion in what in the academic context we call digital mental health. And that's been so good for so many people, particularly if digital mental health is now covered by American health insurance. And in our context in the UK, there's much more of an evidence base now behind digital mental health, which is one of the problems, right, with digital technologies is that they are often not evidence based and everybody's got a new app coming out every day. So really important to have an evidence base. But another kind of problem that's emerged in the telehealth industry specifically is about quality control of people who are providing resource through telehealth. So the psychologists, et cetera. And so I wonder if you can talk a little bit about as your work at HealthUniverse expands how you're thinking about quality and evidence in the context of your work. Because as you say, you're working with very vulnerable groups. I'm sure this is something that's on your mind. Yeah, it absolutely is. And we really made the pivot to being a medical intervention, which is a coaching intervention back in 2018. So we were lucky. We did it a while ago in digital health terms and healthcare were babies, brand spanking new, but in the digital health world, especially in the venture world, we've been around for a while. So we pivoted in 2018 and we did a few things that were a little bit apart from the norm. So when we built our program on an evidence base and on research, so we started working with NIDA in NIH, National Institute of Health here in America, right away. So we received research grants to do our research and build up this evidence base. And we only stand, we call it the philosophy there of the content of work at health because it's really, we call it standing on the shoulders of giants. So we don't do anything that hasn't been tested in a clinical trial. So we use medication assisted treatment, which is the gold standard of treatment in the world, basically when you're treating OUD, opioid use disorder. There's so many acronyms for the opioid use disorder or alcohol use disorder where we employ evidence-based protocols as well. So that's on the clinical side. There's something that I'm particularly passionate about that we were talking about before opening the session a little bit is the side of actually the app itself. I come from a design and development background and I think so routinely we see things that are stood up without HIPAA compliance, meaning the highest security standards you could have in America. Despite having large and hefty fees, I think still you see so much on the app store that you think, oh my goodness, they're taking so much patient health information, PHI. So from the very beginning, we were lucky enough, I mean, lucky enough to work with a really large health plan here in the States. And I think we weren't ready for it, but at the same time we got ready pretty quickly. And we had our application, our mobile app, which 99% of our, which I'm surprised because I still use a web browser, but 99% of our people, our members use their mobile app to interface with work it and their care teams. So we aligned because of this health plan mostly, but also because we have a background of this, we aligned to really stringent accessibility standards from the very beginning. So that means that all language at a fourth grade reading level, high contrast colors, things like that, just these considerations for all sorts of accessibility. So I really urge when I talk to early founders and when I talk to people that are creating digital applications, especially in the health world, I really urge people to start there because I know people that are part of companies that have 20,000 users and it's so difficult to retroactively apply those standards. And I think it's something that we need to have in our minds as we create these beautiful things that we put out into the world, not only the clinical rigor, but also the UX and UI rigor and the technological rigor of having security standards at the highest level. I don't want to regale you with the boring details, but I think it's all about having that mentality and starting from the beginning, despite being small. Well, I also very, very small way have dabbled in digital tools for research with young people. So I wouldn't mind just following up to ask you, because certainly something we realized was exactly as you say, that if you don't build it in from the beginning, once you're down a road, it's really hard. So I'm just thinking in case there are people in the audience who are designers and thinking about building tools for mental health, interventions, perhaps you have one example of something that you did go back and change or wish you'd gone back and changed. The clearest example, the clearest example, when we started work at, so I have a design background, so Lisa has a clinical background and others she's not a nurse practitioner and I'm not the chief technology officer we have today. We, in a startup you make do with what you have, especially work it, we were really underfunded for a very, very long time, we bootstrapped for a long time. So anyway, so when we started work it, I created this color scheme. I mean, I don't know really what I was thinking, but it was this like beautiful poppy color scheme. I almost think it was a little Easter egg colors, which is totally humiliating now to look back on it, but when we were playing, so we had that color scheme for a while and as a designer and you probably even know this, and when you put in a, you want to stay there forever, especially me, I'm quite rigid when it comes to my design, but I'm kind of like that about everything. So anyway, so when we were going through this a healthcare audit, they were like, you have to change all of your colors and then they sent back the color scheme and they weren't just like these muddy greens and these muddy blues. That was an example of like having to go and rip up the whole product in a way and align it to more rigid standards of high contrast and usability, legibility on all devices. It was interesting, but I mean, it's a shallow example a little bit, but it was very, very hard for me. So it was impactful for Lisa and I. Yes, well, I don't think shallow at all because one of the things we talk about in our work and again, thinking about the population that you're working with particularly is, these apps have to be sufficiently engaging. Some people would say entertaining to keep users using them, even on days when they don't want to or on days when they really are kind of falling. And so balancing that with as you know, particularly if you have a medical device with something that's actually delivering a treatment is really difficult, it's very ethically difficult and the ways in which a lot of digital design as you know, works outside the medical sphere is it actually is intended to be designed to be addictive. So I mean, this is a very fine line for you particularly, I imagine to be treading. Right, it is. That is a fine line. The behavioral economics piece of work at health is a fine line and thinking about something like a near an AL hooked framework, right? Does that apply to our population? On the other hand, I think you can look at it two different ways. One kind of gaming your product or gaming your app to be addictive. But the other way is instilling the best installing the best standards into your app to make it usable and enjoyable. So I think you have to walk that line constantly and you know, we do the best job we can. It's very hard to, we don't do anything like, like we're not for a reality, we don't do gaming, we don't have games inside the app. Like, you know, the highest, the highest because of our specific population, we try as best we can to design with the patient in the middle and the patient in mind and the journey is long. So people on average are with us for about a year and some a lot longer and some shorter, of course. But, you know, at the beginning, the beginning when you think about the state that most people come to us in, it's really, they're very scared. They have nowhere else to turn. A lot of times people call us five, six, seven times in one day because they forget that they had just recently called. So, you know, so for us, it's not about the bells and whistles. For us, the highest, you know, pinnacle that we can reach is true functionality and usability. So we don't walk the line as closely as, you know, a company like, I don't know, I don't want to mention names, but another company. But it is something to consider and it's something really interesting, I think. It's, you know, especially in the addiction space, I say this sometimes to our design team and it sounds a bit crude, but it's true. It's really hard to compete with the lure, the lure of drugs and alcohol, right? Like it's hard to compete with the high moments of what it's like to be using in the world and to be out there in kind of the maelstrom of things. So we think about instilling values like joy and optimism into the app, but not, of course, having it be truly addictive in any way to try our best. Yes, yeah. Well, I was looking at some of the website material and seeing that actually you seem to have outcomes that are sustaining, are sustained and maybe better so relative to other digital technologies. So what do you think the driver is for that? Yes, that's a great question. I mean, that's a wonderful question and something that I'm very passionate about. So, you can't, to our outcome specifically, rehab setting and a 30-day inpatient life we talked about at the beginning, 60 to 70% of people drop out within that first 30 days. So the outcome is small. That would mean like 10 to 20% retention or 30, but usually it's 10 to 20% retention. And sometimes even that, it's a black box industry. I think other countries, I'm Canadian, so I always compare that that's my kind of foil and comparison, but other countries I think do a lot better as exposing the outcomes of their healthcare. In America, especially in addiction, it's always been a black box. So even with those outcomes, you have to take it with a giant grain of salt and ocean of salt. So, but we've always been committed to data and we've always committed to clear outcomes, but we retain around 83% of people after 30 days and over 50% at six months, which is very high, but I wouldn't credit anything. This sounds, you know, this sounds a little, it's simplistic, but I wouldn't credit anything special. It's not like we're doing anything incredibly wild over here. Like, you know, we're not putting on like cartwheel shows or something for our patients, but what we're doing is providing an experience that is as easy and analogous, right, to an Instagram or to another app we're using from the beginning, accessibility standards, USUI standards. We do things like instead of hire, in America there's this idea of a side hustle with clinicians, but you hire the 1099s if you basically hire them as at-will employees that can come and go and they can have 17 jobs, et cetera. We hire our clinicians full-time and we were talking about quality, but this really contributes to full quality, right, that you enter work it, you have your clinician, you become attached to your clinician and you build up that patient clinician rapport and that continues through your span of experience at work it. So, and then I think we just honor those two pieces of work it that we set out to accomplish in 2015. So that would be affordability. We can talk about that beast in a second. So affordability, so I'll shelve that for a second and then accessibility, which we've talked a lot about. We provide an experience that's convenient and easy to use in the fabric of someone's day to day. So a really good example of this is drug testing. So 90% of rehab centers make most of their money. This is wild. I didn't know this before I entered the field, but most rehab centers make most of their money because of the backward incentive structure of the healthcare system on things like your analysis. So things like drug testing. And for a patient, from a patient, it's very arduous. You have to go into a facility, you have to wait there for an hour, do a drug testing, come home, you don't have to wait for your results. And if you fail a drug test, you fail a drug test. I don't even like using that word, but you get kicked out of the program. So the work it, this is all digital and it's all automated. So if you wake up in the middle of the night and you have an appointment the next morning, you have an appointment the next morning, you can take your drug test asynchronously. We have a lot of async stuff built into the product and that's so convenient, but it's also coming at it from a place of trust and a place of ownership, right? Like I own my data, I own my world and I can do this myself and I can be on my own time. So I think all of those things and building a product that ultimately respects the end patient really has led to very high retention. So let me ask you, I'm really taken with how much you've thought about this from the patient's view and I do think all of our academic work suggests that that's really what's needed in order to make these initiatives success. But let me ask you the hard question about the social justice end of this. So from what I understand, well, not just in America but maybe particularly in America, substance use and abuse is very much caught up in structural inequalities. So large proportion of people who live in poverty don't have a home and are race and ethnic minorities so I wonder and we have only five minutes to talk about this very very big topic but I wonder specifically a few questions. One is, do you feel that your work is has that population engaged and if not, what would you need to do to engage them? And just one thing I noticed again on your website is that you often talk about the comfort of home and it made me think about people who, with substance abuse who live on the street, again, disproportionately homeless. So I wonder how you're thinking about that as you build up and extend the reach of your work? Absolutely, I think that's an interesting insight, the home-based language and I know why they do that, I do that for a specific reason but so we can talk about that. As far as the way we think about it, the way I think about it is, you have to kind of follow the dollars, right? So who pays for addiction treatment and when you look at that group of people, the nine out of 10 that don't get the treatment they need, a lot of times it isn't about accessibility, a lot of times it's about affordability, right? So we have different ways for paying for healthcare here. We have what we call Medicare which is government subsidized or fully government subsidized healthcare for our older populations, you have commercial which kind of catches everybody from Medicare to the third way and then I'm grossly overstated, like I'm grossly generalizing but the third way would be Medicaid and Medicaid is our safety net healthcare, like it's our insurance for people in the safety net, meaning low income individuals and then you have certain states that don't have what we call Medicaid expansion. So states like Florida and Texas have huge portions of their population are totally uninsured, just not caught at all because they can't get Medicaid for different reasons. They actually don't, they don't, what's the word? They're not eligible for Medicaid. So when you think about providing the best possible care, sure we can provide great care but can we accept the lowest reimbursement out there? And that's where the technology really comes in and the business side really comes in, work has been able to cut out a lot of the overhead of delivering care and so we can accept Medicaid and we have always, I mean, we do a lot of work with Schwab and we were so grateful to this community but we've always tried to keep in there and as a North Star, treating a Medicaid population. So the vast majority of treatment centers or health providers, especially medication assisted treatment do not accept Medicaid. And we do, and we do in every state that we enter. So this is really important. This means that if I'm on Medi-Cal in California which is their Medicaid system, I can Google providers and say, how do I, to talk in real terms, I can Google providers and say receiving drug treatment, or can I detox from opioids or heroin? 90 results show up, none of them accepts my insurance. So what do I do, right? It was hard enough to kind of scale this mountain of willingness and to do this search. But I might be at my local library to your point using my local internet. I might never do this again. So we try to become highly findable in those searches and we try to pair it with coverage. I think the way to do better in that regard and we can talk clinically but the way to do better in that regard is really opening up more scholarship, what we call scholarship funding. The government has done a fairly decent job, SAMHSA specifically of releasing block grants for addiction treatment, prevention and education. I think we would like to see more of those dollars flow to patients and flow to treatment. But a lot of, if you talk to most people and we've done, you know, so because we're so human centered, we do, we have a patient advisory council. We do tons of ethnographic interviewing all the time. But most of the time, not out of 10 times people, people cite reasons of affordability for not receiving treatment. So I think that's one thing we could do. I'm going to have to stop you because unfortunately we're coming to an end. But I mean, my take home from what you've, this sort of extraordinary work that you've done is that it needs to engage in these structural issues in order to really make an impact at the scale that you want it to make. And I'm personally hopeful that perhaps one day you'll, I work a lot in low and middle income countries. So perhaps you'll be expanding into that setting as well. But I'm also really struck by how patient centered you are and how interdisciplinary your teams are. That there's design, there's academics, there's science, there's clinicians all working together. And the final thing is of course the funding that you need funding and really funding from the outset in order to be able to build a great product as you have. So I thank you so much for speaking and lots of luck as you go forward and I really look forward to it.