Hi friend,
It’s 3am in the Neonatal Intensive Care Unit.
It’s been a busy night, so Dr. Jessica Gaulton (Jess) takes advantage of a quiet moment to type up some patient notes. On her desk there are things you might expect from a neonatologist fellow working eighty hour weeks: a computer, a keyboard with faded letters, discarded snack wrappers, but they’re competing for space with pumping equipment and baby bottles. As usual, Jess is multi-tasking. While she types, she’s also pumping milk for her six-week old newborn, who’s at home with her eighteen month old son.
Then her pager beeps. A baby is coding. Jess jumps up, throws off her pump and runs. She finds the baby, performs CPR and saves the baby’s life. She leaves and walks back towards the call room to finish her notes. As she opens the door she notices her pumping equipment on the floor. Then she notices that it’s sitting in a pool of milk. Milk that has spilled from all the bottles she just pumped for her newborn.
She breaks down.
This was the start of a new chapter in Jess’ journey with postpartum depression.
But it was also the start of her journey to build FamilyWell, a company improving women’s mental health by embedding care directly into OB/GYN practices. They’ve built a care model that helps thousands of Moms across five states and last year, the business raised an $8M Series A.
Today, Jess is the CEO of the business. She is also a practicing neonatologist at Harvard, an institution from which she also holds a Masters in Public Health.
In this Hemingway Guide, we tell Jess’ story and share the business and life lessons that she’s learned along the way.
Building embedded care
It’s 2020, and Jess is going through her second pregnancy. She has an excellent OB/GYN, but despite the load she is carrying at work and at home, she never thinks to turn to her for emotional support. It’s clear to her that there’s a disconnect between women’s mental health needs and their medical providers and it leaves women like Jess without the support they need. After her own experience of postpartum depression, Jess wants to solve this.
Her first solution is a peer-based texting platform. It gets early traction and proves that women want support and will engage with coaches. But when those women need deeper support from therapists or with medication, it’s not available to them. So Jess decides to build an embedded care model that puts a full suite of mental health services directly into OB/GYN practices where women already get care.
Mental health screening, care coordination, therapy, and psychiatric oversight are embedded within the OB/GYN workflow. There’s no external referral, no handoff to an unknown provider, and no break in trust.
Building an innovative care model like this and getting it adopted at scale is not easy. Over the last four years, Jess has learned some important lessons about partnerships, care model design, adoption, go-to market and fundraising that helped her along the way.
1. Be highly selective with your first partnership - it can make or break you
FamilyWell's first, and most important partnership, came from a blog post.
Jess wrote a message to the executive director of the Massachusetts Postpartum Depression Fund, a nonprofit advocacy group for maternal mental health. The director believed in what Jess was building and invited her to write a blog post for their audience. One of the readers was Dr. Melissa Sherman - a prominent OB/GYN at Essex OB/GYN Associates and a long-time advocate for perinatal mental health. She reached out to Jess. She wanted to pilot FamilyWell's model at her practice.
Sometimes the stars align, and you need that to help you get off the ground. I was very fortunate. But you have to be really selective about who you partner with - especially for your first partnership.
This partnership became the foundation for everything FamilyWell would go on to build.
Jess and the Essex team spent a full year together - testing, refining, and ironing any kinks in the model before rolling it out to other practices. Jess firmly believes if they had partnered with a practice that wasn't fully bought in, or that didn't have the operational framework to iterate quickly, it all could have been a very different story.
What to look for in your first partner
Jess identifies three things that make an early partnership work. First, is your champion a key decision maker? Dr. Sherman had real authority in her practice. She could commit to a pilot with FamilyWell and push through the changes needed to make it work. Second, does the broader team buy in? The whole practice at Essex was able to get behind this new initiative, which mattered massively for day-to-day execution. Third, does your champion have a track record of innovation? When Jess first met Dr. Sherman, she had already built an innovative substance use disorder program at her practice. Jess didn't realise at the time just how important this was, but it’s critical to have a partner that can operationalise something new - not just be a cheerleader for it.
How to get the right partner on board
Jess didn’t actually find Dr. Sherman. Dr. Sherman found her. But that wasn’t a coincidence. Jess’ advice is to start by identifying the credible people and organisations who are already advocating for the problem you're solving - the more niche the better. For her, that was a small nonprofit that happened to be the leading voice in maternal mental health in Massachusetts. Then, write for them. Speak to their audience. Plant a flag for what you believe in and make it easy for the believers to find you.
Many founders acknowledge the importance of thought leadership but let it inevitably slide to the bottom of their to do list. Jess’ advice to combat this is to be extremely strategic about who you work with.
If I'm going to spend time on something like a thought leadership piece, it's got to fit into what our goals are for the year. Or for the quarter.
Jess said yes to the Mass PPD Fund blog because they were the leading advocacy voice in maternal mental health in Massachusetts. It wasn’t a big audience but it was a highly credible channel speaking directly to the niche of people she wanted to reach.
2. Use design thinking to iterate on your care model
The Collaborative Care Model was originally designed with a single behavioural health care manager (BHCM) handling everything: coordinating care, conducting brief therapy, tracking patient progress, managing documentation. In practice, Jess found that this model wasn’t built to scale in real world practices.
We learned that narrowing and redefining the role - and ultimately evolving to a ‘team care manager’ approach - was essential. We broke the responsibilities into several distinct roles, and today it’s a team, not a single person, addressing the full scope of what the BHCM was meant to do.
Evidence-based models are designed for specific contexts. When you move them into a different context - higher volume, different staffing economics, a different patient population - fidelity to the original design isn’t always a virtue.
If I were starting over, I’d move to that team-based model much sooner and let go of the idea that fidelity meant rigidity.
While Jess’ ability to adapt the care model to real world needs is valuable, her meta learning has been to embed design thinking and human centred design into the business in a way that makes this sort of iteration and continuous improvement part of FamilyWell’s DNA. As they enter new markets and build new products, they can flex this muscle to create services that outperform competitors.
3. Don’t wait for the system to change, use existing reimbursement infrastructure
FamilyWell has a clear way to get paid. The whole model runs entirely on existing billing codes for therapy, psychiatry and other mental health services. Collaborative Care billing codes ensure that the OB/GYN practices get paid for their extra work to facilitate the mental health care for their patients. Jess feels strongly that founders need to be very clear on how they will get paid.
Know exactly how you get paid, and avoid building a model that depends on the system changing to accommodate you.
This was important when Jess was raising FamilyWell’s Series A, she wasn’t asking investors to bet on some future reimbursement model. The financial infrastructure already existed and FamilyWell (and its customers) plugged directly into it.
My biggest advice is to be clear about how you get paid and to avoid swimming upstream. If your model depends on creating entirely new reimbursement pathways or waiting years for new CPT codes, that’s a long and risky road, especially in today’s funding environment.
New CPT codes take years. Be wary of a commercial strategy that requires something that doesn’t exist yet. Many mental health innovations have died waiting for such system change.
4. Make sure your product is used by providers, before you try to grow
Good growth happens backwards. That means solving for adoption first. When your product is adopted and actually used repeatedly, you’ll have high retention. With high retention, you get higher customer lifetime value (CLTV) which gives you both the unit economics and the confidence you need to invest in marketing and sales. Most people do this backwards. They start by focusing on closing more deals before they know that they have a high retention product.
But Jess learned this lesson early on and focused on maximising adoption with their OB/GYN customers so that they would have a high retention product. She spent time understanding their perspectives - their incentives, their fears about liability, their staffing realities, and the operational pressure they’re under.
My core framework is simple: start with your customer, not the model. In embedded care, it’s easy to design around the patient experience alone, but if you don’t deeply understand the clinicians and practices who have to make it work day to day, the model will fail.
Then she focused on three things to ensure FamilyWell adoption was high in the practices they served.
Make it easy for the practice
The OB/GYN practice doesn't have to do any of the heavy lifting to adopt FamilyWell. FamilyWell hires the mental health team, handles all scheduling and paperwork, takes care of billing, and manages compliance. From the practice's perspective, the service slots into the workflows that already exist.
Make it easy for the provider (and build trust)
Outside of solving problems for the practice, you need to solve problems for the individual providers you want to use your service. Make life easier for them, reduce their workload, give them easy referral pathways. And most importantly, build trust with them.
Build something that reduces burden for clinicians, fits into existing workflows, and earns trust, because no matter how evidence-based the model is, it only works if providers actually use it.
Create a financial incentive
FamilyWell gives practices a way to make money. By using Collaborative Care billing codes that insurers - including Medicare and Medicaid - already pay for, the practice earns incremental revenue for delivering a service they want to deliver, without taking on new costs.
If you get this right, every party gets value from the model and incentives are aligned. This is crucial for driving adoption.
Patients get timely, trusted, stigma-free mental health care, providers improve outcomes and generate sustainable revenue, health systems and payers see reduced complications, lower costs, and better maternal outcomes.
5. Be wary of top-down, enterprise deals
The puzzle pieces were fitting together for Jess and FamilyWell. She had a care model that worked and was adopted by providers and patients. She also had a way to get paid for it all. With this, Jess shifted her focus towards growth.
But her biggest lesson on growth came from a failed deal.
Jess was working to launch a pilot of the model inside a large health system in Philadelphia. She had a champion at the executive level who had been pushing the deal through for more than twelve months. Then that champion left, and the whole thing fell apart.
It was over a year of work. And then my champion ended up leaving, and the whole deal fell through.
Top-down enterprise deals are fragile - executive sponsors leave, priorities shift, committees slow things down. And even when a deal does close at the C-suite level, it doesn't guarantee that front-line providers will actually use the product. You have to ensure you have the providers bought in so that if your champion leaves, you have the support of the physicians who can advocate for the deal and push it through. Their buy-in is also necessary for referrals & patient engagement.
If I had a redo, I would have started by gaining buy-in with the OB/Gyn department first, then gone to the executives.
6. Grow your own market
The best products grow the market they serve.
When physicians don’t have a good referral pathway for their patients, they’re less likely to screen for mental health issues and less likely to make referrals. But when they’re confident that they have good mental healthcare services available for their patients, they’re more likely to have that conversation in the first place.
Jess found this to be true for OB/GYNs when FamilyWell is embedded in their practice. It’s good for the patients, but also great for FamilyWell. Their presence actually grows the number of total referrals coming from OB/GYNs.
About 25% of pregnant patients are referred into our program - meaning 1 in 4 patients is identified and connected to care, which is far higher than what we typically see with standalone mental health referrals.
This also compounds. When FamilyWell delivers outcomes for patients, providers trust them more which increases screening and referrals.
7. Come to fundraising conversations with outcomes and engagement metrics
Investor expectations have shifted. When Jess started building FamilyWell in 2022, the common wisdom was that a seed round only needed a good proof of concept and a plan. But by the time she was having conversations with investors, that had changed.
Seed investors wanted revenue and actual customers, not just proof of concept.
Jess’ advice for founders is to get as much traction as possible before having investor conversations.
Revenue in the door is obviously best, but also signed contracts, pilot data, something you can show investors that demonstrate your model has traction.
Investor conversation around metrics has also shifted. They want to see both outcome and engagement metrics.
For tech-enabled services businesses especially, you need both clinical outcomes and engagement outcomes. For Seed or Series A conversations you have to be able to show that your model at the very least has the potential to deliver clinical outcomes. But investors also really want to see that your program has strong engagement and retention.
Jess had clear outcomes to communicate to investors as part of her Series A conversations. Once enrolled, 70% of patients reach clinical remission by the end of their four-month program. FamilyWell have also just had a paper accepted for publication by the Maternal and Child Health Journal on the clinical outcomes of a tech-enabled perinatal collaborative care program to treat depression and anxiety. Jess is able to complement these validated measures with non-clinical outcomes data like NPS (which was 80) which showed that the program provides a care experience that patients genuinely value.
Alongside clinical outcomes, investors also want engagement metrics. Several businesses in the last generation of digital mental health failed because people simply didn’t use them. You need to prove to investors that this won’t be the case for your business. Be clear on what engagement actually means and communicate that to investors. Early on, Jess mapped out the entire funnel for FamilyWell and made precise definitions for each stage. What exactly does enrolment mean? What about activation and retention, and how do we measure them?
The earlier you define engagement, the better. Be specific on your definitions and explain these clearly to investors.
Investors are not the only ones looking at both outcomes and engagement metrics. Payers are too. As the conversation in mental health shifts past access, its important for founders to be on top of this and to know how to build the right evidence over time.
The permission to let go
Jess feels a hand on her shoulder. Mary has noticed her crying. She’s having the thoughts that so many new Mom’s have. “Her baby would be better off without her. So would her family.” She just wants to disappear.
But Mary is sitting beside her now in the fellow’s on-call room. She tells her she’s going to help her through everything. And she does. Mary helped Jess find support and connected her with a therapist. But it’s her introduction to the Chair of Paediatrics that really opens things up.
She tells Jess she doesn’t have to do it all. That she needs to take care of her own mental health first, before she can take care of others. And that includes her own family. She tells Jess that if she wants to, she can stop pumping and that her baby will be fine, or she can pause her fellowship and focus on her baby and that that will be OK too.
She gives Jess permission to let something go.
People who go into healthcare often feel they have to be the strong ones. The ones who carry everyone else around them. They forget about their own needs as they bend themselves for their patients, their family and their friends.
Jess’ kids are now eight and ten. They’re beautiful and thriving. Their Mom is a Founder, a CEO, a neonatologist and an empowering advocate for women’s health.
But, if you ask her kids what she does for work, they’ll simply say that “she helps sad Mommies feel better”.
That’s all for this week. If you’d like to connect with other leading founders like Jess, consider joining The Hemingway Community, a vetted group for those shaping the future of mental health.
Keep fighting the good fight!
Steve
Founder of Hemingway
