For Fiscal Year 2018, the state of Indiana’s Medicaid budget was a whopping $11.8 billion. Despite its investment, Indiana struggles with its health outcomes: for example, it places 44th in the nation for adult smoking, and is 7th worst in the country for its rates of infant mortality. These statistics have plagued Indiana in recent years and were recognized as a detriment to the future growth of the state. Former governor Mitch Daniels started the Healthy Indiana Plan in 2008 as a tool to expand access to health insurance. The plan initially prioritized healthcare coverage for Hoosiers and this vehicle for health insurance has expanded over a decade from 40,000 enrolled to over 400,000 under the Affordable Care Act. Health and human services workers in the state, including Jennifer Sullivan, Secretary of Indiana’s Family and Social Services Administration, began to wonder whether the Healthy Indiana Plan could do more than just ensure healthcare coverage: could the “Plan” be a broader vision to lead to better health outcomes through preventative and wraparound care and connectivity to social services and the community? In other words, as opposed to only ensuring that Hoosiers had coverage after health catastrophes, could the Plan work to create a healthy state through preventing devastating health issues in the first place, and through making health (not just health care) a shared responsibility and goal?
At Leadership for a Networked World’s 2019 Health and Human Services Summit: Purpose, Passion and Impact for the Future, Sullivan shared how her office set a strategy to move upstream in value by focusing on social determinants of health, in other words, focusing on the environmental conditions and factors such as housing, nutrition, transportation, education, etc., that influence health and human services outcomes. This new initiative would put Hoosiers and their families at the center of its work.
Strong in their belief that health care should be a shared responsibility and goal, Sullivan and her team decided that to work toward a healthy Indiana, it was essential to uncover the social determinants of health outcomes that were most relevant for Indiana. They invited community partners to collaborate, and together, began with the premise that while we invest heavily in health care in the United States, we don’t invest in health – in other words, we don’t consider the kinds of preventative care that would help to avoid more expensive, later interventions. Sullivan describes this as the “two-thirds/one-third paradox” : in this country, two-thirds of our health care spending is on delivery and one-third is on social services. This, Sullivan says, is the most expensive approach. In nations with better health outcomes, this ratio is reversed, and fewer costly, late interventions are necessary .
Sullivan and her team started by building an external advisory board with a shared vision: that “all Hoosiers have equitable access to social and physical supports needed to promote health from birth to end of life”. Their journey toward making this goal a reality was iterative, and grounded in the idea that if asked, people will say what they need.
Sullivan decided to begin with curiosity as opposed to implementation of pilot programs because in the past, it had been a challenge to scale and pivot programs so they best serve the people who need them. “It’s easy to start with programs”, says Sullivan, “But we thought, ‘you know what? If we build programs without understanding our members better, then we probably are going to go in a bad direction and have to pivot a lot faster than we ever thought we could.’ We wanted to understand our members first. And so we asked them. It seems kind of simple, but it’s really powerful” By the end of August 2018, Sullivan and her team asked a social determinants of health question at the end of every SNAP, Medicaid, and TANF application. In response, 66 percent of applicants shared that they experience food insecurity , which gave the external advisory board key information in thinking through the programs that they wanted to implement.
In addition to gathering key information from Hoosiers who struggle with poverty and health outcomes, Sullivan and her colleagues decided that interventions with staff were needed. It was essential to view interactions between staff and members as a relationship instead of a transaction. Front line staff had to become experts in social determinants of health, and so they were educated and trained to assess, recognize, and assist with needs at every point of contact. For example, they learned that filling out an application for SNAP might be an indicator that a member is also in need of other services. Front line staff could discover members’ needs through the practice of being curious and listening carefully. Asking the right questions at the end of interventions with the goal of staff development is also important, says Sullivan – for example, asking members: “are we doing our job and have we communicated to you well?” . Delving into members’ struggles and consistently reflecting on how staff can improve their work became the foundation of the new Healthy Indiana plan.
Most important, Sullivan says, is upstream work. This means ensuring that policies reflect the values of aligning resources to preemptively solve challenges, and that initiatives are grounded in community expertise and collaboration as opposed to redundancy, silos or competition. To catalyze this, Sullivan and her team built a network that united many public, private, and community-based organizations in Indiana. Together, they helped to direct referrals and create blended funding streams, which continue to support and evaluate whether initiatives are successful over time. Building on Indiana Governor Eric Holcomb’s inspiring hashtag “Why We’re Here,” Sullivan says, “This is why we’re here: to make sure that the things we build outlast any of us and they reflect our priorities and our purpose and our reason for getting up and coming to work every day”. Systems, she states, come down to how we build our communities, and how well we draw on the expertise that is already there. “There’s not a lot of creation of anything new”, Sullivan says, “It’s just a connection of the folks that have been studying and have been doing this work for a really long time and putting them all in a room and saying ‘you were right’”. Through iterative work that is grounded in asking questions and tapping into community expertise, Sullivan reports, it’s possible to change life trajectories for a countless number of people. “We don’t have the answers”, she says. “They did all along. We just had to ask” .
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