When Jennifer Sullivan, MD, was named the Secretary of the Indiana Family and Social Services Administration in early 2017, the state had an HIV outbreak in rural communities—one town in particular had 200 residents infected with the disease. Moreover, the Hoosier State ranked 41st in America’s Health Rankings.
Sullivan’s background as a pediatric emergency department physician taught her to look at each encounter as the stories that patients bring in with them and the larger societal problems they represent. “If you see hunger in the emergency department, it’s not just that one person. It reflects a larger societal unmet need,” says Sullivan. “Everything we do, whether it’s a public health crisis with the current pandemic or the HIV outbreak we had in rural communities in Indiana, or poverty, or Medicaid expansion, underlying all those pieces are the framework of social determinants of health, the prevention and planning to meeting unmet social needs.”
Sullivan says the state had spent a lot of time talking and admiring social determinants of health, but they hadn’t done enough to act on it. That’s when Healthy Opportunities came into the picture, an initiative developed in 2018 on the realization that no one has social determinants of health figured out, including various stakeholders within Indiana.
The agency aims to take the issues head on by a) identifying health care-related social needs across the state b) working with various private and public partners and c) creating policies and programs to fulfill unmet needs. The secret to the sauce, Sullivan says, is plugging social determinants of health into the business model.
“What I fully believe, and I didn’t really know then but certainly know now, is the only way to make sure this is lasting and meaningful is to build it into your business model. The funding is in health care delivery and social services delivery programs, like Medicaid, so even though we may not be the experts on social determinants of health, since this is where the funding goes, if we build into the business, it won’t go away,” she says.
Zip code level SDOH
The first phase of Healthy Opportunities was understanding the social drivers of health in Indiana, figuring out the latest best practices in addressing those issues, finding programming and education opportunities, and building overall awareness across the state. They also created an advisory board representing a broad swath of demographics and stakeholders.
In terms of what’s happening on the ground, Healthy Opportunities has 8,000 people across 110 offices in Indiana that do eligibility determination for Medicaid, Supplemental Nutrition Assistance Program (SNAP) and other programs working to address social determinants. They also have offices that do vocational rehabilitation and early intervention programs.
“We have this incredible network where we can become the face of ‘how can I do one more thing to augment your ability to be healthy?’” Sullivan says. She has workers ask those in need of assistance to answer 10 questions based on social determinants of health. By deploying those surveys both in-person and online, they’ve accumulated half a million responses.
“We’re down to the zip code level on where unmet needs are occurring and to whom. We will be releasing that map as a tool for communities to better understand their needs and to track and improve our programming at the state level as well,” she says. “In order to actually get to programming, we needed to understand our members better in a way that we hadn’t been able to before.”
As of July 1, the agency has integrated 211 calling service into the work the Indiana Family and Social Services Administration is doing on social determinants. “That answers the question, what do you do about it? Now we can start solving the issues that are in front of us. The final step is building out healthy communities, so you don’t have those unmet needs in the first place.”
Sullivan says the agency is taking existing health outcomes metrics and reframing them in the framework of this social determinants’ initiative. For instance, the agency used to just track overall churn numbers. Now it counts a successful outcome if someone leaves the state Medicaid plan because they got a job or moved into a different health plan. And an unsuccessful outcome is if they left because of administrative barriers. If it’s the latter, they work to fix the issue.
Money and data: the two biggest challenges
The success and sustainability of this initiative would be impossible if it were not for partnerships developed at the public and private level, says Sullivan. This has been important as the agency has dealt with the COVID-19 pandemic in particular. Partnerships mean blended programming, easy handoffs, and combined funding streams. This last point, she says, will be the biggest challenge in the long run.
“I can’t use community dollars as a Medicaid match, but what would happen if I could? What would happen if I said to a statewide housing organization, if you put up 35 percent, I can get you the other 65 percent through Medicaid because housing is important to health outcomes and has a huge return on investment. At every level we have to have conversations to make sure we’re capitalizing on every single penny we spend.”
Another challenge, she says, is data, which goes hand in hand with funding. The public health IT infrastructure leaves a lot to be desired, which is unfortunate, because as Sullivan says, “As a scientist, I don’t like to do things because I think they are a good idea, I like to know they are a good idea. And I only know if I have information I can digest and interpret.”
Unfortunately, those working on social determinants at an individual level don’t have the time or funding to develop sophisticated databases that are needed for this type of work, Sullivan says, adding that one of the reasons the initiative hasn’t developed at a faster pace is there isn’t an underlying data infrastructure to enable a free flow of useful information across agencies and stakeholders.
Early research has shown that COVID-19 pandemic has exposed and worsened health inequities that have plagued vulnerable populations for decades. Leaders in this space like Sullivan say they hope this will create renewed interest in tackling these issues.
She advises health care leaders who have a renewed interest in social determinants to have the humility and wherewithal to understand they don’t need to build or buying anything new. While it’s tempting to buy something, she says, that should be the last plan of action, especially if it’s done without an understanding of what needs to be done.
“The first part of social determinants of health, meeting those individual unmet needs, is all about networking. It’s about connecting existing resources and understanding what those resources are and where they are located,” she explains. “It doesn’t need to be new and flashy to be effective. That involves more time and more talking, but the outcomes are richer and more sustainable.”
