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.