Not Answers, Just Leadership

Reforming States Group State Health Policy Leadership Population Health Social Determinants of Health COVID-19

The Indiana Family and Social Services Administration (Indiana’s Health and Human Services agency) has been virtual for 12 weeks. Running health care and social services from our kitchen tables has been an extraordinary transformation in how we work—and something that we were fairly certain we couldn’t do. Until we had to, and then we just did.

With that boost of confidence, we went on to make hundreds of changes, some new and some that we had wanted to initiate for years. We removed barriers to telehealth, augmented child care vouchers and Supplemental Nutrition Assistance Program (SNAP) benefits, we designed and implemented safe recovery sites for individuals experiencing homelessness, we built a just-in-time COVID research consortium, and we modeled public health responses. The list goes on and on.

All of this happened without having clear answers as to whether anything would actually work. Instead, we made these changes because they were the right things to do. In a time of crisis, doing the right thing guides everything you do.

The Indiana Family and Social Services Administration’s overarching mission is to integrate all of the tools we oversee to improve health in Indiana. Responding to COVID-19 has galvanized our agency’s staff in extraordinary ways and provided a sense of clarity about exactly how each of our divisions (Medicaid, SNAP/Temporary Assistance for Needy Families [TANF], Mental Health, Disability and Rehabilitation, Aging, Early Childhood, and Social Security Disability) connects to health. Our executive team has been talking about the tension that we feel between the sadness of the unfolding tragedy of human suffering and the excitement associated with the innovative and enhanced services we are offering.

As an agency head, my day-to-day role is to shape the agency’s vision for success, build and shepherd the team, make decisions, and serve as a policy advisor to the governor. Most of the time I can perform these tasks by drawing on exceptional scientific literature and data.

In this pandemic response, leaders across the country, including me, have to rapidly become comfortable with being uncomfortable (my other job as an emergency physician gave a little leg up on that). We don’t have a lot of evidence to guide our teams, and there often isn’t time to wait for it. With every problem we face there are countless questions. What do we do? What are the risks? What does success look like? But in a crisis moving as fast as this one you cannot always provide answers. Sometimes you just have to provide leadership. That means working with the best science, listening to the experts, weighing the risks and benefits, and then charting the course forward.

Counter-intuitively, activities related to the Indiana Family and Social Services Administration’s long-term priorities are on fast-forward rather than on hold. The areas of most importance to our agency before were the gaps in care and services—and they are chasms now. For example, our focus on building services that address the social determinants of health, such as housing, child care, transportation, and food security, into medical care has come to fore.

In our last legislative session, one of Governor Eric Holcomb’s agenda items was the integration of Indiana 2-1-1—a free service that connects residents with community services and resources—and the Indiana Family and Social Services Administration. This integration was slated to begin in July, but because of the pandemic, the timeline has been accelerated. During the month of April, Indiana 2-1-1, with support from the Indiana Family and Social Services Administration, provided information and referral assistance to over 15,600 people. It has become a new front door to all our services.

Although I’m grieving the loss of life in my state, I’m not grieving the loss of our agency’s original plans to improve social services and health care delivery. I’m watching them become reality under different, difficult circumstances.

Leading from my kitchen table has ended up being an exceptional opportunity to engage our teams. As I wrote in my weekly agency-wide email, “Broken Pieces,” last month, we are thinking about every unexplored corner that could support the continuum of health and well-being. Our Virtual Care at Home model, for example, which connects individuals with COVID to federally qualified health centers for monitoring and virtual care, is an example of caring for people while keeping them in their own beds.

When we started working on hospital surge planning, my framing question was, “What are all the places that we can use as hospitals?” We came up with a TON, but the one area that was really intriguing to me was taking care of people at home. We do this all the time already for chronic illness, but what if we shifted our paradigm to take care of acute illness this way and in doing so open up critical capacity needed inside hospitals?

With a lot of teamwork, the Virtual Care at Home pilot sites in partnership with our community health centers and federally qualified health centers went live in three regions on Monday. Over 50 patients are already “admitted” to their homes and receiving care and monitoring from health care providers. Here’s a note from one physician team leader:

The providers and staff see this as giant win—I can’t overstate how positive their comments were yesterday.  Most importantly, of course, the patients feel taken care of and reassured and are grateful. We are already planning for how this can be sustained post-COVID and include others who are fragile and complex.

We are still living in a time of great uncertainty. We’ll face even bigger decisions in the coming months and even years as we see the impact of our COVID-19 response in policy and practice. We’ll need to determine what to continue and what to change in order to decrease health inequity. It’s like walking into the trauma bay in the ER and not knowing what you’ll find there but knowing that lives depend on your decisions. What I see in action at the state level is leadership despite that uncertainty. We will eventually find ourselves on the other side of this pandemic with the answers that we found as we led.

Jennifer Sullivan is  secretary of the Indiana Family and Social Services Administration.