With a meager few percentages of the budget invested in prevention, we lose a lot of healthy life years and money. Changing the culture of the health community is no easy task. Thinking and reading about things to do and change can help. I was happy to find a real breadcrumb trail of interesting documents, one proposing a solid model, others giving specific, practical pointers. Thanks to VOKA and imec for putting me on the trail…

I started with…
VOKA and imec join forces on March 20th in Leuven, exploring opportunities in internationalizing healthcare ('Je grenzen verleggen in health!'). It’s always worthwhile to explore websites announcing such venues: this one was packed with interesting references.

One of the keynotes is titled Activ84Health (Roel Smolders). Following a real “breadcrumb trail” of interesting documents, I discovered an interesting Whitepaper: The Promise and Realization of Community Assisted Self-Management (CASMA) (08/08/2016). Find some other breadcrumbs in the text boxes.

I obviously recommend reading the whole document, but for those who need a shortcut, go on discovering this compilation of what I picked up reading the whitepaper:

In some 26 pages, the state of prevention in Belgium and surrounding countries is described. Lacking elements are put together in a comprehensive document, describing “CASMA” (Community Assisted Self-Management). It is a strong, comprehensive model, much broader than what most of us normally would describe as (medical) prevention. It aims to really empower the individual, but cleverly embeds this change of focus in a context of behavioral science, change management and social components.  

What’s wrong (a.o.)
For years, chemotherapy was modeled on antibiotic therapy. Heart conditions are treated with bypasses as the modern successor to the curative removal of abscesses. Most suitable and innovative, but nothing causative.

Social expectations in society reflect the present predominant care model. People subconsciously believe that a ‘magic bullet’ will resolve any health issue, with a focus on treating the symptoms. (…) The sale of curative novelties (often of marginal use) turns us all into more passive consumers instead of active co-producers of our own health. (...) We need to make a switch from care and disease to behavior and health. From within our dominant culture, we devalue prevention.

Eight good objectives
In the whitepaper, the CASMA model is described as combining 12 criteria in one preventive trajectory, but with a little tweaking, I resume them in the following 8 objectives:

1. CASMA puts prevention to the centre of the action, applying primary, secondary or tertiary prevention all at once (treatment or cure alone is out of scope).
    
2. Self-management by the individual is the starting point: promoting health literacy and helping people to make their own decisions on health and wellbeing.
    
3. It uses customized, personalized and tailor-made communication, modified depending on the user. Disseminated information is evidence based.
    
4. Data are collected based on evidence based aims. CASMA promotes, produces and uses open data, thereby contributing to open knowledge sharing and quality, with the user at the steering wheel.
    
5. It uses the local community or network: variable and flexible communities bring individuals in contact with each other, with cooperation or partnership of several organizations and enterprises along the value chain of health.
    
6. It uses several techniques of rewarding or nudging, based on insights of social psychology and incorporating and using elements of social, cultural and/or public environment.
    
7. New business models and funding are used to scale up the prevention trajectory.
    
8. Technology is incorporated to support the trajectory.

Recommendations
The authors propose five general recommendations (resumed as follows):

1.     Drop the term prevention and opt for Community Assisted Self Management instead: radically play the CASMA card and invest in knowledge and support for self- management trajectories within a whole of alternating networks. Turn each and every preventive action into a combination of individual and network components. Avail of the environment and technology to foster healthy behavioral changes.

2.     Involve patients or ‘citizens formerly known as patients’ in self management: valorize the knowledge and experience of every citizen (…) Allow people to set their own targets and offer them a choice of tailored services to attain that goal. You will develop tremendous drive and self-esteem among those who were previously only qualified as ‘patients’. (…) In a world that facilitates more accurate and more predictions about one’s health in later life, there is no point blocking information. Sharing medical information and informing people correctly and pointing out the context and possible choices will become all the more important in fact.

3.     Start from the economic strengths and develop Flanders into an international CASMA cluster, within the Belgian Digital Health Valley. (…) Bring all the research expertise, care quality and entrepreneurship into one health care cluster that will put Flanders on the international map as a region that specializes in the testing, valorization and implementation of CASMA products and services.

4.     Give care professionals the tools and structures to become and remain architects of choice / prevention professionals. This requires a reorientation of the initial and continuous training programs. New roles and accreditations are born, for instance the role of coach, without lapsing back into the cast roles.

5.     Develop a financing system that stimulates CASMA and take stock of all the derivative benefits. (…) The available models are already on the radar: shared- and inclusive shared savings, backpack models and a value based benefit design (contribution based on added value instead of patient contributions).
Providers of supplementary insurance schemes would also be wise to legally and financially reorganize themselves and to focus on prevention rather than on isolated hospitalization. The budgetary prevention component should in the short term be increased in line with the average in our neighboring countries by moving around resources that are spent inefficiently.

Tax incentives work but, so far, are only used in a purely negative sense (excise duties, sugar tax...) or act as an impediment (such as prevention at work). (…) There is also a need to support and reward citizens in a positive sense.

Prevention is an integral policy responsibility and calls for an integrated action.

 Dirk BROECKX -- 12 March 2017