Evaluation of a patient-centred biopsychosocial blended collaborative care pathway for the treatment of multi-morbid elderly patients

ESCAPE will rethink current practice for treating multimorbidity in elderly patients and break down health care silos that impede integrated care and lead to adverse outcomes.

We will coordinate and optimise care, prioritising integration of treatment for mental distress and disorders in the treatment of multimorbidity.

Our interdisciplinary multinational consortium of experts from general and hospital medical practice and psychology, health economics, ICT development and social innovation as well as patient and informal carer representatives, will develop a holistic, patient-centred intervention based on the blended collaborative care (BCC) approach and enhanced by cutting-edge information and communication technologies.

Trained Care Managers will work closely together with the patient’s general practitioner under supervision of a Clinical Specialist Team.

They will use a meta-algorithm integrated in the interactive imergo® e-health Integrated Care Platform to customise patients’ treatment to their individual needs and preferences and liaise among providers. The platform will also empower patients and informal carers to increase their intrinsic capacities.

ESCAPE as a social innovation will decrease disease burden for patients, informal carers and ultimately society and improve their quality of life (QoL), prioritised as the most important treatment outcome by patients, carers, and multimorbidity guidelines.

ESCAPE will conduct for the first time a randomised controlled trial embedded in a comprehensive cohort study design to compare BCC and usual care. We will include patients with heart failure, ≥2 medical comorbidities and psychological distress. The primary effectiveness endpoint will be patients’ health-related QoL.

Medical outcomes, cost-effectiveness, and several other patient-relevant outcomes will be secondary endpoints.

We will apply an active dissemination and exploitation strategy to derive maximum impact from the new pathway for multimorbidity care.