As the ESCAPE project progresses in its mission to enhance care for older adults living with chronic heart failure and multimorbidity, specifically, in shaping and refining the project’s intervention, Blended Collaborative Care (BCC).
Developing the ESCAPE Intervention
The intervention design phase concluded in 2022 with the publication of the Care Management Manual —a resource outlining the approach, tools, and practices of BCC. This patient-centred, biopsychosocial care model supports the coordination of care for elderly patients living with multiple chronic conditions, emphasising goal setting, mental health support, and cross-disciplinary communication.
Supporting Implementation: Train-the-Trainer Meetings
To support consistency and high-quality intervention delivery, the team has facilitated regular Train-the-Trainer (TTT) meetings with care manager trainers at each site. Initially held biweekly, these sessions provided an opportunity to troubleshoot technical and procedural issues, discuss clinical content, and share site-specific experiences.
Topics included conducting Specialist Team meetings, documenting treatment updates for GPs, and effective use of the project’s digital platform, the imergo® registry. As implementation matured, TTT meetings shifted to a monthly format in mid-2023, focusing on the end-of-intervention phase and country-specific implementation challenges. By the end of 2024, the WP2 team had hosted 35 TTT meetings.
Monitoring Fidelity: Ensuring Adherence and Quality
In 2024, WP2 launched a fidelity monitoring process to ensure the intervention was delivered consistently and according to protocol across sites. This involved a detailed review of imergo® registry data for the 113 intervention patients documented at the time. The analysis focused on:
- Completeness of key data
- Number of care manager contacts
- Goal setting and goal attainment
- Symptom and mental health monitoring
- Red flag alerts and responses
- Involvement of informal carers
- Documentation of Specialist Team recommendations
While no major protocol violations were identified, some documentation inconsistencies, especially around goal classification and follow-up, were flagged. These were addressed through collaborative discussions in the TTT meetings, and corrective actions were implemented based on care managers’ comments and registry entries.
Looking Ahead: Finalising the Manual and Collecting Site Feedback
The key objective for WP2 in 2025 is to gather structured feedback from all participating sites on the intervention’s delivery. This qualitative insight will be used to update and finalise the Care Management Manual, ensuring it is adaptable across diverse European healthcare systems and scalable for future use.
This work is crucial not only for the success of the ESCAPE project, but also for the broader adoption of patient-centred, integrated care for older adults with complex health needs.
Publication Highlight
ESCAPE’s intervention development and pilot study findings have been published in Behavioural Sciences.
You can access this paper here: Schulze J, Lühmann D, Nagel J, Regner C, Zelenak C, Bersch K, Herrmann-Lingen C, Burg MM, Herbeck-Belnap B; ESCAPE Consortium. Adapting and Implementing a Blended Collaborative Care Intervention for Older Adults with Multimorbidity: Quantitative and Qualitative Results from the ESCAPE Pilot Study. Behav Sci (Basel). 2025 Jan 17;15(1):79. https://doi.org/10.3390/bs15010079
