Older heart failure (HF) patients with somatic and mental comorbidity represent a vulnerable population with complicated and multi-faceted healthcare needs. These needs stem from the complexity of their treatment plans, which often include the management of numerous conditions simultaneously.

Within ESCAPE, we address these issues through the involvement of a Care Manager figure. Specifically, Care Managers are dedicated healthcare professionals like nurses, serving as the linchpin in this approach, whose role is to bridge the gaps between patients, caregivers, general practitioners, and specialists to streamline and optimise care. The utilisation of care managers is suggested to improve patient’s health-related quality of life through the development of more personalised treatment strategies and careful observation of patients' symptoms.

Recent findings from the Italian clinical trial team highlight that the patients most frequent needs were related to practical aspects of their treatment and life, including:

  • Education about heart failure and comorbidities
  • Active engagement in their own treatment plans
  • Supportive communication between the CM and other healthcare professionals
  • Monitoring of symptoms related to heart failure and other conditions
  • Coordinated updates on symptom progression

Addressing these needs plays a significant role in ensuring that patients receive comprehensive holistic care that is tailored to their individual circumstances.

Further, ESCAPE’s research has shown many patients experience psychological distress, including anxiety, depression, and feelings of hopelessness, which further impacts their quality of life. These patients expressed a need for more frequent consultations with cardiologists, additional information about their conditions (such as hypertension, diabetes, and osteoarthritis), and written educational materials. They also valued the support of the Care Manager for monitoring symptoms like shortness of breath, weight fluctuations, and blood pressure.

Crucially, the Care Manager is not just a coordinator of care but also a key player in helping patients actively engage in managing their health. By assisting with self-management and addressing treatment burdens, the Care Manager supports patients in adapting their care to everyday life. This collaborative approach empowers patients to take small, manageable steps towards improving their health, resulting in better outcomes.

Our research underscores the complexity of healthcare needs for elderly heart failure patients and the vital role that Care Managers play in meeting these needs. By providing personalised care and addressing the unique challenges faced by these vulnerable patients, the Care Managers helps ensure that each patient receives holistic, person-centered care through models such as Blended Collaborative Care.

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