In today's ever-changing healthcare landscape, a one-size-fits-all approach no longer suffices, especially for individuals with multiple health conditions. The ESCAPE project, an EU-funded Research and Innovation initiative, seeks to enhance care for elderly multimorbid patients through a patient-centred approach known as Blended Collaborative Care (BCC).

Blended collaborative care (BCC) is an approach to improving patients’ health that considers both physical and mental health; it acknowledges that improving physical health will benefit from improvements in mental health, and vice versa. Specifically, this approach addresses patient and carer needs using care managers. Care managers, dedicated healthcare professionals like nurses, serve as the linchpin in this approach. They bridge patients, caregivers, general practitioners, and specialists to streamline and optimize care.

Care managers play a pivotal role in setting and breaking down health goals, similar to how personal trainers assist in achieving fitness objectives. These goals often encompass broad health improvements that are challenging to measure and difficult to act on. Here's where care managers shine by converting these broader goals into manageable steps called micro-goals. These seemingly small steps, like a 5-minute daily walk or 10 sets of toe touches, can contribute enhancements in overall health and quality of life.

As every patient is unique, care managers customize micro-goal plans to individual health issues and life circumstances. They maintain ongoing engagement, monitoring progress, and adapting care plans as needed. It empowers patients to take small, focused steps that lead to substantial improvements in well-being for those dealing with multimorbidity.

The ESCAPE project's feasibility study, conducted at the project's outset, tested these care management principles on a small scale. The patients' response was largely positive, with around 80% achieving some of their micro-goals, indicating the intervention's effectiveness. Patients valued the proactive approach of care managers and found comfort in regular phone calls and support. This approach nurtured trust and open communication about health concerns. The feedback from the trial underscored the pivotal role of the care manager's relationship and trust in achieving positive outcomes.

After positive engagement with patients and carers during the feasibility trial, the ESCAPE team is now implementing a full-scale clinical trial. Assessing the Care Manager model and blended-collaborative care intervention in six different countries for a longer duration. The ESCAPE project is actively seeking patients for the study, patient’s must be over 65 years old, suffer from with chronic heart failure, psychological distress and at least two other physical co-morbidities. The process is convenient, involving phone consultations and mail-in questionnaires. Any individuals in our trial countries, Ireland, Denmark, Germany, Lithuania, Hungary, and Italy are invited to visit ESCAPE’s website ( and contact, ( for more information.