Singapore, 20 January 2025 – Lien Foundation and National Heart Centre Singapore (NHCS) are set to reframe the approach to heart failure with the launch of the Heartlanders programme. Supported by a $6.5 million funding from Lien Foundation, this initiative integrates palliative care into the cardiology specialty so that generalist palliative care is delivered upstream by cardiologists and other healthcare professionals to all patients with needs. Beyond the hospital, NHCS is collaborating with primary care and community partners including SingHealth Office of Regional Health community nurses, to build an ecosystem that supports heart failure patients in the community. 

This care delivery transformation is in line with Healthier SG and aims to improve quality of life and avoid unplanned hospital admissions. Over the next five years, more than 9,000 heart failure patients are expected to benefit from the programme.  

Cardiovascular disease is the top killer in Singapore, accounting for almost a third of fatalities1. Close to 4 to 5% of Singaporeans live with heart failure, a much higher percentage compared to 1 to 2% globally2. Heart failure patients are relatively young, causing them to lose years of productivity and placing an additional emotional and financial strain on their families. As heart failure can have minimal symptoms in its earlier stages, patients are often diagnosed only after their condition has advanced to more severe stages. At that point, prognosis can be short (5 to 10 years) and many struggle to accept the inevitable disease progression, mistakenly believing medication to be a cure. The disease follows an unpredictable course, with seemingly stable periods interrupted by sudden declines. Coupled with infrequent monitoring and poor medication compliance, it is common for patients to be hospitalised multiple times.   

With Heartlanders, during hospitalisation, all patients are screened for clinical and psychosocial needs. Each patient has a dedicated cardio-palliative care coordinator who seeks to understand each individual’s goals of care, as well as coach them to effectively self-manage cardiac symptoms. Most heart failure patients have basic palliative care needs that are addressed by cardiologists and heart failure nurses. For those with more complex needs, care is escalated to palliative care specialists or other professionals such as medical social workers, who are part of a larger multidisciplinary team. The team works closely across different institutions, transcending the traditional boundaries to understand, holistically, each patient’s unique situation and motivations to ensure that they receive appropriate and individualised care.  

Shifting the delivery of palliative care upstream allows patients to benefit much earlier in the disease journey, as part of routine cardiac care. This differs from conventional practice where palliative care is often an afterthought, with heart failure patients referred to palliative care specialists only at the end-of-life. These benefits of early palliative care are applicable to all serious cardiac illnesses, with plans underway to expand to other heart conditions. 

Importantly, post-discharge, coordinators continue to monitor patients’ conditions, provide ongoing coaching, and connect them to suitable wellness and social programmes in the community. Through ongoing engagement, patients are likely to better maintain a stable state in the community and avoid unplanned hospital admissions. 

NHCS and its partners are fostering a heart failure ecosystem to provide patients and their families with robust support systems and equip them to handle the challenges of living with heart failure in the community. As the programme develops, collaborations with new partners will be added. Currently, the key partnerships are as follows: 

Primary care providers will be empowered to manage patients post discharge, including SingHealth’s Delivering On Target (DOT) Primary Care Network (PCN) consisting of 194 GPs. These GPs will oversee patients’ medication needs and liaise with NHCS cardiologists through ongoing case management and established follow-up protocols. When primary care providers identify a patient at risk of deterioration, fast track services will be offered at NHCS’s outpatient clinics and via teleconsultations to provide timely intervention. 

Community nurses

Community nurses, including those from SingHealth Office of Regional Health and other locations across the island are crucial to providing continuous, seamless care to patients. They will provide symptom monitoring, personalised health coaching, medication consolidation, continuing care conversations, and escalation and coordination with specialists and GPs. Nurses are stationed at Community Health Posts, conveniently located in residential areas, Active Ageing Centres (AACs), Community Centres, and faith-based places, making it easier for patients to access care and encouraging community involvement.

Rehabilitation and other partners

Regular rehabilitation is an important component of cardiac care, helping patients regain their independence and strength to improve their quality of life. NHCS will provide patients with inpatient rehabilitation services, and transit them to community rehabilitation services such as Singapore Heart Foundation, following their discharge. NHCS coordinators will work closely with other partners including AACs to ensure patients are appropriately placed, so that they remain socially engaged and keeping them motivated to take medications and stay well.  

Education and research

To equip healthcare professionals to deliver generalist palliative care addressing the majority of palliative care needs, NHCS and Lien Centre for Palliative Care (LCPC) at Duke-NUS Medical School developed a cardio-palliative care course for all NHCS staff and community partners. The course prepares healthcare professionals to initiate care conversations with patients and families, understand the complexities of cardiac and palliative care interventions and manage delicate end-of-life decisions. Furthermore, palliative care education will be incorporated into all cardiology residents’ training, ensuring that future cardiologists are well-versed in this crucial aspect of patient care.       

Using a value-driven evaluation approach, NHCS will collaborate closely with LCPC to study patient outcomes and potential cost savings from reducing unplanned admissions.     

“Primary care plays a vital role in helping heart failure patients navigate their complex medical conditions, coordinate community services, and prescribe preventive interventions. The Heartlanders programme equip family physicians to better manage patients’ medication needs and collaborate with NHCS cardiologists via regular reviews and fast-track outpatient services. By ensuring consistent monitoring, guiding lifestyle modifications, and addressing potential issues early, we empower patients to take charge of their health, reduce hospital admissions, and improve their quality of life,” shared Dr. Teo Cheng Rong, Family Physician at Healthway Medical (Choa Chu Kang, Limbang). Dr Teo is a member of SingHealth’s DOT PCN.

“The Heartlanders Programme is more than a heart failure management initiative; it represents a profound shift in how we approach healthcare in Singapore. This reflects an organisation-wide mindset shift, where cardiologists, nurses and all other healthcare professionals provide palliative care to care for patients more holistically. By integrating hospital expertise with community resources, we are reshaping how we manage heart failure, creating a more responsive and compassionate healthcare ecosystem. Our partnership with Lien Foundation and community organisations allows us to transcend traditional healthcare boundaries and empower patients in their journey. This programme sets a new benchmark for patient-centred, value-driven care in heart failure management, with the potential to transform the nation’s broader healthcare landscape, particularly in palliative and chronic disease management,” said Prof Yeo Khung Keong, Chief Executive Officer, NHCS.

“Palliative care must be a cornerstone of our healthcare system, guided by the duty to alleviate suffering. Far from being for the dying, palliative care embodies the very essence of care. We've embedded it at the heart of cardiology, as early integration of palliative care empowers heart failure patients to manage their symptoms and psychological fears, enhancing their quality of life. To meet this growing demand, Singapore needs a healthcare workforce that is both competent and confident in the practice of palliative care, ensuring patients are well supported at every stage of their heart disease,” said Mr Lee Poh Wah, Chief Executive Officer, Lien Foundation.

References:

1. HealthHub – Principle causes of death

2. Lam CSP. Heart failure in Southeast Asia: facts and numbers. ESC Hear Fail. 2015;2(2):46-49.doi:10.1002/ehf2.12036