Heart failure is a growing health challenge in Singapore, affecting up to 5% of the population and contributing significantly to the nation’s leading cause of death – cardiovascular disease. Not only that, it is a devastating diagnosis, often leaving patients and their families facing a long and uncertain journey.
But what if there was a way to shift the focus from solely managing the disease to embracing a more holistic approach that prioritises quality of life and empowers patients at every stage? This is the vision behind the Heartlanders programme, a groundbreaking initiative launched by the Lien Foundation and the National Heart Centre Singapore (NHCS).
This programme, supported by a $6.5 million grant from the Lien Foundation, seeks to empower over 9,000 patients with better support systems and quality of life improvements over the next five years.
Reframing Heart Failure with Palliative Care
Traditionally, people have associated palliative care with end-of-life support. The Heartlanders programme challenges this perception by introducing early palliative care as an integral part of routine cardiac treatment.
This approach aims to improve the quality of life for patients living with heart failure, regardless of their stage of the disease.
Rather than viewing palliative care as a “last resort,” the Heartlanders programme seamlessly integrates palliative care principles into standard cardiovascular care from the moment of diagnosis. This upstream integration ensures patients benefit from palliative interventions much earlier in their disease trajectory, addressing physical, emotional, and psychosocial needs alongside clinical care.
“Far from being for the dying, palliative care embodies the very essence of care…early integration of palliative care empowers heart failure patients to manage their symptoms and psychological fears, enhancing their quality of life.” remarked Mr Lee Poh Wah, Chief Executive Officer, Lien
Foundation.
From Hospital to Community: Building a Robust Ecosystem
At the heart of the Heartlanders program is a collaborative team approach.
Beyond the hospital walls, NHCS has collaborated with various partners, including SingHealth Office of Regional Health community nurses, to create a seamless support network.
Patients discharged from NHCS will now have access to general practitioners, community palliative care services, and rehabilitation resources tailored to their needs.
A dedicated cardio-palliative care coordinator is assigned to each patient, working closely with cardiologists, heart failure nurses, palliative care specialists, medical social workers, and community partners to create a personalised care plan.
This multidisciplinary team focuses on understanding each patient’s unique goals and preferences, guiding them through the complexities of heart failure management and helping them navigate their journey with confidence.
“By integrating hospital expertise with community resources, we are reshaping how we manage heart failure, creating a more responsive and compassionate healthcare ecosystem.” said
Prof Yeo Khung Keong, Chief Executive Officer, NHCS.
Touching Lives: Mr Lam’s Story
Mr. Lam Theam Fatt, a 63-year-old who enrolled in the programme during its pilot phase, has found this integrated care model essential to his journey back to health.
It started during an overseas trip, where he experienced shortness of breath and difficult breathing. A week later, he experienced swelling of his feet. He was finally diagnosed in Malaysia, but decided to return to Singapore for treatment.
After he was readmitted shortly after his first discharge, the team decided to make it their personal mission to make a difference to his disease trajectory. Before long, one of the staff reached out to interview Mr Lam, and took him under their care.
The Power of A Heart Failure Ecosystem
“After a patient has a heart failure hospitalisation is a very critical two months.” Dr Kenneth Chew, Co-lead of the Heartlanders Programme and Consultant, Department of Cardiology, NHCS, elaborated.
“With very frequent, very intensive kind of follow-ups, we can actually reduce the risk of [the patients] either dying or having a heart failure related hospitalisation by about 40% relative risk.”
This was what Mr Lam experienced – soon after discharge, the care team followed up on him to check on his well-being.
“I was very impressed that a nurse from the hospital came to my house to check on me within a month of my discharge.” Mr Lam shared.
“I felt they were diligent, professional, and very caring about my health. I know I need to take care of myself, but it was very comforting to have that extra support.”
Since the pilot phase, the Heartlanders Programme has supported over 38 patients, with the number increasing daily.
Empowering Healthcare Professionals
Another cornerstone of the programme is its commitment to training healthcare professionals.
To ensure palliative care becomes an intrinsic part of cardiology, NHCS and the Lien Centre for Palliative Care (LCPC) have co-developed a cardio-palliative care course.
The heart failure team has incorporated the training into the postings of cardiology residents. It is also made it mandatory for all NHCS staff and community partners.
Besides, the Heartlanders programme also looks to equip family physicians to better manage patients’ medical needs. These GPs in the SingHealth’s Delivering On Target (DOT) Primary Care Network (PCN) oversee patients’ medication needs. They also liaise with NHCS cardiologists through ongoing case management and established follow-up protocols.
Previously, doctors would have to make the difficult decision to call an ambulance and send the patient back to the hospital for further treatment. Now, NHCS offers fast-track services to provide timely intervention when they identify a patient at risk of deterioration.
“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).
A New Benchmark For Patient-Centered Care
As Mr. Lee Poh Wah, CEO of the Lien Foundation, emphasised, “Palliative care must be a cornerstone of our healthcare system, ensuring patients are well supported at every stage of their heart disease.”
Palliative care is no longer viewed as an end-of-life service. It is now seen as a fundamental part of care that improves quality of life and empowers patients. The Heartlanders programme demonstrates this beautifully, weaving compassion and support into every aspect of heart failure care. This creates a more holistic and empowering experience for patients and families.
With the right support and guidance, even the most challenging journeys can be faced with hope and strength.
