Heartlanders Programme

What is Heartlanders

If you or someone you love is living with heart failure, you are not alone. Between 4 and 5 percent of Singaporeans live with heart failure - a significantly higher rate than the global average of 1 to 2 percent. Heart failure is also one of the leading causes of repeated hospital admissions among cardiac patients.

How the Programme Works: Key Features

Early Integration of Palliative Care Unlike traditional models where palliative care is introduced only at the last stages, Heartlanders incorporates it from the point of diagnosis. This proactive approach addresses not only the physical symptoms but also the emotional, social, and psychological challenges faced by heart failure patients.

Personalised Care Coordination Each patient is assigned a dedicated cardio-palliative care coordinator. The team works closely across different institutions, transcending traditional boundaries to understand, holistically, each patient’s unique situation and motivations, ensuring that they receive appropriate and individualised care.

Community-Based Support After Discharge Support does not end upon your discharge. 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 more likely to maintain a stable state and avoid unplanned hospital admissions.

Network of Community Partners Heartlanders connects patients to a network of 194 GPs under SingHealth’s Delivering On Target (DOT) Primary Care Network and community nurses. For patients requiring rehabilitation, NHCS supports the transition from inpatient services to community providers.

Healthcare Professional Training To support consistent care, NHCS and the Lien Centre for Palliative Care (LCPC) at Duke-NUS Medical School developed a cardio-palliative care course for staff and community partners. This helps healthcare professionals to initiate care conversations, understand the complexities of cardiac and palliative care interventions, and manage end-of-life decisions.

A Patient's Experience

Frequently Asked Questions

Heartlanders is a Singapore programme by NHCS and Lien Foundation that integrates early palliative care into heart failure treatment. It is designed to improve quality of life and support patients from hospital to community.

The programme is for heart failure patients cared for by NHCS. Speak with your NHCS doctor to find out if you are eligible.

Depending on your needs, the possible areas of support include symptom management, care planning, emotional and social concerns, and follow-up after discharge. The programme also connects patients with community partners, so care continues beyond the hospital.

No. Palliative care is a holistic approach to care for all patients with serious illness, for all ages, at all stages of their illness. Palliative care is an extra layer of support that complements illness-directed management.

Under the Heartlanders programme, palliative care is brought in earlier to help with symptoms, goals of care and quality of life.

Yes. The Heartlanders programme is built into standard cardiovascular care. Your usual clinical care team (doctors, nurses, allied health) will still remain involved in your care.

Your dedicated coordinator seeks to understand your goals of care, coaches you to effectively self-manage cardiac symptoms, and works closely with cardiologists, nurses, and other healthcare professionals to develop an individualised care plan. After discharge, they continue to monitor your condition and connect you to community support services.

Depending on your needs, the programme includes community follow-up with GPs and community nurses, who can provide monitoring, health coaching and early intervention if your condition changes. Your care coordinator remains in contact to help keep you stable at home.

Yes. NHCS works with a network of 194 GPs under SingHealth’s DOT Primary Care Network. These GPs oversee medication needs and liaise closely with NHCS cardiologists. When a GP identifies a patient at risk of deterioration, fast-track services are available at NHCS outpatient clinics and via teleconsultation.

We’re working to include our network to spread beyond GPs who are currently not in the DOT Primary care network.

NHCS collaborates with primary care providers and community nurses, including those from SingHealth Office of Regional Health stationed at Community Health Posts in residential areas, Active Ageing Centres, Community Centres, and faith-based locations. NHCS also collaborates with community hospice and rehabilitation services.

More than 9,000 heart failure patients in Singapore are expected to benefit from the programme by 2029.

Contact Us

For NHCS patients and caregivers who would like to understand if the Heartlanders programme may be suitable for your care journey, please speak with your doctor at NHCS.

If you are not currently an NHCS patient, you may make an appointment to consult our cardiologist for further assessment.