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Community Heart Programme

Heart failure remains one of the leading causes of re-admissions among heart patients.

NHCS launched the Community Heart Programme to help heart failure patients better manage their heart conditions at home and live well in the community, thereby reducing the rate of re-hospitalisation. Through the programme, more than 200 community nurses and care providers were equipped with skills and knowledge to care for heart failure patients beyond the hospital premises. The skills and information taught include self-care management, dietary counselling, cardiac rehabilitation and palliative care.

One of the key components of the programme underscores the importance of social health integration to empower our cardiac patients for a good life beyond healthcare. It is led by NHCS Medical Social Services using an empowerment model known as the Local Area Coordination and Empowerment (LACE).

Social Health Integration: Empowering Heart Failure Patients in the Community

Local Area Coordination and Empowerment (LACE)

Aligned with Singapore's HealthierSG and Population Health priorities, there is a growing emphasis on preventive care and strengthening of health-social care integration to improve population health outcomes. 

These driving forces have necessitated a transformation from the current institution-based model of care to one that focuses on community and population-based care while shifting from a disease-centered to a person-centred approach.

In 2020, NHCS introduced the LACE model of person-centred care that was piloted with the Heart Failure population. LACE utilises goal-centric conversations to empower and activate individuals to achieve their vision of a ‘Good Life’ beyond healthcare. Additionally, LACE promotes building relational social capital and community capability by empowering and activating individuals and communities as partners and contributors of health and social care.

LACE Success Stories: Every knot in life unravels gifts, talents and opportunities

Mr Chan's Transformation


(L-R) Mr Chan (middle in blue t-shirt) volunteers his time with meals delivery and accompanying patients for appointments at NHCS.

When 61-year-old Mr Chan was first introduced to NHCS Medical Social Services (MSS), he was experiencing a severe health crisis and relying on a life support machine. He was also grappling with emotional distress over the deaths of his family members and had poor social support. 

Through the 'Good Life' conversations and his journey, Mr Chan discovered his personal strengths and a renewed sense of purpose in life. Today, driven by a strong desire and aspiration to contribute to his community, he voluntarily accompanies NHCS patients for their appointments, shares his life experiences with fellow patients, cooks for the elderly in his community, and even formed a walking exercise interest group in Sengkang!

Ms Nur Azri's Empowerment


Azri shares her experience at NHCS' Pulmonary Arterial Hypertneson support group.

Faced with the onset of a chronic life-limiting disease, Pulmonary Arterial Hypertension, Azri was lost and helpless as she grappled with the notion that her future might not unfold as she envisioned – living a fulfilling life till old age, just like her peers. As Azri started on her journey of working towards her vision of a 'Good Life', she realised that self-acceptance and self-love were essential. Through this journey, she not only cultivated a deeper appreciation and love for herself but also expanded her capacity to extend love to others. An active advocator for PAH, Azri is also a member of NHCS' PAH patient support group as she hopes to bring awareness on her healthcare experiences to the community. 


Late Mdm Juliet's Legacy


Mdm Juliet has lived a life prioritising meaningful connections with loved ones.

Mdm Juliet's journey is a story of resilience and self-discovery where her definition of a 'Good Life' evolved through various chapters of her life. Initially burdened by health challenges, she had a transformative shift in her mindset, aspiring for independence and the freedom to enjoy daily activities. As new challenges emerged, she immersed herself in a spiritual quest to find peace and a deeper connection with God through active participation in church and Bible study. Despite facing the deterioration of her health, Mdm Juliet embraced vulnerability, prioritising meaningful connections with loved ones and a vision of eternal peace in heaven. Though she has passed on, she left a legacy to her loved ones and healthcare team by exemplifying courage, empowerment, and the conscious choice to live well through her life story.

LACE Achievements



SingHealth Allied Health Innovative Practice (AHIP) Awards 2022 - Attained the Ground Up and Emerging (GEM) award in recognition of ongoing innovative projects with the potential to achieve significant impact and outcomes.


Singapore Healthcare Management Congress 2022 -1st Prize for Poster Award (Patient Experience Category). Click here to view project poster.


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