Heartlanders

During hospitalisation, all heart failure 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. This reflects an organisation-wide mindset shift at NHCS, where cardiologists, nurses and all other healthcare professionals provide palliative care to care for patients more holistically.

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 is collaborating with primary care and community partners including SingHealth Office of Regional Health community nurses and the DOT GP Primary Care Network, to build an ecosystem that supports heart failure patients in the community.

Over the next five years, more than 9,000 patients across all stages of heart failure are expected to benefit from the programme.