By Belinda Lim

“I like magic.” 

Mr Lim’s voice was earnest, his expression a little bashful, much like a child’s. He sat on the sofa, bright eyed and eager, his posture betraying his excitement to anyone who knew what to look for. “What would you like me to perform?” he asked enthusiastically. His suitcase full of tricks was ready. 

Empowering life goals and aspirations

A year ago, Mr Lim was diagnosed with heart failure. He became withdrawn and rarely smiled. His care team discovered that Mr Lim was struggling to come to terms with the loss of his health and along with it, his freedom to pursue what he loved, and the identity he once held dearly. Mr Lim’s years of collecting items, including appliances, toys and recyclable items had accumulated, creating tension within the family. 

His life could have continued on the same trajectory under a traditional care model. However, his care team adopted a vastly different approach, and one question sparked a transformation.  “We asked him what he enjoys doing,” said Sim Yu Xuan, Medical Social Worker at the National Heart Centre Singapore (NHCS). “Through simple yet thought-provoking questions, we use goal-centred conversations to empower and activate patients to achieve their vision of a ‘Good Life’ beyond healthcare. In Mr Lim’s case, learning and performing magic was the key to his good life.”

Mr Lim (left) performing a magic trick for his care team, including Sim Yu Xuan, Medical Social Worker, Medical Social Services, NHCS (centre), and Assistant Professor Shirlyn Neo, Deputy Head and Senior Consultant, Division of Supportive and Palliative Care, NCCS (right).

From the very first time Mr Lim performed his magic tricks during a clinic consultation, everything started to change. The looks of joy, admiration and appreciation from his care team lifted Mr Lim’s spirits and, more importantly, revealed the vibrant person he had always been beneath his illness. Soon, his family began seeing him in a different light, recognising how his passion could bring such profound joy to others. For his 90th birthday celebration with extended family members, they planned a wonderful surprise and invited him to perform magic tricks. The response was tremendous, with friends and family cheering him on, creating waves of positivity that flowed into his family relationships and transformed his entire health journey.

A Patient-Centred Approach to Transform Heart Failure Care

At the heart of the Heartlanders Programme lies a fundamental shift in how we care for cardiac patients. Rather than waiting until the final stages of illness, palliative care is woven into a patient’s journey from the very beginning – a compassionate approach that recognises suffering shouldn’t wait for treatment. NHCS has created a care model where cardiologists, palliative care specialists, cardiac nurses, and allied healthcare professionals including physiotherapists, medical social workers and pharmacists, work together to provide integrated cardio-palliative care that addresses not just the medical needs, but the whole person – their fears, hopes and what truly matters to them in their daily lives.  

“We screen heart failure patients as soon as they are admitted to identify their clinical and psychosocial needs, then begin conversations about what truly matters to them. We also help them better understand their condition so they feel confident managing their health when they return home,” shared Assistant Professor Shirlyn Neo, Deputy Head and Senior Consultant, Division of Supportive and Palliative Care, National Cancer Centre Singapore (NCCS), and co-lead of the Heartlanders Programme. 

At each consultation, Mr Lim (second from right) is seen by a multidisciplinary care team in a duo-room setting. Pictured above in one of the consult rooms is (left to right) Shera Wong, Principal Pharmacist, Advanced Practice Nurse Elaine Ng, Nursing Specialty Care Unit, and Dr Jeremy Chai, Associate Consultant, Department of Cardiology, NHCS.

What makes this approach speak is the thoughtfully designed consultation environment. During each visit, patients first meet with their heart failure doctor, nurse and pharmacist, then move to second session with a palliative care specialist, physiotherapist and medical social worker. This coordinated approach ensures patients receive the support they need early in their journey, well before their condition becomes more challenging to manage.

Community collaboration and strategic partnerships

The programme’s strength lies in building meaningful partnerships with community healthcare providers, creating a supportive and holistic network that surrounds patients with care wherever they are. These collaborations ensure patients receive timely access to quality, compassionate palliative care services close to their home, making their healthcare journey less daunting. For instance, General Practitioners (GPs) play a vital role in this network, providing essential support to help patients manage their medications safely after leaving hospital. Through ongoing training, established care protocols, and direct access to NHCS outpatient or virtual consultations, GPs can address concerns quickly and prevent medical emergencies.

Community nurses play an equally important role, ensuring patients receive personalised care by monitoring treatment adherence, providing health guidance and having meaningful conversations about their ongoing care – whether at home or in the community. These services are enhanced through Community Health Posts strategically located in residential areas at Active Ageing Centres and Community Centres. This creates a caring network that reaches into neighbourhoods, empowering individuals and their communities to support each other’s well-being. As part of keeping Mr Lim socially engaged and connected, he now attends a day hospice once or twice weekly where he spends quality time with fellow patients and brings smiles to their faces with his delightful magic performances.

“The Heartlanders Programme represents a fundamental shift in how we think about healthcare. By integrating hospital expertise with community resources, we are reshaping how heart failure patients are cared for. We are creating a healthcare system that truly responds to what patients need and wraps them in compassion at every step of their journey,” said Prof Yeo Khung Keong, Chief Executive Officer, NHCS.

Education, Training and Research Framework

The programme's sustainability is built upon the foundation of comprehensive education and careful evaluation of how well it is working for patients. The Lien Centre for Palliative Care (LCPC) has developed a specialised cardio-palliative care course in partnership with NHCS, with palliative care training now structured into all cardiology residency programmes during heart failure postings, ensuring that future heart doctors understand not just the medical aspects of care, but how to support patients emotionally and help them live well with their condition.

The support network extends well beyond the hospital walls through partnerships with community organisations such as the Singapore Heart Foundation. These collaborations help patients remain socially engaged and motivated to maintain healthy lifestyles. From a research perspective, LCPC evaluates the implementation outcomes through a value-driven approach - whether patients are experiencing better quality of life, spending less time in acute hospital situations, feeling more satisfied with their care.  This thoughtful evaluation ensures the programme continues to evolve and improve, always keeping patients' wellbeing at its heart.

Watch the Heartlanders Programme short film to discover Mr Lim’s heartwarming story. This film is part of the global cardiovascular disease campaign 'Beats of Change', a new series presented by World Heart Federation (WHF) and produced by BBC StoryWorks Commercial Productions!

Mr Lim with Mdm Teh, his wife and caregiver.

The Heartlanders Programme is supported by a $6.5 million funding from Lien Foundation to integrate and deliver generalist palliative care upstream by cardiologists and other healthcare professionals to patients with needs. Over the next five years, more than 9,000 heart failure patients are expected to benefit from the programme. 

The team members include: