Timely Interventions to Enable and Reach Patients With Heart Failure, and Their Caregivers With Palliative Care

Inclusion Criteria: * Patients: 1. 21 years or older and 2. able to communicate in English/Chinese/Malay and 3. be of stage C or D heart failure, as defined by American College of Cardiology/American Heart Association (ACC/AHA) classification system and 4. have functional limitation of New York Heart Association (NYHA) functional status of at least 2 or more and 5. be deemed by their cardiologist's clinical judgement to have an expected prognosis of at least 6 months survival, and 6. have had a heart failure related hospitalization event (e.g. symptomatic decompensated heart failure) within 6 months prior to recruitment and 7. have a phone that allows telecommunication. * Caregivers must meet all the following inclusion criteria to be eligible for the study : * direct, unpaid, family caregiver of the patient; * self-reported by the patient to be the main person to be either: * responsible for up to 4 hours a day of caregiving tasks * and/or decision maker/spokesperson with the medical team * Caregiver may or may not live in the same residence as the patient. * Caregivers must be 21 years and above. * Able to communicate in English/Chinese/Malay. Exclusion Criteria: * Patients: 1. have cognitive impairment (e.g., dementia) 2. have severe, untreated, active mental illness (e.g., major depressive disorder) 3. have ventricular assist device implant. 4. have non-reversible hearing or visual loss or 5. are active drug abuser or 6. already known to a palliative care service. * Caregivers who meet any of the exclusion criteria at baseline will be ineligible for the study: * have cognitive impairment (e.g., dementia) or * have severe, untreated, active mental illness (e.g., major depressive disorder) * have non-reversible hearing or visual loss. * are active drug abuser or * are a domestic helper for the patient