Inclusion Criteria:  inpatient, age >= 20 years old, male or female patient with heart failure with a reduced ejection fraction and discharged alive from the hospital received heart failure disease management program  Exclusion Criteria:  Estimated survival time < 6 months Long-term bedridden for more than 3 months Cannot tolerance exercise test due to muscular-skeletal disorder Cannot co-operate all functional studies Ventilator dependent Terminal heart status The family reject to participate in this project