Inclusion Criteria:  Inclusion criteria for patients:  21 years or older. Able to communicate in English or Chinese. Have a diagnosis of HF (stage C or D) by the American College of Cardiology guidelines and be of New York Heart Association (NYHA) stage 2, 3 or 4 functional statuses. Have an expected prognosis of at least 6 months. Be on disease directed HF management. Have had a hospitalization event within 6 months prior to recruitment.  Inclusion criteria for caregivers:  21 years or older. Able to communicate in English or Chinese. Is a direct family caregiver of the patient.  Exclusion Criteria:  Exclusion criteria for patients:  Patients who are unable to give informed consent Patients who are already known to a palliative care service.  Exclusion criteria for caregivers:  Caregivers who are unable to give informed consent. Caregivers who are domestic helpers.