Curriculum standards
Entrustable Professional Activities
LG7: Longitudinal care
Longitudinal care
Manage and coordinate the longitudinal care of patients with chronic conditions, disability, and/or long-term health issues, including coordinating and delivering a successful transition from paediatric to adult care
This activity requires the ability to:
- assess family dynamics and involvement of the family in the care of adolescents and young adults
- develop management plans and goals in consultation with patients9
- manage chronic and advanced conditions, complications, disabilities, and comorbidities
- collaborate with other care providers
- ensure continuity of care
- facilitate transitions from parent-led care to self-management, according to developing capabilities
- facilitate patients’ self-management and self-monitoring
- coordinate and deliver successful transitions from paediatric to adult care
- engage with the broader health policy context
Professional practice framework domain
Medical expertise
Ready to perform without supervision
Expected behaviours of a trainee who can routinely perform this activity without needing supervision
The trainee will:
- investigate and manage unexplained chronic physical symptoms
- regularly assess and review care plans for patients with chronic conditions and disabilities based on short- and long-term clinical and quality-of-life goals
- manage patients with complex and chronic conditions and disabilities within a multidisciplinary team
- manage patients on a long-term basis, including patients with common mental disorders, substance use problems, eating disorders, and overweight / obese adolescents
- provide documentation on patients’ presentation, management, and progress, including key points of diagnosis and decision making, to inform coordination of care
- ensure patients contribute to their needs assessments and care planning
- differentiate and appreciate the value of adolescents’ perspectives, as well as those of their parents / carers
- monitor treatment outcomes, effectiveness, and adverse events, and adjust care plans accordingly
- assess and support readiness for transfer to adult services
Requires some supervision
Possible behaviours of a trainee who needs some supervision to perform this activity
The trainee may:
- assess patients’ knowledge, beliefs, concerns, and daily behaviours related to their chronic condition and/or disability and its management
- contribute to medical record entries on histories, examinations, and management plans in a way that is accurate and sufficient as a member of multidisciplinary teams
Communication
Ready to perform without supervision
Expected behaviours of a trainee who can routinely perform this activity without needing supervision
The trainee will:
- provide developmentally appropriate anticipatory guidance to parents / carers to support adolescent patients to develop their capacity for self-care in due course
- encourage patients’ self-management through education to take greater responsibility for their care, and support problem solving
- discuss, motivate, and support adherence to treatment plans
- apply the principles of motivational interviewing
- encourage patients’ access to self-monitoring devices and assistive technologies
- communicate with multidisciplinary team members, and involve patients in that dialogue
- promote engagement in follow-up
- liaise across paediatric and adult services, including primary care
- liaise with school and community-based professionals
- write comprehensive and accurate summaries of care, including discharge summaries, clinic letters, and transfer documentation
Requires some supervision
Possible behaviours of a trainee who needs some supervision to perform this activity
The trainee may:
- compile and summarise patient records in preparation for transition of care from paediatric to adult services
- provide healthy lifestyle advice and information to patients on the importance of self-management
- work in partnership with patients and parents / carers, and motivate them to comply with agreed care plans
- appreciate the importance of communicating with schools and community-based professionals
Quality and safety
Ready to perform without supervision
Expected behaviours of a trainee who can routinely perform this activity without needing supervision
The trainee will:
- apply innovative models of chronic disease care, using telehealth and digitally integrated support services
- review medicine use and ensure patients understand safe medication administration to prevent errors
- regularly review the latest evidence and clinical guidelines
- support patients’ self-management by balancing the need to minimise risk while helping patients to become more independent
- participate in quality improvement processes, such as those to improve patients’ and parents’ / carers’ quality of life
Requires some supervision
Possible behaviours of a trainee who needs some supervision to perform this activity
The trainee may:
- know how to review the latest evidence and clinical guidelines
- participate in continuous quality improvement processes and clinical audits on chronic disease management
- identify activities that may improve patients’ quality of life
- use clinical practice guidelines for chronic diseases management
Teaching and learning
Ready to perform without supervision
Expected behaviours of a trainee who can routinely perform this activity without needing supervision
The trainee will:
- contribute to the development of clinical pathways for chronic diseases management based on current clinical guidelines
- educate patients to recognise and monitor their symptoms, and undertake strategies to assist their recovery
- participate in teaching and training of junior staff
- integrate clinical education in handover sessions and other relevant meetings
Requires some supervision
Possible behaviours of a trainee who needs some supervision to perform this activity
The trainee may:
- participate in training more junior staff
Research
Ready to perform without supervision
Expected behaviours of a trainee who can routinely perform this activity without needing supervision
The trainee will:
- prepare reviews of literature on patients’ encounters to present at journal club meetings
- search for and critically appraise evidence to resolve clinical areas of uncertainty
- contribute to wider research efforts as appropriate
Requires some supervision
Possible behaviours of a trainee who needs some supervision to perform this activity
The trainee may:
- search literature using problem / intervention / comparison / outcome (PICO) format
- understand the appropriate use and differences between review articles, systematic reviews, and meta-analyses
Cultural safety
Ready to perform without supervision
Expected behaviours of a trainee who can routinely perform this activity without needing supervision
The trainee will:
- provide culturally safe chronic disease management that improves health and wellbeing outcomes
- encourage patients from culturally and linguistically diverse backgrounds to join local networks to receive the support needed for long-term self-management
- incorporate appropriate LGBTQIA+ safe language
Requires some supervision
Possible behaviours of a trainee who needs some supervision to perform this activity
The trainee may:
- seek out opportunities to improve cultural awareness and cultural safety
Ethics and professional behaviour
Ready to perform without supervision
Expected behaviours of a trainee who can routinely perform this activity without needing supervision
The trainee will:
- share information about patients’ health care, consistent with privacy laws and confidentiality and professional guidelines
- use consent processes for the release and exchange of health information
- assess patients’ decision-making capacity, and appropriately identify and use alternative decision makers
Requires some supervision
Possible behaviours of a trainee who needs some supervision to perform this activity
The trainee may:
- share information between relevant service providers
- acknowledge and respect the contribution of health professionals involved in patients’ care
- comply with workplace guidelines around social media use with patients and families
Judgement and decision making
Ready to perform without supervision
Expected behaviours of a trainee who can routinely perform this activity without needing supervision
The trainee will:
- implement stepped care pathways in the management of chronic diseases and disabilities
- recognise patients’ needs in terms of both internal resources and external support on long-term health care journeys
Requires some supervision
Possible behaviours of a trainee who needs some supervision to perform this activity
The trainee may:
- recognise personal limitations and seek help in an appropriate way when required
Leadership, management, and teamwork
Ready to perform without supervision
Expected behaviours of a trainee who can routinely perform this activity without needing supervision
The trainee will:
- coordinate whole-person care through involvement in all stages of patients’ care journeys
- use a multidisciplinary approach across services and settings, such as health, education, welfare, and justice, to manage patients with chronic diseases and disabilities
- develop collaborative relationships with patients and a range of health professionals
- work collaboratively with medical colleagues and allied health staff
- support colleagues in other disciplines
- participate with colleagues in the provision of palliative care
- support colleagues in paediatric and adult settings to develop transition programs in their specialties
Requires some supervision
Possible behaviours of a trainee who needs some supervision to perform this activity
The trainee may:
- participate in multidisciplinary care for patients with chronic diseases and disabilities, including organisational and community care, on a continuing basis, appropriate to patients’ context
Health policy, systems, and advocacy
Ready to perform without supervision
Expected behaviours of a trainee who can routinely perform this activity without needing supervision
The trainee will:
- use health screening for early intervention and chronic diseases management
- assess alternative models of care delivery to patients with chronic conditions and disabilities
- participate in government initiatives for chronic diseases management to reduce hospital admissions and improve patients’ quality of life
- help patients access initiatives and services for patients with chronic conditions and disabilities, including mental health
- advocate for the provision of skills and services within paediatric and adult sectors to facilitate the development of transition services
Requires some supervision
Possible behaviours of a trainee who needs some supervision to perform this activity
The trainee may:
- demonstrate awareness of government initiatives and services available for patients with chronic diseases and disabilities, including primary care, and display knowledge of how to access them