Curriculum standards
Entrustable Professional Activities
LG6: Management of transitions in care
Management of transitions in care
Manage the transition of patient care between health professionals, providers, and contexts
This activity requires the ability to:
- transfer care at any transition point, including:
- acute to sub-acute care
- inpatient / outpatient rehabilitation care to community care
- paediatric to adult care
- sub-acute to acute care
- manage the transition of patients’ care to ensure the optimal continuation of care between providers
- identify the appropriate health care providers and other stakeholders with whom to share patients’ information
- exchange pertinent, contextually appropriate, and relevant patient information
- perform this activity in multiple settings (appropriate to the speciality), including ambulatory, critical care, and inpatient settings, and in the community
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:
- identify and manage key risks for patients during transition
- anticipate possible changes in patients’ conditions, and provide recommendations on how to manage them
- manage adolescent patients, including transition to adult services
Requires some supervision
Possible behaviours of a trainee who needs some supervision to perform this activity
The trainee may:
- recognise the details of patients’ conditions, illness severity, and potential emerging issues, with appropriate actions
- provide accurate summaries of patients’ information with accurate identification of problems or issues
Communication
Ready to perform without supervision
Expected behaviours of a trainee who can routinely perform this activity without needing supervision
The trainee will:
- write relevant and detailed medical record entries, including clinical assessments and management plans
- write comprehensive and accurate summaries of care, including discharge summaries, clinic letters, and transfer documentation
- communicate with patients, families, whānau and/or carers about transitions of care, and engage and support these parties in decision making
- initiate and maintain verbal communication with other health professionals, when required
Requires some supervision
Possible behaviours of a trainee who needs some supervision to perform this activity
The trainee may:
- communicate clearly with clinicians and other caregivers
- use standardised verbal and written templates to improve the reliability of information transfer and prevent errors and omissions
- communicate accurately and in a timely manner to ensure an effective transition between settings, and continuity and quality of care
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:
- identify patients at risk of poor transitions of care, and mitigate this risk
- use electronic tools (where available) to securely store and transfer patients’ information
- use consent processes, including written consent, if required, for the release and exchange of information
- demonstrate understanding the medicolegal context of written communications
Requires some supervision
Possible behaviours of a trainee who needs some supervision to perform this activity
The trainee may:
- check that handover is complete, or work to mitigate risks if incomplete
- request follow-up of outstanding results or procedures by receiving units and clinicians
- keep patients’ information secure, adhering to relevant legislation regarding personal information and privacy
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:
- integrate clinical education in handover sessions and other transition of care meetings
- tailor clinical education to the level of the professional parties involved
Cultural safety
Ready to perform without supervision
Expected behaviours of a trainee who can routinely perform this activity without needing supervision
The trainee will:
- communicate respectfully with patients about their choices and preferences, discussing whether they are realistic and achievable, with careful consideration of health literacy, language barriers, and culture
- recognise the timing, location, privacy, and appropriateness of sharing information with patients, families, whānau, and/or carers
Requires some supervision
Possible behaviours of a trainee who needs some supervision to perform this activity
The trainee may:
- include relevant information regarding patients’ cultural or ethnic background in handovers, and whether an interpreter is required
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:
- disclose and share only contextually appropriate medical and personal information
- recognise the clinical, ethical, and legal rationale for information disclosure
- share information about patients’ care in a manner consistent with privacy law and professional guidelines on confidentiality
- recognise the additional complexity related to some types of information, such as genetic information and blood-borne virus status, and seek appropriate advice about disclosure of such information
Requires some supervision
Possible behaviours of a trainee who needs some supervision to perform this activity
The trainee may:
- maintain respect for patients, families, carers, and other health professionals, including respecting privacy and confidentiality
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:
- organise patients’ care delivery in the most appropriate setting, with the most appropriate provider
Requires some supervision
Possible behaviours of a trainee who needs some supervision to perform this activity
The trainee may:
- use a structured approach to consider and prioritise patients’ issues
- 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:
- share the workload of transitions of care appropriately, including delegation
- demonstrate understanding of the medical governance of patients’ care, and the differing roles of team members
- show respect for the roles and expertise of other health professionals, and work effectively as a member of professional teams
- provide the opportunity for patients’ engagement and participation across multidisciplinary teams
Requires some supervision
Possible behaviours of a trainee who needs some supervision to perform this activity
The trainee may:
- work to overcome the potential barriers to continuity of care, appreciating the role of handover in overcoming these barriers
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:
- contribute to processes for managing risks, and identify strategies for improvement in transitions of care
- engage in organisational processes to improve transitions of care
- support processes for adolescents transitioning to adult health services
Requires some supervision
Possible behaviours of a trainee who needs some supervision to perform this activity
The trainee may:
- factor transport issues and costs to patients into arrangements for transferring patients to other settings