Curriculum standards
Entrustable Professional Activities
LG8: Longitudinal care
Longitudinal care
Manage and coordinate the longitudinal care of patients with chronic illness, disability, and/or long-term health issues
This activity requires the ability to:
- develop management plans and goals in consultation with patients
- manage chronic and advanced conditions, comorbidities, complications, and disabilities
- collaborate with other health care providers
- ensure continuity of care
- facilitate patients’ self-management and self-monitoring
- 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:
- assess and review care plans for patients with chronic conditions and disabilities regularly, based on short- and long-term clinical and quality of life goals
- 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
- monitor treatment outcomes, effectiveness, and adverse events, including those from immunosuppression
- advise on appropriate preventative measures, such as cancer and cardiovascular screening and vaccination, tailored to patients’ conditions and treatment histories
- plan and support patients’ transitions of care from paediatric to adult rheumatology services, acknowledging that management plans for childhood and adult rheumatic diseases may differ
- demonstrate a reflective understanding of the differences and similarities between paediatric, adolescent, and adult care, and help empower young people to negotiate their own care
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:
- encourage patients’ self-management through education to take greater responsibility for their care, and support problem solving
- encourage patients’ access to self-monitoring devices and assistive technologies
- communicate with multidisciplinary team members, and involve patients in that dialogue
- exhibit high-level communication skills, including active listening, empathy, clarity, adaptability, and continuous self-improvement, to best manage the consultative environment
Requires some supervision
Possible behaviours of a trainee who needs some supervision to perform this activity
The trainee may:
- provide healthy lifestyle advice and information to patients on the importance of self-management
- work in partnership with patients, and motivate them to comply with agreed care plans
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:
- use innovative models of chronic disease care management, such as telehealth and digitally integrated support services
- review medicine use, and ensure patients understand safe medication administration to prevent errors
- support patients’ self-management by balancing between minimising risk and helping them become more independent
- participate in quality improvement processes impacting on patients’ abilities to undertake normal activities of daily living
- contribute to clinical databases or audits to better understand comorbidities, disease progression, and treatment impact
Requires some supervision
Possible behaviours of a trainee who needs some supervision to perform this activity
The trainee may:
- participate in continuous quality improvement processes and clinical audits on chronic disease management
- identify activities that may improve patients’ quality of life
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, and be aware of the limitations of clinical guidelines
- educate patients to recognise and monitor their symptoms, and undertake strategies to assist their recovery
Requires some supervision
Possible behaviours of a trainee who needs some supervision to perform this activity
The trainee may:
- use clinical practice guidelines for chronic diseases management
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 the body of knowledge regarding the management of chronic disease
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
- recognise appropriate use of review articles
Cultural safety
Ready to perform without supervision
Expected behaviours of a trainee who can routinely perform this activity without needing supervision
The trainee will:
- encourage patients from culturally and linguistically diverse backgrounds to join local networks to receive the support needed for long-term self-management
Requires some supervision
Possible behaviours of a trainee who needs some supervision to perform this activity
The trainee may:
- provide culturally safe chronic disease management
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 professional guidelines on confidentiality
- use consent processes for the release and exchange of health information
- assess patients’ decision-making capacity, and appropriately identify and use proxy 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
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
- reflect dispassionately on own actions, behaviours, and decisions
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 to manage patients with chronic diseases and disabilities
- develop collaborative relationships with patients and a range of health professionals
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 health care delivery for patients with chronic diseases 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 diseases and disabilities
- explain the non-biologic determinants of poor health and care, and advocate for the medically underserved
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, and display knowledge of how to access them