Rehabilitation medicine curriculum standards (adult)
Entrustable Professional Activities
EPA 6: Longitudinal care (including end of life care)
EPA 6
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 individualised goals and management plans in consultation with patients their families and/or carers
- manage chronic conditions, complications, disabilities, and comorbidities
- collaborate with other health care providers
- ensure continuity of care
- facilitate patients’, families’ or carers’ self-management and self-monitoring
- engage with the broader health policy context
- support patients to plan for their advance care and document their own wishes.
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:
- evaluate medical, social, emotional, work, and recreational aspects of function
- use the International Classification of Functioning (ICF) to develop a functioning profile beyond the diagnosis of patients’ health conditions
- recognise patients’ specific needs based on their personal circumstances and level of participation
- regularly assess and review care goals and plans for patients with chronic conditions and disabilities based on short- and long-term clinical and quality-of-life goals
- assist patients to maximise functional independence
- adapt care as the complexity, uncertainty, and ambiguity of patients’ clinical situations evolve
- provide documentation on patients’ presentations, management, and progress, including key points of diagnosis and decision making to inform coordination of care
- ensure patients contribute to their needs assessment and care planning
- monitor treatment outcomes, effectiveness, and adverse events
- identify the needs of patients who require modified independence (home modification or equipment) in collaboration with medical teams/health providers
- explain the longer-term impacts of disability to patients, including the economic, environmental, and cultural barriers likely to be encountered
- outline strategies to support patients and their families or carers through different life stages and locations, including uncertainty of prognosis, alternatives, or complications in the timeline
- monitor the impact of interventions on functioning using the ICF framework
- recognise transition points, from restorative to compensatory and palliative management
- provide safe, effective, and goal-directed access to exercise, equipment, and therapy to optimise end-of-life 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 or disability and its management
- contribute to medical record entries on the history, examination, and management plan in a way that is accurate and sufficient as a member of multidisciplinary teams
- not be able to use assessment scales to quantify domains of impairment and disability (in order to establish quantifiable improvements following interventions)
Communication
Ready to perform without supervision
Expected behaviours of a trainee who can routinely perform this activity without needing supervision
The trainee will:
- encourage health promotion by providing healthy lifestyle advice and information to patients on the importance of self-management
- encourage patients’ access to self-monitoring devices and assistive technologies
- communicate with multidisciplinary team members, and involve patients in that dialogue
- discuss patients’ progress towards shared goals
- manage expectations of patients and their families or carers as patients’ conditions change
- thoughtfully explore patients’ concerns across physical, psychological, and cultural domains
- identify opportunities to discuss end-of-life care, aligning it with patients’ values and preferences
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
- ensure consistent messages are given to patients, families or carers about treatment options, the likelihood of success, risks, and prognosis
- discuss with family or carers appropriate support and bereavement 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:
- maintain up-to-date certification
- use innovative models of chronic disease care, including 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 patients to become more independent
- participate in quality improvement processes impacting on patients’ abilities to undertake normal activities of daily living
- review all deaths to determine the safety and quality of patients’ end-of-life care and how it could be improved
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
- communicate the content of discussions about advance care planning to multidisciplinary teams
- ensure that actual care is aligned with documented patient wishes
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
- provide supervision, support, and teaching to develop the skills of junior colleagues on end-of-life care
- recognise feelings of moral distress and burnout in themselves and colleagues
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
- participate in upskilling in best practice of end-of-life care management
- encourage junior colleagues to participate in multidisciplinary case reviews, mortality and morbidity meetings, and adverse event reviews
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
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 law and professional confidentiality guidelines
- use consent processes for the release and exchange of health information
- assess patients’ decision-making capabilities, and appropriately identify and use alternative decision makers when needed
- enhance the quality of life for patients before death to minimise pain and suffering caused by ineffective treatments
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
- ensure that information on advance care plans, treatment plans, goals of care, and patients’ treatment preferences is available to all involved in patients’ care
- ensure patients’ dignity is preserved
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 a long-term health care journey
- maximise patients’ autonomy and their best interests when making treatment 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:
- use a multidisciplinary approach across services to manage patients with chronic diseases and disabilities
- develop collaborative relationships with patients, families or carers and a range of health professionals
- coordinate whole-person care through involvement in all stages of patients’ care journeys
- define the roles and responsibilities of team members involved in patients’ care
- achieve agreement between multidisciplinary teams about patients’ treatment options
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 patient context
- document multidisciplinary care plans, including the terminal phase
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 to 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
- use available resources within the setting to manage the needs of patients and their families or carers
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
- support community-based service providers to build capacity for people to be cared for in their preferred place of death