Entrustable Professional Activities

LG6: Management of transitions in care settings

Learning Goal 6

Management of transitions in care settings

Manage transition of patient care between care settings and contexts, including hospital, home, residential aged care setting, and palliative care units

This activity requires the ability to:

  • organise the transition of patient care to ensure the optimal continuation of care between providers
  • identify the appropriate health care providers and other stakeholders with whom to share patient information
  • communicate pertinent, contextually appropriate, and relevant patient information
  • prepare patients to manage well in new settings / contexts
  • facilitate decision making with patients and stakeholders to inform best care settings
  • organise care to or from rural and remote locations

Professional practice framework domain

Medical expertise

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • facilitate optimal and timely transitions of care for patients
  • identify and manage key risks for patients during transition, including risk of death during transfer, or risk of not being medically stable enough to return to a preferred location of care
  • identify and handover other key risks to patient safety that will continue across transitions, such as:
    • falls
    • polypharmacy
    • pressure areas
    • risks of delirium
  • anticipate and develop management plans for possible changes in patients’ conditions
  • assess patients’ stability, illness trajectory, and prognosis to determine if other supportive services are required
  • develop management plans appropriate for the strengths and limitations of different care settings

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • understand the details of patients’ conditions, illness severity, and potential emerging issues with appropriate actions
  • provide accurate summaries of patients’ information, including accurate identification of problems or issues

Communication

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • explore preferred location for care and preferred location for death
  • actively involve patients in their own care, meet their information needs, and make shared decisions about care settings
  • communicate with patients about options and plans for transitions in care settings, including the reasons and/or risks associated with such transitions
  • communicate and consult with other health professionals and members of the multidisciplinary team regarding transitions of care
  • write relevant and detailed medical record entries, including clinical assessments and management plans
  • provide handovers to receiving health professionals
  • accept handovers from other health professionals
  • write comprehensive and accurate summaries of care and transfer documentation
  • effectively use telehealth to support care

direction
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 health professionals
  • 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 effective transitions between settings, and continuity and quality of care

Quality and safety

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • use triage tools to prioritise order of transfers in or out of care settings
  • identify patients at risk of adverse outcomes, including symptom crisis or death during transition of care, and mitigate this risk
  • use consent processes, including written consent if required, for the release and exchange of information
  • analyse adverse incidents and sentinel events during transitions of care to identify system failures and contributing factors

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • ensure that handovers are complete, or work to mitigate risks if incomplete
  • ensure all outstanding results or procedures are followed up by receiving units and clinicians
  • keep patients' information secure, adhering to relevant legislation regarding personal information and privacy

Teaching and learning

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • supervise junior colleagues in managing transitions of care Teaching and learning
  • use teaching and learning opportunities arising from transitions of care, including teaching patients and during handover sessions

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • take opportunities to teach junior colleagues during handovers, as necessary

Cultural safety

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • communicate in a culturally appropriate way by considering health literacy, language barriers, culture, religion, and belief systems when discussing transition of care with patients
  • use culturally appropriate services to support patients in care transitions

direction
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

confident
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 during transitions of care in line with clinical, ethical, and legal requirements
  • work effectively with primary / community-based care

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • maintain respect for patients and other health professionals, including respecting privacy and confidentiality

Judgement and decision making

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • ensure patients’ care is aligned with their own goals and is occurring in the most appropriate facility, setting, or provider

direction
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

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • delegate appropriately during transitions of care
  • work effectively with the multidisciplinary team and other clinicians to ensure smooth transitions of care
  • demonstrate knowledge of the medical governance of patient care, and the differing roles of team members

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • recognise factors that impact on the transfer of care, and help subsequent health professionals to understand the issues to continue care
  • work to overcome the potential barriers to continuity of care, appreciating the role of handover in overcoming these barriers

Health policy, systems, and advocacy

confident
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 transition of care
  • engage in organisational processes to improve transitions of care, such as formal surveys or follow-up phone calls after hospital discharge

direction
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