Entrustable Professional Activities

LG6: Management of transitions in care

Learning Goal 6

Management of transitions from paediatric to adult care

Manage transitions of patient care from paediatric to adult medicine

This activity requires the ability to:

  • assess the timing and risks in transition from paediatric to adult care
  • assess patients’, families’, and/or carers’ readiness for transition to adult care
  • create goals of transition in care specific to patients and their care needs
  • develop a transition plan in collaboration with patients, family, and/or carers, and the medical team
  • summarise and document the clinical case for handover to the adult endocrinologist

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:

  • assess patients’ health literacy and developmental readiness for the demands of the adult care setting
  • assess adherence to treatment and monitoring plans
  • outline the key components of a transition program and the differences between the cultures of paediatric and adult care services, including the role of the adult physician
  • evaluate environmental and lifestyle health risks, and advocate for healthy lifestyle choices
  • anticipate, prevent, and manage changes in health status at the time of transition
  • adapt transition to meet individual patients’ needs
  • identify youth-focused adult services and local transition coordinators / facilitators

direction
Requires some supervision

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

The trainee may:

  • recognise the importance of maintaining continuity of care and prevention of loss to follow up at the time of transition
  • assess psychosocial issues that may affect health and/or access to services
  • identify the ways in which disease may impact on patients’ lifestyles, such as contraception, pregnancies, employment, sport / leisure activities, and smoking
  • establish plans for ongoing care that include monitoring health status and managing adherence

Communication

confident
Ready to perform without supervision

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

The trainee will:

  • explain the impact of an endocrine disorder on adolescents’ and young adults’ leisure and work activities
  • explain confidentiality to the young person
  • adopt a developmentally appropriate approach to transition, and assess patients’ understanding of their illness and health care needs, and work with them to increase their understanding
  • identify the need to shift responsibility for decision making from parents or carers to patients, and work with parents or carers and patients on planning this
  • ensure all members of the multidisciplinary team contribute to transition plans
  • ensure communication regarding transition includes the general practitioner and all current care providers

direction
Requires some supervision

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

The trainee may:

  • perform appropriate psychosocial and mental health assessments using recognised tools
  • use communication skills and strategies that help patients make informed decisions
  • recognise and explore the worries and concerns of adolescent patients and their family and/or carers
  • communicate sensitively with adolescents and young adults
  • recognise when it is appropriate to communicate with patients individually versus when it is appropriate to communicate with patients and their family members and/or carers
  • discuss with patients the differences between paediatric and adult care, such as the involvement of the parent or carer in decisions for adult patients versus paediatric patients

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:

  • ensure patients are informed of risks associated with any part of proposed management plans
  • use of “Transition readiness checklist” to assess preparedness of young person for transition

direction
Requires some supervision

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

The trainee may:

  • document patients’ histories with clarity and completeness

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:

  • educate adolescents and young adults about their conditions and their impacts on their lives

direction
Requires some supervision

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

The trainee may:

  • explain how patient education can empower young adults to take responsibility for their health
  • ensure the young person understands and has a sick day management plan, and knows who to contact during the transition process

Cultural safety

direction
Requires some supervision

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

The trainee may:

  • discuss topics including sexuality and contraception sensitively, and consider the cultural and religious beliefs of patients and their families

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:

  • explain the role of GPs in patients’ care, including relevant guidelines and how they apply
  • explain confidentiality and what this means for young people and their family and/or carers
  • recognise legal issues around consent and assessment of capacity and competence

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:

  • identify the right time to start facilitating transition by considering the needs of individual patients, and discuss this with the patient
  • select the appropriate specialist to transition the patient, taking into account the availability of youth-orientated services

direction
Requires some supervision

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

The trainee may:

  • consider whether a paediatric or adult setting may be more appropriate to conduct procedures and/or investigations
  • communicate with the GP regarding transition

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:

  • ensure sufficient handover, including robust notes to convey complex history and/or rationale for past decisions
  • consider the timing of transition in relation to other specialties in which the patient is receiving care

direction
Requires some supervision

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

The trainee may:

  • recognise the importance of, and integrate with, the multidisciplinary team in the management of adolescents and young adults
  • recognise and work collaboratively with other health care providers, including allied health workers and psychologists

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:

  • connect patients with local or online peer support groups
  • contribute to the development of a written transition policy, which is a document that sets out principles, standards, and practices of how transitions are managed at the centre
  • advocate for resources to support efficient and more effective transitions

direction
Requires some supervision

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

The trainee may:

  • apply local and international guidelines around transitions