Entrustable Professional Activities

LG6: Management of transitions from paediatric to adult 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 patient, family, and/or carer readiness for transfer 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 respiratory physician

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:

  • assist patients from early adolescence to prepare for transfer to adult care at an appropriate age
  • 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 transitional care program and the differences between the cultures of paediatric and adult care services, including the role of the adult physician / GP
  • evaluate environmental and lifestyle health risks, and advocate for healthy lifestyle choices
  • anticipate, prevent, and manage changes in health status at the time of transfer
  • adapt transition to meet individual patients’ needs (e.g., if a patient has an intellectual disability)

direction
Requires some supervision

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

The trainee may:

  • assess psychosocial issues that may affect health and/or access to adult health services
  • identify the ways in which chronic respiratory conditions may impact on patients’ lifestyles, such as contraception, pregnancy, employment, sport / leisure activities, and smoking / vaping / risk taking activities
  • 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 chronic respiratory disease on adolescents’ and young adults’ leisure, educational, and work activities

direction
Requires some supervision

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

The trainee may:

  • assess patients’ understanding of their illness and health care needs, and work with them to increase their understanding
  • use communication skills and strategies to help patients make informed decisions
  • recognise and explore the worries and concerns of adolescent and adult patients with chronic respiratory disease
  • identify the need to shift responsibility for decision making from parents to patients, and work with patients and their carer on planning this
  • 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 consent processes, including written consent if required, for the release and exchange of information

direction
Requires some supervision

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

The trainee may:

  • document and provide handover of patient history 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

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:

  • use culturally safe health information resources to assist with the provision of health information to Aboriginal and Torres Strait Islander and Māori peoples
  • discuss topics including sexuality and contraception sensitively and in line with the cultural and religious beliefs of patients

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

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 their family members or carers
  • select the appropriate specialist to transition the patient to (e.g., GP, respiratory physician, metro versus outreach / regional)

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 in young people

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:

  • recognise and work collaboratively with other health care providers, including allied health workers and psychologists
  • ensure sufficient handover to all care providers (including primary care and community care providers), including robust notes to convey complex history and/or rationale for past decisions

direction
Requires some supervision

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

The trainee may:

  • recognise the importance of the multidisciplinary team in the management of young people
  • consider how to transition other specialties in which the patient is receiving care into adult care

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 in chronic respiratory disease