Curriculum standards

Ready to perform without supervision

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

The trainee will:

• encourage patients’ access to self-monitoring devices and assistive technologies
• communicate with multidisciplinary team members, and involve patients in that dialogue
• help patients navigate the healthcare system by collaborating with other services, such as community health centres and consumer organisations, to improve access to care
• link patients to specific community-based health programs and group education programs
• identify opportunities to discuss end-of-life care, aligning it with patients’, families’ and/or carers’ values and preferences
• identify appropriate timing of palliative care involvement

Requires some supervision

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

The trainee may:

• work in partnership with patients, and motivate them to comply with agreed care plans
• wherever practical, meet patients’ specific language and communication needs
• facilitate appropriate use of interpreter services and translated materials
• recognise when it is appropriate to communicate with young people individually versus when it is appropriate to communicate with patients and their family members and/or carers
• discuss appropriate support and bereavement care with family or carers

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 using innovative models of chronic disease care (e.g., telehealth and digitally integrated support services)
• participate in quality improvement processes impacting on patients’ ability to undertake normal activities of daily living
• practice health care that maximises patient safety
• adopt a systematic approach to the review and improvement of professional practice in the outpatient clinic setting
• identify aspects of service provision that may be a risk to patients’ safety
• review all clinical incidents / deaths to determine the safety and quality of patients’ care (including end-of-life care where relevant) and how it could be improved
• participate or support benchmarking through chronic disease registries

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
• address issues if patients’ safety may be compromised
• employ a systematic approach to improving the quality and safety of health care
• participate in organisational quality and safety activities, including clinical incident reviews

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 (national and international)
• educate patients to recognise and monitor their symptoms, and undertake strategies to assist their recovery
• evaluate own professional practice
• role model effective clinical care
• demonstrate learning behaviour and skills in educating junior colleagues
• contribute to the generation of knowledge
• maintain professional continuing education standards relevant to the profession
• recognise and support feelings of moral distress and burnout in self 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
• recognise the limits of personal expertise, and involve other professionals as needed to contribute to patients’ care
• use information technology appropriately as a resource for modern medical practice
• encourage junior colleagues to participate in multidisciplinary case reviews, mortality and morbidity meetings and adverse event reviews

Ready to perform without supervision

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

The trainee will:

• prepare critical analysis of current literature on the management of chronic conditions to present at journal club meetings
• search for and critically appraise the evidence to resolve clinical areas of uncertainty
• obtain informed consent or other valid authority before involving patients in research
• inform patients about their rights, the purpose of the research, the procedures to be undergone, and the potential risks and benefits of participation before obtaining consent

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
• refer to evidence-based clinical guidelines
• consult current research on clinical practice, including investigations and management

Ready to perform without supervision

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

The trainee will:

• apply knowledge of the cultural needs of the community serving and how to shape service to target the needs of the community
• provide culturally sensitive chronic disease management, and practice strengths-based holistic care
• mitigate the influence of own culture and beliefs on interactions with patients and decision making
• adapt practice to improve patient engagement and healthcare outcomes

Requires some supervision

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

The trainee may:

• practice cultural competency
• identify when to use interpreters
• allow enough time for communication across linguistic and cultural barriers
• acknowledge the social, economic, cultural, and behavioural factors influencing health, both at individual and population levels

Ready to perform without supervision

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

The trainee will:

• encourage and support patients and, when relevant, their families or carers, in caring for themselves and managing their health in a respectful professional relationship
• share information about patients’ health care, consistent with privacy laws and professional guidelines about confidentiality
• use consent processes for the release and exchange of health information
• identify and respect the boundaries that define professional and therapeutic relationships
• respect the roles and expertise of other health professionals
• comply with the legal requirements of preparing and managing documentation
• demonstrate awareness of financial and other conflicts of interest
• recognise the complexity of ethical issues related to human life and death, when considering the allocation of scarce resources

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
• understand the responsibility to protect and advance the health and wellbeing of individuals and communities
• behave equitably towards all, irrespective of gender, age, culture, socioeconomic status, sexual preferences, beliefs, contribution to society, illness-related behaviours, or the illness itself
• maintain the confidentiality of documentation, and store clinical notes appropriately
• ensure that the use of social media is consistent with ethical and legal obligations
• respond appropriately to patients’, family members’, carers’ or colleagues’ distress or concerns

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 long-term care journeys
• integrate prevention, early detection, health maintenance, and chronic condition management, where relevant, into clinical practice
• work to achieve optimal and cost-effective patient care that allows maximum benefit from available resources

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
• understand the appropriate use of human resources, diagnostic interventions, therapeutic modalities, and health care facilities

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, and/or carers, and a range of health professionals
• coordinate whole-person care through involvement in all stages of the patients’ care journey
• prepare for and conduct clinical encounters in an organised and efficient manner
• work effectively as a member and/or a leader of multidisciplinary teams or other professional groups
• formulate strategies to respectfully negotiate plans in the best interest of the patient at times when there are differences in opinions between health professionals
• review discharge summaries, notes, and other communications written by junior colleagues
• support colleagues who raise concerns about patient safety
• facilitate an environment where all team members feel they can contribute and their opinion is valued
• support the wellbeing of team members

Requires some supervision

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

The trainee may:

• participate in multidisciplinary team care for patients with chronic diseases and disabilities, including organisational and community care, on a continuing basis appropriate to patient context
• attend relevant clinical meetings regularly
• ensure all important discussions with colleagues, multidisciplinary team members, and patients are appropriately documented
• communicate effectively with local service providers, primary care and other community organisations in planning and management of care, including referring and receiving health services

Ready to perform without supervision

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

The trainee will:

• assess alternative models of health care delivery to patients with chronic diseases and disabilities
• participate in initiatives for chronic diseases management to reduce hospital admissions, prevent deterioration, and improve patients’ quality of life
• help patients access initiatives and services for patients with chronic diseases and disabilities
• demonstrate the capacity to engage in the surveillance and monitoring of the health status of populations in the outpatient setting
• maintain good relationships with health agencies and services
• apply the principles of efficient and equitable allocation of resources to meet individual, community, and national health needs
• consider location and urgency of care / treatment to ensure that, when feasible, it is provided as close as possible to home, and that travel to and within the networked services only occurs when essential, ensuring timely care access and the best possible outcomes
• effectively and safely utilise appropriate / approved digital technologies and systems to facilitate improved communication and access to care
• for the care of young people with cystic fibrosis, recommend and advocate for transition of care to specialised adult cystic fibrosis multidisciplinary clinics

Requires some supervision

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

The trainee may:

• demonstrate awareness of initiatives and services available for patients with chronic diseases and disabilities, and knowledge of how to access these support
• identify common population health screening and prevention approaches