Entrustable Professional Activities

LG 6: Management of transitions in care

Learning Goal 6

Management of transitions in care

Manage the transition of patient care between health professionals, providers, and contexts

This activity requires the ability to:

  • manage 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
  • exchange pertinent, contextually appropriate, and relevant patient information
  • perform this activity in multiple settings (appropriate to the speciality), including inpatient, ambulatory, and critical care settings

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 an optimal age-appropriate transition of care for patients
  • identify and manage key risks for patients during transition
  • anticipate possible changes in patients’ conditions, and provide recommendations on how to manage them
  • deliver age-appropriate care and adapt care in recognition of the increased role for the young person in managing their chronic condition
  • assess patients’ health literacy and developmental readiness
  • 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:

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

  • write relevant and detailed medical record entries, including clinical assessments and management plans
  • write comprehensive and accurate summaries of care, including discharge summaries, clinic letters, and transfer documentation
  • include appropriate transfer of care information from other multidisciplinary team members
  • initiate and maintain verbal or written communication with other health professionals involved in patients' care
  • communicate with patients, families and/or carers about transition of care, and engage and support these parties in decision making

direction
Requires some supervision

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

The trainee may:

  • identify local transition coordinator or facilitator
  • communicate clearly with clinicians and other caregivers
  • 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 an effective transition 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:

  • identify patients at risk of poor transition of care, and mitigate this risk through identification of support services
  • use electronic tools (where available) to securely store and transfer patient information
  • use consent processes, including written consent if required, for the release and exchange of information
  • demonstrate understanding of the medicolegal context of written communications

direction
Requires some supervision

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

The trainee may:

  • ensure that handover is complete, or work to mitigate risks if the handover was 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:

  • integrate clinical education in handover sessions and other transition of care meetings
  • tailor clinical education to the level of the professional parties involved
  • evaluate patients’ understanding of their health condition and ability to perform self-care at all transition points

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 handover, 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 with careful consideration to health literacy, language barriers, and culture about patient preferences, and whether they are realistic and possible, respecting patient choices
  • recognise the timing, location, privacy, and appropriateness of sharing information with patients and their families or carers

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
  • identify and link patients with culturally appropriate services to assist with transition in care

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
  • demonstrate understanding of the clinical, ethical, and legal rationale for information disclosure
  • share information about patients’ health care in a manner consistent with privacy law and professional guidelines on confidentiality
  • demonstrate understanding of the additional complexity related to some types of information, such as genetic information and blood-borne-virus status, and seek appropriate advice about disclosure of such information
  • interact in a collegiate and collaborative way with professional colleagues during transitions of 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, families, carers, 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 in the most appropriate facility, setting, or provider and consider impact of age and comorbidities on types of supports needed

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:

  • share the workload of transitions of care appropriately, including delegation
  • demonstrate understanding of the medical governance of patient care, and the differing roles of team members
  • show respect for the roles and expertise of other health professionals, and work effectively as a member of professional teams
  • ensure that multidisciplinary teams provide opportunities for patients’ engagement and participation when appropriate

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 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 or transfer of care to new health care providers

direction
Requires some supervision

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

The trainee may:

  • factor transport issues, costs to patients and continued access to appropriate care into decisions to transfer patients to other settings