Entrustable Professional Activities

LG 8: Longitudinal care

Learning Goal 8

Longitudinal care

Manage and coordinate the longitudinal care of patients with chronic illness, disability, and/or long-term health issues

This activity requires the ability to:

  • develop management plans and goals in consultation with patients, carers, and/or families
  • manage chronic and advanced conditions, complications, disabilities, and comorbidities
  • collaborate with other health care providers
  • ensure continuity of care
  • facilitate patients’ and/or families’ and/or carers’ self-management and self-monitoring
  • engage with the broader health policy context

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:

  • regularly assess and review care plans for patients with chronic conditions and disabilities based on short- and long-term clinical and quality of life goals
  • provide documentation on patients' presentation, management, and progress, including key points of diagnosis and decision making to inform coordination of care
  • ensure patients contribute to their needs assessments and care planning
  • monitor treatment outcomes, effectiveness, and adverse events

direction
Requires some supervision

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

The trainee may:

  • assess patients’ knowledge, beliefs, concerns, and daily behaviours related to their chronic condition and/or disability and its management
  • contribute to medical record entries on the history, examination, and management plan in a way that is accurate and sufficient as a member of multidisciplinary teams

Communication

confident
Ready to perform without supervision

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

The trainee will:

  • encourage patients’ self-management through education to take greater responsibility for their care, and support problem solving
  • work in partnership with patients, and motivate them to adhere to agreed care plans
  • communicate with multidisciplinary team members, and involve patients in that dialogue

direction
Requires some supervision

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

The trainee may:

  • provide healthy lifestyle advice and information to patients on the importance of self-management
  • encourage patients’ access to self-monitoring devices and assistive technologies

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 innovative models of chronic disease care using telehealth and digitally integrated support services
  • review medicine use and ensure patients understand safe medication administration to prevent errors
  • support patients’ self-management by balancing between minimising risk and helping patients to become more independent
  • initiate and participate in quality improvement processes impacting on patients’ abilities to undertake normal activities of daily living

direction
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

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:

  • contribute to the development of clinical pathways for chronic diseases management based on current clinical guidelines

direction
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
  • educate patients to recognise and monitor their symptoms, and undertake strategies to assist their recovery
  • educate patients regarding sick day management plans for common and important endocrine conditions

Research

confident
Ready to perform without supervision

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

The trainee will:

  • prepare reviews of literature on patients' encounters to present at journal club meetings
  • search for and critically appraise evidence to resolve clinical areas of uncertainty
  • prepare research protocols to evaluate interventions and outcomes for chronic disease

direction
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 and limitations of review articles
  • explain that routine care will continue if the participant decides not to participate in research

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:

  • encourage patients from diverse backgrounds to join local networks to receive the support needed for long-term self-management

direction
Requires some supervision

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

The trainee may:

  • provide culturally safe chronic disease management

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:

  • share information about patients’ health care, consistent with privacy laws and confidentiality and professional guidelines
  • use consent processes for the release and exchange of health information
  • assess patients’ decision-making capacity/competency and appropriately identify and use alternative decision makers

direction
Requires some supervision

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

The trainee may:

  • confidentially share information between relevant service providers
  • acknowledge and respect the contribution of other health professionals involved in patients’ care
  • seek consent from patients to discuss their care at multidisciplinary team meetings

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:

  • 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 health care journeys

direction
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

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:

  • coordinate whole-person care through involvement in all stages of the patients’ care journey
  • use a multidisciplinary approach across services to manage patients with chronic diseases and disabilities
  • develop collaborative relationships with patients, families, carers, and a range of health professionals

direction
Requires some supervision

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

The trainee may:

  • participate in multidisciplinary care for patients with chronic diseases and disabilities, including organisational and community care on a continuing basis, appropriate to patients’ context

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:

  • use health screening for early intervention and chronic diseases management
  • assess alternative models of healthcare delivery to patients with chronic diseases and disabilities
  • participate in government initiatives for chronic diseases management to reduce hospital admissions and hospital related complications, and improve patients’ quality of life
  • assist patients to access initiatives and services for patients with chronic diseases and disabilities

direction
Requires some supervision

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

The trainee may:

  • demonstrate awareness of government initiatives and services available for patients with chronic diseases and disabilities, and display knowledge of how to access them