Entrustable Professional Activities

LG8: Transitions, transfers, and handovers of care

Learning Goal 8

Transitions, transfers, and handovers of care

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

This activity requires the ability to:

  • manage transitions of patient care to ensure the optimal continuation of care between providers
  • identify the appropriate 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 and current environment, including ambulatory, critical care, inpatient and retrieval settings
  • organise or perform prehospital and interhospital transfers
  • appropriately accept transfer of patients into the department
  • appropriately handover patient care to other teams or at end of shift

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 optimal transitions 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 
  • identify ideal locations and management teams, and arrange transfers required to achieve this
  • identify time-critical versus team-critical transfers of care
  • take appropriate referrals into the unit
  • provide appropriate phone and/or telehealth advice to external clinicians

direction
Requires some supervision

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

The trainee may:

  • demonstrate understanding of the details of patients’ conditions, illness severity, and potential emerging issues, with appropriate actions
  • provide accurate summaries of patients’ information with accurate identification of problems or issues
  • identify patients who require expertise not available in the emergency department, but need assistance to determine where and how to arrange this expertise
  • require assistance with incoming referrals and providing phone and/or telehealth advice to external clinicians

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
  • initiate and maintain verbal communication with other health professionals, when required
  • communicate with patients, families, and/or carers about transitions 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:

  • communicate accurately and in a timely manner to ensure effective transitions between settings, and continuity and quality of care
  • communicate clearly with clinicians and other caregivers
  • use standardised verbal and written templates to improve the reliability of information transfers and prevent errors and omissions

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 transitions of care, and mitigate this risk
  • 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 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

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 regarding patient preferences, and whether they are realistic and possible, respecting patient choices
  • recognise the timing, location, privacy, and appropriateness of sharing information with patients, their families, whānau and/or carers
  • identify the appropriate family / whānau connections, and facilitate these as required

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

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’ 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

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 the opportunity 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 transfers 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 handovers 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 transitions of care
  • engage in organisational processes to improve transitions of care, such as formal surveys or follow-up phone calls after hospital discharge

direction
Requires some supervision

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

The trainee may:

  • factor transport issues and costs to patients into arrangements for transferring patients to other settings