Entrustable Professional Activities

LG6: 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 patients’ 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, including ambulatory, critical care, and inpatient 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:

  • manage referrals, including discharges to primary care, complex ambulatory care models (such as hospital in the home), in- and out-bound interhospital transfers, and handover between shifts
  • apply understanding of transition needs between life stages, including the role of healthcare systems
  • facilitate an optimal transition of care for patients, including, but not limited to, handover meetings
  • identify and manage key risks for patients during transition
  • anticipate possible changes in patients’ conditions, and provide recommendations on how to manage them
  • implement measures to ensure patient care is appropriately monitored and reviewed as required

direction
Requires some supervision

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

The trainee may:

  • demonstrate awareness 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

Communication

confident
Ready to perform without supervision

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

The trainee will:

  • use digital communication tools and applications to aid in safe communication at transitions of care
  • 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, including appropriate safety-netting advice
  • communicate proactively with peers and managers regarding workload and patient care issues when required
  • incorporate appropriate LGBTQIA+ safe language, including gender affirming language
  • communicate effectively and apply understanding of the role of primary care providers
  • check quality and accuracy of reports or documentation generated by others and technologies, including artificial intelligence-informed large language models

direction
Requires some supervision

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

The trainee may:

  • 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 effective transitions 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 and mitigate risks present during transitions of care or handover
  • use and respect the expertise of primary care professionals in coordinating care of patients outside hospital
  • recognise the importance of the context of care in the environments to which patients transition
  • work with colleagues to ensure management plans are appropriate and sustainable in the new context
  • 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
  • recognise the medicolegal context of professional communications, including confidentiality and conflicts of interest

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
  • demonstrate and teach best practice in handover, including closed-loop communication, and written and oral communication between health professionals

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:

  • ensure culturally safe communication, paying attention to culture and language
  • ensure patient-centred care by eliciting patient preferences
  • respect patients’ choices whenever they are realistic and possible
  • acknowledge and allow for differences in worldview and how this may impact on transitions in care and care planning
  • recognise the timing, location, privacy, and appropriateness of sharing information with patients, whānau, 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

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 only contextually appropriate medical and personal information
  • recognise the clinical, ethical, and legal rationale for information disclosure
  • share information about patients’ care in a manner consistent with privacy laws and professional guidelines on confidentiality
  • explain 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 collegial 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 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
  • facilitate patient care provision when disadvantage or vulnerability is present, such as lack of services or geographical isolation
  • make appropriate decisions regarding referring or transferring patients to other services for further assessment, including regional and remote patients

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
  • recognise the medical governance of patient care, and the differing roles of team members
  • work effectively as a member of professional teams, showing respect for the roles and expertise of other health professionals
  • 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 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 transitions of care
  • engage in organisational processes to improve transitions of care, such as formal surveys or follow-up phone calls after hospital discharge
  • work with primary care liaison teams and networks to foster continuous improvement in safe transitions to primary care
  • identify and build partnerships between metropolitan and rural health services to enable optimal patient care
  • recognise equity barriers that may impact on safe transitions of care, and mechanisms through which these may be addressed
  • be familiar with institutional support frameworks and options when advocating for patients or disadvantaged populations

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