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’ self-management through education to take greater responsibility for their care, and support problem solving
• counsel patients on the impacts of the disease and/or treatment on fertility, driving, and employment
• liaise with employers, education providers, and licensing authorities to safely manage illness or impairment when indicated
• explain remedial risk factors and intervention strategies to patients and carers
• discuss risks and benefits of proposed management plans with patients in an appropriate way
• encourage patients’ access to self-monitoring devices and assistive technologies
• use motivational interviewing to encourage self-care and lasting behavioural change in patients
• adapt communication techniques used to build and maintain clinical rapport with patients, including interpreters where appropriate
• actively listen to patients
• incorporate appropriate LGBTQIA+ safe language, including gender affirming language
• communicate effectively with multidisciplinary team members, and involve patients in that dialogue
• define discharge / handover endpoints during treatment planning
• communicate regularly with other specialist providers who are directly involved in ongoing management
• seek appropriate advice through accurate communication of the clinical question and patient-specific context when needed
• synthesise and communicate all relevant specialist input into patients’ care
• provide effective communication of assessments, management plans, and outcomes of care to all relevant healthcare providers
• check quality and accuracy of reports or documentation generated by others and technologies, including artificial intelligence-informed large language models
• discuss sensitive and highly emotive issues with patients, such as poor prognosis, medical futility, and advanced care planning
• demonstrate the ability to constructively navigate conflict situations with patients

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 on the importance of self-management to patients
• work in partnership with patients, and motivate them to participate in and adhere to agreed care plans

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, such as 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 them become more independent
• participate in quality improvement processes impacting on patients’ abilities to undertake normal activities of daily living
• calibrate practise through attendance at morbidity and mortality meetings, and collegiate case discussion
• ensure evidence-based care by remaining up to date with current medical literature
• independently plan and undertake continuous professional development

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

Ready to perform without supervision

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

The trainee will:

• independently plan and undertake continuous professional development
• contribute to the development of clinical pathways for chronic diseases management, based on current clinical guidelines
• educate patients to recognise and monitor their symptoms, and undertake strategies to assist their recovery
• actively seek to educate junior team members during daily practice by using available opportunities for teaching and encouraging curiosity for learning

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

Ready to perform without supervision

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

The trainee will:

• use information from a variety of sources to synthesise management plans
• prepare reviews of literature on patients’ encounters to present at journal club meetings
• maintain up-to-date knowledge of relevant medical literature, and apply evidence-based practice when formulating patient management plans
• search for and critically appraise evidence to resolve clinical areas of uncertainty
• seek expert advice from colleagues when medical literature is lacking
• use epidemiological and public care research in the context of individual patients with chronic complex illness

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

Ready to perform without supervision

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

The trainee will:

• ensure care plans are culturally safe and feasible in local circumstances
• integrate culturally safe care of Aboriginal and Torres Strait Islander peoples and Māori into care planning and patient management
• encourage patients from culturally and linguistically diverse backgrounds to join local networks to receive the support needed for long-term self-management
• reflect critically on internal and systemic bias, including how these may impact patient care, and take active steps to minimise these in practice
• actively offer use of interpreters and translated resources
• refer to specialised services when available
• consider whether the location for patient consultation is safe, and adjust accordingly
• recognise the potential for differing cultural needs, especially during discharge planning, family meetings, and discussions about advanced care planning and end-of-life care
• ensure use of patients’ preferred names and terms of address

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

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 professional guidelines on confidentiality
• use consent processes for the release and exchange of health information
• assess patients’ decision-making capacity, and appropriately identify and use alternative decision makers

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

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
• prioritise and rationalise treatment for frail patients
• refer patients to appropriate supportive services
• identify patients who will benefit from a rehabilitative approach
• appropriately time and proactively manage escalations or transitions of care

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

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 patients’ care journeys
• work with community multidisciplinary teams and primary care health professionals to facilitate effective patient care
• use rehabilitation resources to maximise ability to return to education, employment, and independence after illness
• work with general practitioners and screening services to ensure patients with chronic disease also present for routine preventive measures
• develop collaborative relationships with patients, families, carers, and a range of health professionals
• identify roles within the chronic disease care team, and conduct collaborative case conferences as needed
• maintain a level of supervision and task delegation to other staff members

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

Ready to perform without supervision

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

The trainee will:

• be proactive in identifying and removing barriers to access health care
• recognise the multifactorial inequity that exists in accessing health care, and use available and novel strategies to overcome this
• advocate for patients to be able to meet their goals when feasible, within the healthcare system and the wider community
• be familiar with institutional support frameworks and options when advocating for patients or disadvantaged populations
• use health screening for early intervention and chronic disease management
• assess and initiate alternative models of care delivery
• participate in government initiatives for chronic diseases management to reduce hospital admissions and improve patients’ quality of life
• help patients with chronic diseases and disabilities access initiatives and services
• develop systems that allow regular comprehensive assessments of all patients and completion of care-related tasks

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