Entrustable Professional Activities

EPA 5: Management of transitions in care

EPA 5

Management of transitions in care

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

This activity requires the ability to:

  • assess and manage the impact of complex medical comorbidities, functional impairments, and psychosocial factors in the planning of discharge destination from hospital settings
  • manage a 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
  • work flexibly between settings, including emergency departments, acute, subacute, outpatient, community / home visits, and residential and aged care

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:

  • assess risk management strategies in planning discharges, including navigating patients’ right to risk
  • facilitate an optimal transition of care for patients
  • identify and manage key risks for patients during the transition
  • anticipate possible changes in patients’ conditions, and provide recommendations on how to manage them
  • assess the need for and manage patients’ access to rehabilitation services
  • assess patients’ suitability for residential care
  • consider and balance the needs of the patients’ family and/or carers, including stress mitigation
  • identify strategies to improve the patients’ experience at vulnerable points in the peri- and postoperative pathway

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 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:

  • write relevant and detailed medical record entries, including clinical assessment 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 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:

  • 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 a poor transition 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 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

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, whether they are realistic and possible, respecting patient choices
  • recognise the timing, location, privacy, and appropriateness of information sharing 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

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, 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 and families or 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 think about patients’ issues, and prioritise these
  • recognise situations in which to ask for help

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 care 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 the transfer of care and help subsequent health professionals to 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
  • identify and recommend available community support services
  • assist patients, family and carers to navigate system complexities, e.g. facilitate communication between patients, family and carers and service care providers such as home care and hospital administration

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