Curriculum standards
Curriculum standards
Advanced Training in Rheumatology (Paediatrics and Child Health)
Entrustable Professional Activities
LG6: Management of transitions in care
Management of transitions in care
Manage the transition of patient care between health professionals, providers, and contexts
This activity requires the ability to:
- manage the transition 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
- explain the challenges surrounding the transition to adult care for patients and clinicians
- perform this activity in multiple settings, appropriate to the speciality, including inpatient, ambulatory, and critical care settings
Professional practice framework domain
Medical expertise
Ready to perform without supervision
Expected behaviours of a trainee who can routinely perform this activity without needing supervision
The trainee will:
- facilitate an optimal transition of care for patients
- identify and manage key risks for patients during transition
- explain the importance of comprehensive and structured transition to adult services for patients with chronic rheumatic disease
- prepare patients for transition
- collaborate with other medical services to appropriately manage patients with rheumatic disorders, and work in a multidisciplinary team
Requires some supervision
Possible behaviours of a trainee who needs some supervision to perform this activity
The trainee may:
- explain 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
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 about transitions of care, and engage and support them in decision making
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
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
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
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
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
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 patients’ preferences, and whether they are realistic and possible, respecting patients’ choices
- incorporate appropriate LGBTQIA+ safe language
- recognise the timing, location, privacy, and appropriateness of sharing information with patients
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
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 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
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
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
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
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
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
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
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