Entrustable Professional Activities

EPA 6: Longitudinal care, including transitions and end-of-life

EPA 6

Management of gastroenterological conditions from birth to adolescence, including transitions and end-of-life care

Manage and coordinate the longitudinal care of patients with complex gastroenterological conditions, including transitions and end-of-life

This activity requires the ability to:

  • develop management plans and goals in consultation with patients, families and carers, including advanced care directives
  • manage complex and advanced chronic conditions, complications, disabilities, and comorbidities
  • collaborate with other health care providers, including transition of patient care
  • ensure continuity of care, including appropriate patient support for end-of-life care plans
  • facilitate patients’, families’ or carers’ self-management and self-monitoring
  • engage with the broader health policy context.

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:

  • regularly assess and review care plans for patients with chronic conditions and disabilities based on short- and long-term clinical and quality of life goals
  • provide documentation on patients' presentations, management and progress, including key points of diagnosis and decision making to inform coordination of care
  • ensure that patients contribute to their needs assessments and care planning
  • monitor treatment outcomes, effectiveness, and adverse events
  • facilitate an optimal transition of care for patients, including from paediatric to adult care
  • develop and clearly document individualised end-of-life care plans

direction
Requires some supervision

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

The trainee may:

  • assesses patients’ knowledge, beliefs, concerns, and daily behaviours related to their chronic condition or disability and its management
  • accurately and sufficiently contribute to medical record entries on histories, examinations, and management plans as a member of multidisciplinary teams
  • demonstrate an understanding of the principles of care for patients at the end of their lives

Communication

confident
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
  • encourage patients’ access to self-monitoring devices and assistive technologies
  • communicate with multidisciplinary team members, and involve patients in that dialogue
  • communicate with patients, families, or carers about transition of care, and engage and support these parties in decision making
  • identify opportunities to discuss end-of-life care, aligning it with patients’ values and preferences

direction
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 to patients on the importance of self-management
  • work in partnership with patients, and motivate them to comply with agreed care plans
  • ensure consistent messages are given to patients, families, or carers about treatment options, their likelihood of success, risks and prognosis

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:

  • maintain up-to-date certification
  • use innovative models of chronic disease care, using 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 patients to become more independent
  • participate in quality improvement processes impacting on patients’ abilities to undertake normal activities of daily living

direction
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

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:

  • 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

direction
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

Research

confident
Ready to perform without supervision

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

The trainee will:

  • prepare reviews of literature on patients' encounters to present at journal club meetings
  • search for and critically appraise evidence to resolve clinical areas of uncertainty

direction
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

Cultural competence

confident
Ready to perform without supervision

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

The trainee will:

  • encourage patients from culturally and linguistically diverse backgrounds to join local networks to receive the support needed for long-term self-management

direction
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

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:

  • share information about patients’ health care, consistent with privacy laws and professional guidelines about confidentiality
  • use consent processes for the release and exchange of health information
  • assess patient decision-making capacity, and appropriately identify and use alternative decision makers

direction
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

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:

  • 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 a long-term health care journey
  • recognise appropriate stages of end-of-life and limitation of treatment

direction
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

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:

  • use a multidisciplinary approach across services to manage patients with chronic diseases and disabilities
  • develop collaborative relationships with patients, families, or carers, and a range of health professionals
  • coordinate whole-person care through involvement in all stages of the patients’ care journey
  • effectively manage challenges of dealing with death and grief

direction
Requires some supervision

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

The trainee may:

  • participate in multidisciplinary team care for patients with chronic diseases and disabilities, including organisational and community care on a continuing basis appropriate to patient context

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:

  • use health screening for early intervention and chronic diseases management
  • assess alternative models of health care delivery to patients with chronic diseases and disabilities
  • participate in government initiatives for chronic diseases management to reduce hospital admissions and to improve patients’ quality of life
  • help patients access initiatives and services for patients with chronic diseases and disabilities

direction
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 knowledge of how to access them