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 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 patients’ information
  • exchange pertinent, contextually appropriate, and relevant patient information
  • perform this activity in multiple settings (appropriate to the speciality), including inpatient, ambulatory, and critical care situations
  • recognise clinical deterioration, and respond by following the local process for escalation of 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:

  • assist patients from early adolescence to prepare for transfer to adult care at an appropriate age
  • facilitate an optimal transition of care for patients
  • identify and manage key risks for patients during transition
  • anticipate possible changes in patients’ conditions, and provide recommendations on how to manage them

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
  • recognise seriously unwell patients requiring immediate care

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 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

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
  • determine patients’ understanding of their diseases and what they perceive as the most desirable goals 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 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 an understanding of the medicolegal context of written communications
  • maintain up-to-date certification in advanced life support

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
  • raise appropriate issues for review at morbidity and mortality meetings

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
  • educate adolescents and young adults about their conditions and their impacts on their lives
  • consider the involvement of parents or carers in the education process

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 may:

  • communicate with careful consideration to health literacy, language barriers, and culture about patient preferences, and whether they are realistic and possible, respecting patient choices
  • recognise the timing, location, privacy, and appropriateness of sharing information with patients and their families or carers
  • negotiate health care decisions in a culturally appropriate way by considering variation in family structures, cultures, religion, or belief systems

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 an 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 an 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 colleagues

direction
Requires some supervision

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

The trainee may:

  • maintain respect for patients, families, 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
  • recognise the need for escalation of care, and escalate to appropriate staff or services

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
  • demonstrate an 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
  • recognise and work collaboratively with other health care providers, including allied health workers and psychologists

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 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
  • connect patients with local or online peer support groups

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
  • understand the systems for the escalation of care for deteriorating patients