Adult Rheumatology — Transition to Practice

TTP2 Planning and implementing transfers of care through the health care system

Key Features:
- The focus of this EPA is the transfer of professional responsibility for patient care from one physician to another.
- This EPA can be observed through simulation of a written transfer or care plan appropriate for setting/context.

Assessment Plan:
Review of written transfer of care plan by supervisor
Use Form 1. Form collects information on:
- Case complexity: medium; high
- Setting: longitudinal clinic (continuity of care); transitional clinic (from pediatrics to adult care); leave of absence; patient moving jurisdiction; consult service
Collect 2 observations of achievement
- At least 2 complex patients

Form

F1: Observation

Milestones

• L 2.1. Apply knowledge of health care resources available in other care settings

• ME 4.1. Assess the need, timing, risk and benefits of referring a patient to another health professional and/or care setting

• COL 3.1. Facilitate the handover of care to the most appropriate physician

• COL 3.2. Summarize the patient’s issues including plans to deal with ongoing concerns as well as anticipated changes in the clinical course

• HA 1.1. Work with patients to facilitate access to needed health services or resources

Context Variables

• Case complexity (single-choice)
  • medium
  • high
• Setting (single-choice)
  • longitudinal clinic (continuity of care)
  • transitional clinic (from pediatrics to adult care)
  • leave of absence
  • patient moving jurisdiction
  • consult service

Requirements

• Collect 2 observations of achievement (minimum 2)
• At least 2 complex patients (minimum 2)
  • Only counts when Case complexity is high