MoE Edinburgh

Information

MoE Edinburgh specialise in Comprehensive Geriatric Assessment for the frail elderly. We recommend you use the Rockwood Clinical Frailty Scale (Rockwood Clinical Frailty Scale April 2020-1.pdf) in all referrals and your clinical practice. There are a range of community based services that provide assessment for frail elderly and offer alternatives to admission or alternative admission pathways for suitable patients.

Community Services

Team / service	Patient need/ type of service required:	How to refer:
Social care Direct	Non urgent PT / OT / Social Care advice or intervention	0131 200 2324  Email: socialcaredirect@edinburgh.gov.uk
Community falls services	Falls services	See full list of falls resources at Edinburgh Falls RefHelp   Edinburgh Falls – RefHelp (nhslothian.scot)
Physio@Home	Physio at Home for Housebound	SCI gateway referral If urgent then contact North: 07890531695 or South: 07890532988 Physio@Home (Edinburgh) – RefHelp (nhslothian.scot)
IMPACT	ANPs, DNs and staff nurses in long	Single point of contact:  07917215009

Frail and housebound or Care Home residents

Team / service	Patient need/ type of service required:	How to refer:
Frail and housebound in SW/SE locality	MoE advice to SW/SE hub teams for frail and housebound	Email LibertonDayHospital@nhslothian.scot.nhs.uk to discuss at weekly Thursday 1pm Microsoft Team meeting. Referrals will be consider for Liberton Hub review or Home Visit.
Care home polypharmacy reviews	MoE supported care home polypharmacy review	An annual MDT review for complex patients in your care home can be arranged through your practice pharmacist. If care home polypharmacy review required then refer to your own practice pharmacists who can then contact LibertonDayHospital@nhslothian.scot.nhs.uk to arrange polypharmacy review with Geriatrician. Responsible GP/ANP expected at review on Microsoft teams or in person.

Advice or Outpatients

Team / service	Patient need/ type of service required:	How to refer:
Advice or outpatients or day hospital in South Edinburgh	MoE advice and / or outpatients / day hospital including blood transfusions South Edinburgh doogal.co.uk	Urgent: Flow Centre 03000 134 000 Option 1 & 4 and ask for Duty Geriatrician on for Edinburgh H@H. Outpatients usually available within 2 working days depending on transport. Advice: Email LibertonDayHospital@nhslothian.scot.nhs.uk Routine referrals: SCI gateway via Liberton MoE Medicine of the Elderly – RefHelp (nhslothian.scot)
Advice or outpatients or day hospital in North Edinburgh	MoE advice and / or outpatients / day hospital North Edinburgh doogal.co.uk	Urgent Advice and Admission Avoidance: Duty Geriatrician for North Edinburgh (07815 493 034) Multidisciplinary Day Hospital Review in ARC / OPRA usually available within a few days.  Email contact for advice: Geriatricmed.north@nhslothian.scot.nhs.uk  Routine referrals: SCI gateway via MoE WGH / ARC / OPRA Medicine of the Elderly – RefHelp (nhslothian.scot)
Specialist clinics	Specialist clinics for movement disorders, TIA and stroke, Life after stroke	Parkinsons Disease/Movement disorder clinics for older people – RefHelp (nhslothian.scot) Transient Ischaemic Attack (TIA) And Stroke – RefHelp (nhslothian.scot)
Polypharmacy reviews	MoE advice to Edinburgh Primary Care Pharmacy Teams and GPs for polypharmacy or high risk medicine reviews	Discuss with your practice pharmacist for a polypharmacy review.  The pharmacist can link in with the MoE team for support at a regular meeting with a geriatrician on alternate Tuesdays 12.30 – 13.00 if required. Specific Geriatrician advice can be sought via email LibertonDayHospital@nhslothian.scot.nhs.uk

Alternative to admissions and Edinburgh Hospital at Home

Team / service	Patient need/ type of service required:	How to refer:
Edinburgh Home First Navigator	PT and OT requirement where urgent assessment, equipment and support could prevent a hospital admission	Flow Centre 03000 134 000 Option 1 & 4 Monday to Friday 8.30am – 2pm Urgent Therapy and Social Care – RefHelp (nhslothian.scot)
Edinburgh Hospital at Home (H@H)	Acute medical needs +/- therapy needs as an alternative to hospital admission. Priority is given to patients with complex care needs and frailty. Patient requires to be safe at home and patient/ family happy for acute medical care under H@H.	Flow Centre 03000 134 000 Option 1 & 4 Monday to Friday 8am – 8pm (last referral 5pm) Then send SCI gateway referral to MoE Liberton marked urgent for HaH Patients prioritised according to their NEWS Can be redirected to duty doctor for advice. Consider additional discussion with home first navigator if urgent therapy need. Edinburgh Hospital at Home page
Out of Hours Edinburgh H@H	Acute medical presentations in frail patients who would benefit from admission avoidance. Sat/Sun 8am-5pm: Care home/HBCCC residents OR known to the service previously in last 6months with same condition, and safe to remain at home. 2 slots for care home residents or HBCCC overnight.	Call flow centre Tel: 0300 013 400 option 1 then 4 Sat/Sun 8am-5pm: Flow will transfer calls to Nurse co-ordinator to discuss patient. Overnights 6pm-8am- Must be either care home resident or HBCCC. Flow centre will take patient details and add to workbench for review following morning. When closing Adastra notes, please ensure that referral to relevant H@H team and email option is selected, with ‘referred to H@H’ in informational outcomes. Edinburgh OOH Hospital at Home page
Step up care for rehabilitation	Patient requiring a community bed for intercurrent illness with rehab needs (Liberton or Findlay House) and cannot be accommodated by Home First Navigator via Flow Centre	Flow Centre 03000 134 000 Option 1 & 4 and ask for Home First Navigator. If requires step up admission then ask for Duty Geriatrician on for Hospital at Home. Patient may be assessed at home in the first instance by HaH team. Bed availability cannot be guaranteed.
Step up care for complex care	Patient requiring a community bed for complex healthcare need and / or end of life care (Ellens Glen or Ferryfield) and cannot be accommodated by Home First Navigator or urgent care home referral via social care direct	Flow Centre 03000 134 000 Option 1 & 4 and ask for Duty Geriatrician on for Hospital at Home. Patient may be assessed at home in the first instance by HaH team. Alternatively email aahdischargehub@nhslothian.scot.nhs.uk for advice. Bed availability cannot be guaranteed.

Mental Health and / or Memory Assessment and Dementia Services

Team / service	Patient need/ type of service required:	How to refer:
Rapid Response Team	To prevent admission to psychiatric hospital for older people with mental ill health and for people living with young onset dementia.	All referrals to RRT require a telephone call to the service prior to sending electronic referral forms on 0131 537 6882 RRT provide a 7 day service form 8am – 8pm Mon to Friday and 8am – 5pm at weekends.  SCI Gateway forms should be submitted to Older People Mental Health Services (North or South). Rapid Response Team – Edinburgh – RefHelp (nhslothian.scot)
Edinburgh Community Mental Health Teams for Older People	Assessment and treatment to anyone over the age of 65 with a mental health problem Assessment and treatment for those under 65 years presenting with diagnosis of dementia Support for individual patients within Care Homes	Emergency – Rapid Response Team – Edinburgh – RefHelp (nhslothian.scot) Urgent –   response within 5 working days (CMHTOP is a Monday – Friday service) – telephone discussion needed with the relevant Single Point of Referral Routine – at least / minimum 4 weeks Older Peoples Mental Health-Edinburgh – RefHelp (nhslothian.scot)