MoE Edinburgh

Information

MoE Edinburgh specialise in Comprehensive Geriatric Assessment for the frail elderly. We recommend you use the Rockwood Clinical Frailty Scale 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 on RefHelp
Physio@Home	Physio at Home for Housebound	SCI gateway referral If urgent then contact North: 07890531695 or South: 07890532988 Edinburgh Physio@Home on RefHelp
IMPACT	ANPs, DNs and staff nurses in long term conditions	Single point of contact: 07917215009 loth.impactclinical@nhs.scot IMPACT on RefHelp

Frail and housebound or Care Home residents

Team / service	Patient need/ type of service required:	How to refer:
Frail and housebound in SE locality	MoE advice to SE hub teams for frail and housebound	Email LibertonDayHospital@nhslothian.scot.nhs.uk and referrals will be considered for Liberton Hub review or ANP 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 See DOOGAL if any uncertainty on what area patient is in	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 Geriatric Medicine
Advice or outpatients or day hospital in North Edinburgh	MoE advice and / or outpatients / day hospital North Edinburgh See DOOGAL if any uncertainty on what area patient is in	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 (MOE will allocate to ARC or OPRA)
Specialist clinics	Specialist clinics for movement disorders, TIA and stroke, Life after stroke	Parkinsons Disease/Movement disorder clinics for older people on RefHelp Transient Ischaemic Attack (TIA) And Stroke on RefHelp
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 on RefHelp
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.	Please see Edinburgh Hospital at Home page on RefHelp
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.	Please see Edinburgh OOH Hospital at Home page on RefHelp
Considering admission for bed based rehabilitation	Patient requiring a community bed for intercurrent illness with rehab needs (Ellens Glen Hospital Ward 2 or Findlay Hospital ward 2)	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. Bed availability cannot be guaranteed.
Considering admission for complex care for frail, complex, palliative or end of life care	Patient requiring a community bed for frail, complex, palliative or end of life care in Ellens Glen Hospital Ward 1 (9 beds) and cannot be supported via by Hospital at Home, Hospice services 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. This email inbox is monitored regularly throughout the day Monday to Friday. After discussions (as above) the referrer will be asked to complete a referral form (this will be emailed to the referrer). These referrals will be discussed at a weekly complex care MDT. Urgent referrals will be circulated to the MDT for decision in between the weekly MDT and will not have to wait for the weekly meeting before being actioned. 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.	Please see Rapid Response Team – Edinburgh on RefHelp
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	Please see Older Peoples Mental Health-Edinburgh on RefHelp

Outpatients – South Edinburgh and Midlothian
South Edinburgh and Midlothian MoE Outpatient Clinics including access to Comprehensive Geriatric Assessment (formerly Day Hospital): Currently at Liberton Hospital moving to Ellens Glen Hospital by end of 2025

The South Edinburgh and Midlothian Older Peoples Service provides Outpatient Comprehensive Geriatric Assessment for frail older people. This is an outpatient service, which may involve one or several attendances. We have daily clinics at the Liberton Hub (moving to Ellens Glen Hospital from end of 2025.) There is also a weekly clinic at Midlothian Community Hospital and Sighthill Health Centre. The Liberton Hub (and Ellens Glen Hospital setting from 2025) are open between 9 – 4pm Monday to Friday. Patients usually attend for up to 2 hours in the morning or early afternoon. Return visits are scheduled as necessary. A full medical and nursing assessment will be completed. Physiotherapy will be provided where indicated at the hub or home. Most Occupational Therapy assessments are completed at home. Limited ambulance transport is available to and from appointments for those who need it.

Available resources include: Full medical and nursing assessment with physiotherapy, occupational therapy and access to speech and language therapy; Continence and cognition assessment; ECG and bloods; Synacthen testing, blood transfusion, ferrinject and iv zoledronic acid. All other investigations available through usual pathways.

Medical staff: Consultants – Dr Andrew Coull, Dr Carolyn Armstrong, Dr Ren Ping Lee. Dr Deepa Rangar. Speciality Doctor – Dr Claire Robson.

Outpatients and Day Hospital – North Edinburgh

For specifics of services offered in North Edinburgh for MOE Outpatients please see: WGH-MoE Outpatient Clinics and LCTC-MoE Outpatient Clinics

MOE Day Hospital is still offered in North Edinburgh please see: WGH- MoE ARC and LCTC-MoE OPRA

Who to refer

Patients aged > 65 with Clinical Frailty Scale ≥4 with any of the following:

Requiring outpatient comprehensive geriatric assessment including admission prevention or full functional assessment
Acute functional decline for multidisciplinary assessment
Declining mobility, recurrent or unexplained falls or syncope
Non-specific symptoms requiring further assessment eg. dizziness (MDT vestibular assessment available), weight loss and abnormal blood tests (including anaemia)
Exacerbations of chronic medical problems or complex comorbidity
Review of complex polypharmacy

Patients aged > 65 with Clinical Frailty Scale ≥4 with General and MoE issues can be supported

Specialist medical and nursing procedures
Crisis intervention to prevent hospital admission
Management of complex long term conditions e.g. heart failure, COPD, leg ulcers, Parkinson’s disease
Falls assessment and prevention programme
Rehabilitation
Supported discharge of hospital inpatients

Please avoid referring to multiple specialities for the same problem – e.g. cardiology AND MOE for syncope. Referral to MOE alone is sufficient. If the MOE team assess that additional specialty input is required, they will arrange this.

Who not to refer

Patients aged under 65 years (unless discussed with consultant first)
Single organ pathology in an otherwise fit older person (please refer to appropriate specialty – examples given below)
- Acute stroke or TIA (refer to Neurovascular clinic)
- Patients of all ages with post-acute stroke problems should be referred to Life After Stroke Clinic
- Memory Clinic patients: Should be referred to the MATS Service (Memory Assessment and Treatment Service in Psychiatry of Old Age). If patients are identified as having cognitive impairment through comprehensive geriatric assessment then we will complete a memory assessment.
- Possible Parkinson’s or other movement disorders should be referred to Movement Disorder Clinic (Dr Marrinan)

Unstable clinical condition (please refer via Flow Centre – examples given below)
- Acute stroke/TIA
- Suspected DVT or PE
- GI haemorrhage
- Chest pain/acute cardiac problems

Patients whose needs can be addressed by community services e.g. only requiring physiotherapy

How to refer – South Edinburgh

Routine Referrals

Please use SCI Gateway. Please note that even when services have moved from Liberton to Ellens Glen, continue to use the Liberton Hospital pathway as below. When this is updated all GPs will be informed and this page will be updated.

Liberton Hospital >> Geriatric Medicine >> LI Basic Sign Referral

Urgent Referrals

Referrals can use SCI Gateway as above, selecting Urgent priority

Additionally, referrers have the option to discuss urgent or rapid access referrals:

Please contact the Consultant on for Edinburgh Hospital at Home:

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.

Email: LibertonDayHospital@nhslothian.scot.nhs.uk

After discussion referrers will be asked to send in a SCI Gateway referral using the above pathway, with details of any review that was agreed.