Medicine of the Elderly Edinburgh specialise in providing multidisciplinary Comprehensive Geriatric Assessments for older people living with frailty. We support the recommendations in the Frailty Enhanced Service and suggest using the Rockwood Clinical Frailty Scale in all referrals and clinical practice.
There are a range of community-based services that provide assessment for older people living with frailty and offer alternatives to admission or alternative admission pathways for suitable patients. Some of these services are Edinburgh-wide, some of these services are particular to either Edinburgh North or South. On this page you will find details of both the city wide and the Edinburgh North services.
Edinburgh Wide Community Services including Prevention of Admission and Hospital at Home
| Team / service | Patient need/ type of service required: | How to refer: |
|---|---|---|
| Risk of admission | Urgent (same day) Social Care intervention | If the patient is at imminent risk of hospital admission follow the Urgent Therapy and Social Care pathway by checking the referral criteria. Call the Flow Centre 8:30am to 2pm on 0300 013 4000 option 1 and 4, or Social Care Direct on 0131 200 2324 outwith these times. |
| 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. | Referral is via Flow Centre. Please see Edinburgh H@H RefHelp page for referral criteria and referral process |
| 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 H@H 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 H@H team. Alternatively email loth.aahdischargehub@nhs.scot 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. |
| Social Care Direct | Urgent and non-urgent PT / OT / Social Care advice or intervention | 0131 200 2324 Email: socialcaredirect@edinburgh.gov.uk |
| Community Falls services | Patient experiencing falls | 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 can call directly: see Edinburgh Physio@Home RefHelp page for Professional to Professional phone number |
| IMPACT | ANPs, DNs and staff nurses in long term conditions | SCI gateway referral Please see IMPACT RefHelp page for referral criteria and for contact details for Professional to Professional discussion if required. |
| Primary Care Pharmacy Team | Polypharmacy reviews (including for Care Home Patients) | A polypharmacy review can be arranged via your Practice Pharmacy Team. Please refer by Email to the GP Clinical inbox, with the subject line: FAO Pharmacy Team Please include patient name, CHI, and a brief reason for referral (What is your concern? What triggered the referral?) |
| 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 |
Advice or Outpatients (including Day Hospital) in North Edinburgh
| Team / service | Patient need/ type of service required: | How to refer: |
|---|---|---|
| Advice | Advice | Urgent Advice and Admission Avoidance Duty Geriatrician for North Edinburgh (07815 493 034) Referrals For new patients: please refer via SCI Gateway and note in Reason for Referral that this is a request for Advice For existing patients or for queries that are not patient-specific then can email using loth.geriatricmednorth@nhs.scot |
| Outpatient comprehensive geriatric assessment (day hospital) in North Edinburgh ARC and OPRA (see below for further information) | 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. Referrals SCI Gateway via MoE WGH: MOE will allocate to ARC or OPRA Email contact for advice: loth.geriatricmednorth@nhs.scot |
| Outpatient Clinics | – Medicine for the Elderly – Parkinson’s and Movement disorders – TIA and stroke – Life after stroke | As well as MOE Clinics, MOE also run clinics for: – Parkinsons Disease/Movement disorder clinics for older people – Transient Ischaemic Attack (TIA) And Stroke |
J.B & A.C – 9-7-26
Medicine of the Elderly services in North Edinburgh are provided at both the Western General Hospital and Leith Community Treatment Centre.
Outpatient Comprehensive Geriatric Assessment Service (Day Hospital) – North Edinburgh
Leith CTC: Older Peoples’ Rapid Access (OPRA)
- Outpatient Comprehensive Geriatric Assessment Service for the Northeast Locality.
- Service run between 0800 – 1600 Monday to Friday.
- Patients have an initial telephone assessment and then a face-to-face appointment. Return visits are scheduled when required.
- Limited ambulance transport is available to and from appointments for those who need it.
Western General Hospital: Assessment and Rehabilitation Centre (ARC)
- Outpatient Comprehensive Geriatric Assessment Service for people living in the Northwest Locality.
- Service run between 0900 – 1600 Monday to Friday.
- Patients attend for the whole morning, to early or mid-afternoon (sandwich lunch provided). Return visits are scheduled, as necessary.
- Limited ambulance transport is available to and from appointments for those who need it.
Outpatient Clinics – North Edinburgh
Leith CTC Medicine for the Elderly
- Medicine for the Elderly, Parkinson’s, and Movement Disorders
Western General Hospital Medicine for the Elderly
- Medicine for the Elderly, Parkinson’s and Movement Disorders and Stroke
Who to refer
Patients aged > 65 with Clinical Frailty Scale ≥4 living in North Edinburgh, with any of the following
- Requiring outpatient comprehensive geriatric assessment including Admission Prevention or full medical and functional assessment
- Acute functional decline for multidisciplinary assessment
- Declining or reduced mobility
- Recurrent or unexplained falls
- Syncope or loss of consciousness
- Non-specific symptoms requiring further assessment e.g. dizziness, weight loss
- Abnormal blood tests, e.g. hyponatraemia and anaemia (including anaemia), which cannot be explained but also see Specialty ref Help pages first for useful advice.
- Review of complex polypharmacy after review by the Primary Care Pharmacy Team
For referrals re Parkinson’s Disease diagnosis and management please see separate guidance: Parkinsons (MoE)
Who not to refer
- Patients aged under 65 years (please discuss with on call consultant first)
- Unstable medical or clinical conditions requiring urgent assessment.
- Acute stroke or TIA
- GI haemorrhage
- Chest pain
- Acute cardiac problems
- Suspected DVT or PE
- Acute shortness of breath
- Head injury
- Trauma with injury
- Single organ pathology in an otherwise fit older person – please refer to appropriate specialty
- Patients whose needs can be addressed by community services e.g. only requiring occupational therapy and or physiotherapy (please see other pathways above)
- Patients who are unable or unwilling to participate in assessment, treatment, or rehabilitation
- Suspected Dementia and Cognitive impairment / Memory Clinic patients: Should be referred to Older Peoples Mental Health-Edinburgh – see RefHelp page for details of referral pathway
- Suspected Mood disorders: Should be referred to Older Peoples Mental Health-Edinburgh – see RefHelp page for details of referral pathway
- Parkinson’s and Movement Disorders patients: For referrals re Parkinson’s Disease diagnosis and management please see separate guidance: Parkinsons (MoE)
How to refer – North Edinburgh
Please refer via SCI Gateway, selecting Routine or Urgent
- Leith CTC >> Geriatric Medicine >> LI Basic Sign Referral
OR
- Western General Hospital >> Geriatric Medicine >> LI Basic Sign Referral
For advice or discussion about urgent referrals including Prevention of Admission, please contact the Consultant on call for MOE at WGH:
- Geriatric Medicine Advice Hotline: 0131 465 9107 (8am to 4pm Monday to Friday)
- Consultant on call for WGH MOE: 07815 493034
- Email: loth.geriatricmednorth@nhs.scot
Please consider
- Please refer the patient to the locality service (Leith or WGH) closest to their home address, please note the service will also review and decide on most appropriate service and location.
- A MOE consultant triages all referrals to the most appropriate service.
- The MOE consultant may contact the practice to ask for more information, provide advice, suggest an alternative pathway, or ask for additional investigations (e.g. blood tests) that have not been done prior to referral, this will ensure the MOE team have as much information as possible when assessing the patient.
- There is the same referral route for both Day Hospital and Outpatient Clinic Appointments. Referrers are welcome to note in the referral if they feel the patient would benefit from medical AND nursing or AHP input / full functional and multidisciplinary assessment (i.e. Day Hospital services)
- Please be aware that the AHP services available at Day Hospital are PT and OT.
- Dietetics and SALT are not part of the MDT and can be referred to by Primary Care directly.
- When a patient being referred has weight loss as part of their reason for referral please provide clear documentation of weight loss, when possible, noting actual weights along with total kg lost and/or total % of body weight loss. Please also consider if requires referral to Dietetics.
Please also consider if the primary care open access imaging is indicated
