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. Some of these services are Edinburgh wide, some of these services are particular to Edinburgh South. On this page you will find details of both the city wide and the Edinburgh South 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?) |
Frail and housebound or Care Home residents in South Edinburgh
| 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 loth.outpatientsegch@nhs.scot and referrals will be considered for Ellens Glen 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 loth.outpatientsegch@nhs.scot to arrange polypharmacy review with Geriatrician. Responsible GP/ANP expected at review on Microsoft teams or in person. |
Advice or Outpatients (including Day Hospital) in South Edinburgh
| Team / service | Patient need/ type of service required: | How to refer: |
|---|---|---|
| Advice or outpatients or day hospital in South Edinburgh (see below for further information) | 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 loth.outpatientsegch@nhs.scot Routine referrals SCI gateway via Ellens Glen Community Hospital >> Geriatric Medicine |
| 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 loth.outpatientsegch@nhs.scot |
Mental Health and / or Memory Assessment and Dementia Services
| Team / service | Patient need/ type of service required: | How to refer: |
|---|---|---|
| Rapid Response Team | MoE advice and / or outpatients / day hospital 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 |
J.B & A.C – 9-7-26
Outpatients – South Edinburgh and Midlothian
South Edinburgh and Midlothian MoE Outpatient Clinics including access to Comprehensive Geriatric Assessment (formerly Day Hospital) at Ellens Glen Hospital
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 Ellens Glen Hospital.
There is also a weekly clinic at Midlothian Community Hospital and Sighthill Health Centre. The Ellens Glen Hub is 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 Grace Lindsay. Speciality Doctor – Dr Claire Robson.
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 e.g. 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
- 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: Ellens Glen Community 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: loth.outpatientsegch@nhs.scot 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.
