{"id":28841,"date":"2026-07-09T10:41:08","date_gmt":"2026-07-09T09:41:08","guid":{"rendered":"https:\/\/apps.nhslothian.scot\/refhelp\/?page_id=28841"},"modified":"2026-07-16T14:38:08","modified_gmt":"2026-07-16T13:38:08","slug":"moe-edinburgh-south","status":"publish","type":"page","link":"https:\/\/apps.nhslothian.scot\/refhelp\/moe-edinburgh-south\/","title":{"rendered":"MoE Edinburgh South"},"content":{"rendered":"\n

MoE Edinburgh specialise in Comprehensive Geriatric Assessment for the frail elderly. We recommend you use the Rockwood Clinical Frailty Scale <\/strong><\/a>in all referrals and your clinical practice.<\/p>\n\n\n\n

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.<\/p>\n\n\n\n

Edinburgh Wide Community Services including Prevention of Admission and Hospital at Home<\/h4>\n\n\n\n
Team \/ service<\/strong><\/th>Patient need\/ type of service required:<\/strong><\/th>How to refer:<\/strong><\/th><\/tr><\/thead>
Risk of admission<\/strong><\/td>Urgent (same day) Social Care intervention<\/td>If the patient is at imminent risk of hospital admission follow the Urgent Therapy and Social Care pathway<\/a> by checking the referral criteria. Call the Flow Centre<\/a> 8:30am to 2pm on 0300 013 4000 option 1 and 4, or Social Care Direct<\/a> on 0131 200 2324 outwith these times.<\/td><\/tr>
Edinburgh Hospital at Home (H@H)<\/strong><\/td>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.<\/td>		Referral is via Flow Centre.
Please see Edinburgh H@H RefHelp page<\/a> for referral criteria and referral process<\/td><\/tr>
Out of Hours Edinburgh H@H<\/strong><\/td>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.<\/td>		Please see Edinburgh OOH Hospital at Home page on RefHelp<\/a><\/td><\/tr>
Considering admission for bed-based rehabilitation<\/strong><\/td>Patient requiring a community bed for intercurrent illness with rehab needs
(Ellens Glen Hospital Ward 2 or Findlay Hospital ward 2)<\/td>		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. <\/td><\/tr>
Considering admission for complex care for frail, complex, palliative, or end of life care<\/strong><\/td>Patient requiring a community bed for frail, complex, palliative or end of life care in Ellens Glen Hospital Ward 1 (9 beds) and\u00a0cannot<\/strong>\u00a0be supported via by Hospital at Home<\/a>, Hospice services<\/a> or urgent Care Home referral via social care direct.\u00a0<\/td>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\u00a0loth.aahdischargehub@nhs.scot<\/a>\u00a0for advice. This email inbox is monitored regularly throughout the day Monday to Friday.
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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.
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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.
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Bed availability cannot be guaranteed.<\/strong>\u00a0<\/span><\/td><\/tr>
Social Care Direct<\/strong><\/td>Urgent and non-urgent PT \/ OT \/ Social Care advice or intervention<\/td>0131 200 2324 <\/strong>
Email: socialcaredirect@edinburgh.gov.uk <\/a><\/td><\/tr>
Community Falls services<\/strong><\/td>Patient experiencing falls<\/td>See full list of falls resources at Edinburgh Falls RefHelp Edinburgh Falls on RefHelp<\/a><\/td><\/tr>
Physio@Home<\/strong><\/td>Physio at Home for Housebound<\/td>SCI gateway referral
If urgent then can call directly: see Edinburgh Physio@Home RefHelp page<\/a> for Professional to Professional phone number<\/td><\/tr>
IMPACT<\/strong><\/td>ANPs, DNs and staff nurses in long term conditions<\/td>SCI gateway referral
Please see IMPACT RefHelp page<\/a> for referral criteria and for contact details for Professional to Professional discussion if required.<\/td><\/tr>
Primary Care Pharmacy Team<\/strong><\/td>Polypharmacy reviews (including for Care Home Patients)<\/td>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?)<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n

Frail and housebound or Care Home residents in South Edinburgh<\/h4>\n\n\n\n
Team \/ service<\/strong><\/th>Patient need\/ type of service required:<\/strong><\/th>How to refer:<\/strong><\/th><\/tr><\/thead>
Frail and housebound in SE locality<\/strong><\/td>MoE advice to SE hub teams for frail and housebound<\/td>Email\u00a0loth.outpatientsegch@nhs.scot<\/a> and referrals will be considered for Ellens Glen Hub review or ANP home visit.<\/td><\/tr>
Care home polypharmacy reviews<\/strong><\/td>MoE supported care home polypharmacy review<\/td>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\u00a0loth.outpatientsegch@nhs.scot<\/a> to arrange polypharmacy review with Geriatrician. Responsible GP\/ANP expected at review on Microsoft teams or in person.<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n

Advice or Outpatients (including Day Hospital) in South Edinburgh<\/h4>\n\n\n\n
Team \/ service<\/strong><\/th>Patient need\/ type of service required:<\/strong><\/th>How to refer:<\/strong><\/th><\/tr><\/thead>
Advice or outpatients or day hospital in South Edinburgh
(see below for further information)<\/strong><\/td>		MoE advice and \/ or outpatients \/ day hospital including blood transfusions South Edinburgh
See DOOGAL if any uncertainty on what area patient is in<\/a><\/td>		Urgent<\/strong>
Flow Centre 03000 134 000 Option 1 & 4 and ask for Duty Geriatrician on for Edinburgh H@H.
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Outpatients usually available within 2 working days depending on transport.

Advice<\/strong>
Email\u00a0loth.outpatientsegch@nhs.scot<\/a>
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Routine referrals<\/strong>
SCI gateway via Ellens Glen Community Hospital >> Geriatric Medicine<\/td><\/tr>
Specialist clinics<\/strong><\/td>Specialist clinics for movement disorders, TIA and stroke, Life after stroke<\/td>Parkinsons Disease\/Movement disorder clinics for older people on RefHelp<\/a>

Transient Ischaemic Attack (TIA) And Stroke on RefHelp<\/a><\/td><\/tr>
Polypharmacy reviews<\/strong><\/td>MoE advice to Edinburgh Primary Care Pharmacy Teams and GPs for polypharmacy or high-risk medicine reviews<\/td>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 \u2013 13.00 if required.
Specific Geriatrician advice can be sought via email\u00a0loth.outpatientsegch@nhs.scot<\/a><\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n

Mental Health and \/ or Memory Assessment and Dementia Services<\/h4>\n\n\n\n
Team \/ service<\/strong><\/th>Patient need\/ type of service required:<\/strong><\/th>How to refer:<\/strong><\/th><\/tr><\/thead>
Rapid Response Team<\/strong><\/td>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.\u00a0<\/td>Please see Rapid Response Team \u2013 Edinburgh on RefHelp<\/a><\/td><\/tr>
Edinburgh Community Mental Health
Teams for Older People<\/strong><\/td>		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\u00a0<\/td>		Please see Older Peoples Mental Health-Edinburgh on RefHelp<\/a><\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n

J.B & A.C – 9-7-26<\/strong><\/p>\n\n\n\n