DME (Care of the Elderly) (GP information)
Introduction
Our Department of Medicine for the Elderly (DME) prides itself in offering comprehensive care for older adults, through close interdisciplinary working between nurses, therapists, pharmacists, dietitians, social workers and other health professionals. Our care is truly patient and family centred, with patient safety at the heart of everything we do.
We provide a full range of general and specialist medical services for older people both on an inpatient and outpatient basis. We recognise that our patients’ situations can be very complex so their physical, social and emotional needs are also addressed. The team works in close collaboration with community, mental health and social services, to ensure that care is provided in an integrated and seamless fashion to ensure all our patients receive the very best clinical outcomes in the most appropriate healthcare setting.
Our staff care passionately about improving the quality of life for our elderly patients so that they can live as independently as possible, with fast access to all of the support that they need.
We are pleased to give all our patients equal access to specialist assessments and medical treatments – regardless of their age.
The frailty ‘silver’ phone is available Monday to Sunday, 8am to 8pm on 07971 037 491.
We are here to support with:
- People with complex co-morbidities
- Frequent users of GP or acute services
- Complex medical/social problems including cognitive impairment and capacity issues
- Frail; unwell older people with unexplained illnesses or decline in function who you feel might need admission if not assessed quickly, including fallers
- Anything else the GP requires support with.
We can provide:
- Advice and guidance where this would avoid unnecessary hospital admission
- Support in decision making
- Signposting to alternatives to admission
Patients with ? stroke or ? fractured hip
Specialist OPD
- Parkinson’s and Movement Disorder
- Syncope and Transient Loss Of Consciousness
- Falls and Bone Health
- via email at ldhtr.dmesecretaries@nhs.net
Same day emergency care
- Urgent review by MDT
- Rapid access to diagnostic and investigations
- Comprehensive Geriatric Assessment
Person must be able to tolerate sitting for at least 4 hours. Person must be able to transfer either independently or need +1 support.
Virtual MDT
- Available 1-2pm Monday to Friday via Microsoft Teams
- Available for any patient requiring multi-professional discussion for complex care
- Support with complex case management.
Virtual follow up
- With community support and a dedicated Geriatrician to review all investigations and test, then a follow up by Frailty Nurses.
ED Frailty Pathway
- 90 year old
- 75 year old with 2 Frailty Syndrome
- 65 year old from care home or nursing home.
BGS: Fit for Frailty
Consider referral to geriatrician when:
- Significant complexity
- Diagnostic uncertainty
- Challenging symptom control.
Referral Process
All of our Medicine for the Elderly (DME) outpatient services are available via E-RS.
Procedures Provided
Inpatient – Acute medical and inpatient rehabilitation for adult patients with multiple conditions, with complex medical and care needs (78 years or older with acute medical problems or 65 years and older if living in a residential / nursing home or already attending outpatient clinic). There are two dedicated DME wards which are led by senior nursing members of staff with the support of the Complex Medicine Divisional Matron. Both wards have dedicated medical teams lead by DME Consultants where all patients are reviewed on a daily basis by one of the DME Consultants (7 days a week) either via a full board or ward round. Furthermore, the DME team provide a full interprofessional referral service (Yellow Board) for any patient who isn’t residing on either of the DME wards.
Specialist inpatient care – Frailty Service and Orthogeriatrics Rehabilitation. These two sub specialities are Consultant led services offered at the L&D but incorporate the full MDT (nursing, therapy, social services and discharge planning teams).
Navigation Team / Hospital at Home (H@H) – These teams are currently led by Matron Vanda McGibbon. The Hospital at Home team helps to facilitate early discharges for all inpatients (not just DME) from hospital who no longer require their treatment to be provided in an acute hospital setting. The clinical navigation team work in collaboration with the Trust’s Emergency Department, Acute admission wards, inpatient therapy teams and Social Services to avoid unnecessary hospital admissions and help to ensure all patients are cared for in the most appropriate environment.
Clinics
General Elderly Medicine Clinics:
These clinics are run by all of the DME consultants on a varying frequency and can be referred into via your local GP, other medical staff or by one of the DME consultants following an inpatient hospital stay. A variety of general health issues relating to elderly medicine patients can be discussed during these clinics.
Osteoporosis and Metabolic Bone Disease Clinic:
This specialist clinic is currently run by Dr Chanda as the Orthogeriatric Consultant for the Trust, who works closely with other DME and Orthopaedics colleagues.
Parkinson’s Disease / Movement Disorder Clinic:
Dr Nawaratne Wijayasiri runs this specialist clinic on a weekly basis in collaboration with the Trusts Neurology department. A referral into this clinic for elderly patients can be made via your local GP.
Transient Loss of Consciousness (Falls):
Dr Didi runs this specialist clinic on a weekly basis with the support of other senior DME doctors and the Trust’s Falls Specialist Nurse, Sandra Cowley. Patients can be referred into this clinic via your local GP or following a recent hospital admission.
Transient Loss of Consciousness (Arrhythmia):
As per above.
Patient Information Leaflets
Clinicians - Consultants/Specialist Nurses
DME (Care of the Elderly)
DME (Care of the Elderly)
Useful Contacts
pals@bedfordhospital.nhs.uk
John.Fitzmaurice@ldh.nhs.uk
Mohamed.Didi@ldh.nhs.uk
PALS@ldh.nhs.uk