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Collaboration between geriatricians and psychiatrists

Guidelines for collaboration between physicians of geriatric medicine and psychiatrists of old age

A joint policy statement by the British Geriatrics Society and the Royal College of Psychiatrists

The following principles should apply:

  1. Specialist Services for older people should be seamless for all users. Transfers should be smooth and mutually agreed by the professionals to ensure the most appropriate management of individual patients, even when an initial referral was not to the most appropriate provider.
  2. Seamless does not mean a loss of specific skills of the particular professions and facilities within the service, or the patients’ right of access to them (wherever they may reside).
  3. Access to assessment by physicians in geriatric medicine and psychiatrists of old age must be included as an essential component of local delivery plans for older people’s services. Where appropriate, this should include involvement of the specialties in assessing older people at the transition between care at home and care in a ‘home’.
  4. Adequate resources in the whole range of geriatric medicine, the psychiatry of old age and social services provision are required to draw up Community Care Plans and for the best management of individual older people.
  5. Clear criteria for division of responsibility must be known and accepted both inside and outside the specialties. Responsibility should be determined by the assessed clinical and care needs of the patient, not by quirks of referral or exigencies of resource constraints (e.g. bed shortages).
  6. Some patients fall into a “grey area” where they might appropriately be dealt with by either service. This then becomes a matter for negotiation between the two services, but the service which first made contact should retain ultimate responsibility until placement is agreed. No patient should be allowed to “fall between two stools”.
  7. Liaison between the two specialties should be included in “Consultant Job Plans”, “Service Agreements” and “Business Plans”. Effective liaison requires good lines of communication (verbal and written) which will foster mutual confidence and trust. Liaison between the services should involve all professional groups.
  8. Mutual confidence requires understanding of each other’s disciplines. Some reciprocal training in each other’s specialty should be mandatory for accreditation for higher professional training. The presence of a physician in geriatric medicine as an additional member on the appointment panel for a psychiatrist of old age, and vice versa, is desirable.
  9. Both physicians and psychiatrists should be able to make diagnoses of delirium and dementia, assess their severity and carry out appropriate investigations. Where the investigation and management of delirium requires more than basic medical care, the physicians should be responsible. Where there are concerns about a patients capacity for decision making the responsibility for assessment and recommendations rests with the clinical team treating the patient working within the framework of the relevant capacity legislation.
  10. The presence of behavioural and psychological symptoms of dementia, except in the very few cases where physical dependency needs are paramount, would indicate responsibility for management lies with psychiatric services.
  11. Assessment units should be easily accessible, preferably both on the general hospital site, to allow easy transfer of patients if health needs changes
  12. When older people are admitted to hospital there should be a clear local arrangement to gain assessment easily when another speciality opinion is required. For patients in acute hospitals with mental health needs the developing model of multidisciplinary liaison psychiatry based in the acute hospital is preferred. Some patients with complex physical and mental health needs would benefit from a shared care ward.
  13. The currently assessed health needs of patients at home rather than their past medical or psychiatric history should determine their referral and placement.
  14. Speedy systems of cross-referral between physicians and psychiatrists should be established to expedite a patient’s passage through the care management process. The speed of response depends on the clinical urgency.
  15. Joint assessment depends more on the good will and co-operation of professional colleagues than on the presence of a specifically joint assessment unit. However, separate assessment units should be reasonably accessible, preferably both on the District General Hospital site.
  16. These principles of collaboration also apply to physicians and psychiatrists who combine general medicine or psychiatry with a special interest in, or responsibility for, older people. The guidelines are as relevant to the management of patients referred from other hospital settings (e.g. orthopaedic wards), as they are to those in the community or already within geriatric or psychiatric facilities.
  17. Representatives of consultants in both geriatric medicine and the psychiatry of old age should have continuing involvement in, and influence on, the Joint Planning of services by local health and social services.

Review date: November 2010

Authors: Duncan Forsyth , for BGS Policy Committee
Dave Anderson, for Faculty of Old Age Psychiatry

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