The specialist old age psychiatry team

The specialist team consists of the consultant psychogeriatrician, hospital and community nurses (often trained in both the physical and psychiatric care of the elderly), social workers, occupational therapists, recreation therapists, physiotherapists, psychologists, and clerical staff. Although often hospital-based, the team carries out its most important role in the community and in collaboration with community agencies. The WHO-WPA recommends that the initial psychiatric assessment be held in the patient's home, and this is the practice in many areas, most notably the United Kingdom, where the system has been designed around the principle of domiciliary care. During a home visit, the history can be taken, the patient and family can be interviewed, and the environment as well as the support system assessed, with risk factors being identified in a more comprehensive way than is possible in an office-based interview. Home assessments are carried out by two team members, preferably one being a physician, and the findings and treatment plan discussed in a team conference. Team members are assigned and a follow-up plan is established at the first conference. If necessary, inpatient, day-care, day-hospital, or long-term care admission can be arranged, and families can be assisted with other interventions found to be necessary, such as durable power of attorney. All efforts are made to maintain the patient in her home. The specialist team can assist the primary care team by carrying out further diagnostic evaluation and treatment and developing a care plan for the patient that can be continued after discharge, the team can also remain available for support and follow-up on an as-needed basis after the patient has stabilized. Moreover, the team should function as an educational resource for primary health-care providers, long-term care staff, and the community.

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