Summary of the example
The Care Home improvement team in Herts valley CCG is a multidisciplinary team which includes pharmacists, nurses, emergency care practitioners and GPs in an advisory role. They work collectively with the homes to improve the quality of care and reduce hospital admissions.
A multidisciplinary approach is used to deliver medicines optimisation in care homes and achieve patient orientated outcomes by conducting focussed comprehensive medication reviews. Pharmacists work with residents, their families and carers, care home staff and GPs to review and optimise their medicines and improve their quality of life.
Why we think it’s important
Potentially inappropriate polypharmacy is the prescribing of multiple medicines inappropriately, or where the intended benefit of the medicines are not realised. The risk of harmful effects and hospitalisations increases when patients are taking many prescription medicines.
A comprehensive medication review is a systematic process of collecting patient specific data, assessing medication therapies to identify medication-related problems, prioritizing a list of medication-related problems, and creating a plan to resolve them with the patient, caregiver, and prescriber
Deprescribing forms part of comprehensive medication review and is part of good prescribing.
The inappropriateness of polypharmacy should be judged on a case by case basis and a structured approach to reducing polypharmacy – including deprescribing can support this.
Learn more about the example
Aims and objectives of the work
The overall aims of the care home pharmacy service is to:
- Optimise use of medicines prescribed for residents in the care home setting
- Reduce the risk of medicines related hospital admission
- Reduce medicines wastage
Deprescribing is an active process of tapering, withdrawing, discontinuing or stopping medicines to reduce potentially problematic polypharmacy, adverse drug effects and inappropriate or ineffective medicine use by regularly re-evaluating the ongoing reasons for, and effectiveness of medication therapy. The overall goal of deprescribing is to maintain or improve quality of life.
A standard operating procedure (SOP) describes the process for the Medicines Optimisation (excluding preparation and delivery of informal and formal training).
- Identifies the care home using defined criteria
- Liaises with the care home and the GP practice using standardised checklists
- Arranges initial access to the care home
- Prioritises patients and then undertakes the medication reviews in the care home using a 3 step process
- Links the reviews with systems & process reviews
- Arranges a follow-up GP meeting
- Provides feedback (written communication) to the care home and community pharmacist
- Follows reporting, safeguarding and information governance processes
The SOP includes all necessary associated paperwork, checklists, letter templates, posters and other useful information used to aid the process. The medication reviews and any subsequent deprescribing follow criteria mentioned in the SOP.
In general, the evidence to support deprescribing as a measure to improve clinical outcomes is weak. However literature indicates that when the evidence about deprescribing is organized by the intentions to stop drugs that are no longer indicated, that are no longer appropriate or that no longer align with goals of care, deprescribing appears to be potentially helpful without causing substantial harm.
This work recognises some of the barriers and challenges to deprescribing which include:
- Establishing a successful deprescribing plan takes time and open discussion between those involved
- Variation in stopping preventative medication by GPs due to lack of evidence i.e. primary prevention
- Difficulty in explaining to patient’s about their life expectancy vs. goals of treatment
- Addressing patient’s belief
- Reluctance to stop medications started in secondary care
- No obvious harm from polypharmacy so clinicians reluctant to deprescribe
Patient examples have added to the findings:
- Patients are treated with dignity and respect
- There is a reported reduction in the cumulative side effects of medicines
- Patients report finding it easier to take fewer medicines
For example, in the case explained, the number of medicines decreased from 17 before the review to 9 after the review. There was also financial benefit to the CCG described in the example given in the order of £1,000 a year.
Ratification of the SOP is awaited and will appear on this site in due course.
National guidance, data and publications
Links below to useful national guidance and other publications.