The Health Innovation Network Polypharmacy programme is working with healthcare professionals to address problematic polypharmacy by supporting easier identification of patients at potential risk from harm from multiple medications. Our evidence-based polypharmacy Action Learning Sets (ALS) are being rolled out across England to support GPs, pharmacists and other healthcare professionals who undertake prescribing or medication reviews to understand the complex issues around stopping inappropriate medicines safely. To drive and accelerate changes in practice, delegates complete a quality improvement project to address problematic polypharmacy in their workplace. This poster summary, Comprehensive and person centred approach to addressing Polypharmacy in adult care home residents, can be viewed here. For more information about the polypharmacy programme, please visit https://thehealthinnovationnetwork.co.uk/programmes/medicines/polypharmacy/

1. Comprehensive and person-centred approach to addressing
polypharmacy in adult care home residents
Background
Polypharmacy is the use of multiple medicines and tends to
be a common occurrence amongst elderly care home
residents. Evidence shows that the average number of
medicines care home residents tend to be on is 7 per day (1).
With substantial and increasing medication use, there is also
a growing risk of harm and admissions to hospital. According
to evidence, medication contributes towards approximately
5 – 20% of admissions and readmissions into hospital (2).
Results/Data (also see above)
6 patients were recruited for the project and a total of 59 medicines were reviewed. Out of the
total number of medicines reviewed, 24% were recommended to be deprescribed or stopped
(figure includes prescribed as well as over-the-counter medicines).
A total of 49 pharmaceutical interventions were communicated to the multidisciplinary team
(approximately 6 interventions per patient), and each intervention was assigned a severity
grading between I to V. The most common intervention grade was Grade III. The interventions
belonged to various different types of categories such as medication formulation changes,
documentation/record keeping advice, deprescribing recommendations, medication monitoring
advice and more. It is estimated that 10 of the interventions recommended by the Care Home
Pharmacist (20%) may have prevented potential call-outs to the London Ambulance Service
(LAS) and/or admissions into hospital.
Manisha Bhatt, Care Home Lead Clinical Pharmacist, The Hillingdon Confederation CIC
Understanding some of the (national) challenges:
• Lack of patient involvement
• Silo working and lack of joint-up care across
organisations/services
• Difficulties with achieving consistency of care
• High risk of medication errors/incidents in care homes
• Care home staff knowledge gaps/training requirements
Care home residents are therefore at high risk of inappropriate and
problematic polypharmacy
Method
Patients were flagged initially via an established local
referral system and the study period spanned from
16/12/2022 to 18/01/2023. The criteria for referral
included care home/extra care housing residents
registered with any GP practice that was a member of the
local GP Federation (alongside additional criteria) and
referrals were sent directly to the Care Home Pharmacist
by healthcare professionals working across the healthcare
system, including GPs and Care Home Matrons. Following
receipt of the referral, patients who were identified to be
on 2 or more medicines were automatically selected to be
included in the study. For the purpose of this project the
number of medicines defining polypharmacy was in
accordance with the definition stated in the NHS Scotland
Polypharmacy Guidance document (3).
Medication reviews were conducted and a personalised
approach (tailored to the individual patient),
multidisciplinary working and principles of shared
decision-making with patients/carers were applied. This
was followed by documentation of the medication review
outcomes, findings, queries and recommendations etc. on
the GP EMIS system and a notification email was sent to
the GP practice. A copy of the consultation note was also
securely emailed to the care home team alongside a
request to share with the community pharmacy if
appropriate.
Medication and interventions data was recorded on a
Microsoft Excel spreadsheet to facilitate data analysis.
What went well during the project Some challenges encountered during the
project
Multidisciplinary team helped to identify
patients requiring medication reviews via local
referral system and locally agreed referral
criteria.
Some patients were not willing to engage in an
open discussion regarding their medication.
Some of the learning from Polypharmacy
Action Learning Sets was usefully applied
during the project e.g. terminology used with
patients when it came to discussions regarding
potentially withdrawing their medication.
Some resistance was initially encountered
from a patient when advice to stop a particular
medicine was given.
Good multidisciplinary and partnership
working made the process more efficient e.g.
from identification of patients requiring a
medication review to completing the review
with various interventions made successfully.
IT limitations and lack of shared information
records/systems made the review process
more time consuming.
0
2
4
6
8
10
12
14
16
18
20
Grade I - Good
practice was
implemented, but
there was no intent
to have a clinical
effect on the patient.
Grade II - The
contribution was of
minor benefit to the
patient, prevented
minimal harm or
prevented the need
for extra patient
observation
Grade III - An incident
or situation which
could have led to an
increased length of
stay was prevented
or improved upon OR
A change was made
to ensure that
evidence-based
standards of
treatment and/or
clinical protocols
were followed.
Grade IV - Potential
readmission, transfer
to an increased level
of care or reversible
organ failure or harm
was prevented.
Grade V - A life or
death situation,
permanent organ
damage, permanent
or severe harm was
prevented.
Grading of Interventions Recommended by Care Home
Pharmacist
Aim
This mini project focussed on evaluating the effectiveness
and impact of medication reviews conducted for adult
care home/extra care housing residents on 2 or more
medicines, with the aim of reducing inappropriate
polypharmacy and optimising outcomes with medication
use.
59
Total number of medicines
reviewed
Estimated number of LAS call-outs /
hospital admissions potentially prevented
10
Total % of medicines recommended
to be stopped/deprescribed
24%
Total number of medicines recommended to
be stopped/deprescribed
14
Total number of interventions
relayed to MDT
49
Some change ideas for consideration…
Conclusions/Some Lessons Learned
• Inappropriate polypharmacy is a complex issue which needs to be resolved via a
multifaceted approach.
• Comprehensive structured medication reviews by Pharmacists combined with shared
decision-making and joint multidisciplinary working can significantly reduce the
likelihood of inappropriate polypharmacy in care home residents.
• It is vital for adequate time to be allocated for these comprehensive reviews and for
follow-up reviews as required, to deliver high qualities/standards of care.
• Having access to all of the necessary information and patient history is crucial for
being able to intervene effectively.
• Pharmaceutical interventions can significantly contribute towards reducing
medicines-related harm, hospital admissions and costs.
Some limitations of the project
- Small sample size (sample size to be increased if project repeated and more time
available)
- Grading of interventions was subjective (peer reviews would be beneficial if project
repeated)
References
1. The Royal Pharmaceutical Society (2016) The Right Medicine – Improving Care in Care homes. Available from: https://www.rpharms.com/
2. Barnett N., Athwal D. and Rosenbloom K. (2011) Medicines related admissions: you can identify patients to stop that happening. Available from: https://www.pharmaceutical-
journal.com/learning/learning-article/medicines-related-admissions-you-can-identify-patients-to-stop-that-happening/11073473.article?firstPass=false
3. NHS Scotland (2018). Polypharmacy Guidance Realistic Prescribing; 3rd Edition 2018. Available from: https://www.therapeutics.scot.nhs.uk/wp-
content/uploads/2018/04/Polypharmacy-Guidance-2018.pdf