Guidance for a deprescribing approach that can be implemented in care homes: STOPPING study findings and lessons
Authors: Warmoth K , Rees J , Day J , Cockcroft E , Aylward A , Pollock L , Coxon G , Craig T , Walton B , Stein K 
Published: April 2024

Abstract

Introduction
Care home residents often have multiple long-term conditions and experience polypharmacy. Deprescribing is the reduction or stopping of prescription medicines that may no longer be providing benefit. Deprescribing is generally safe but it is unknown how to make it work well in practice, like care homes. Current tools and approaches often overlook the specific contextual factors and various stakeholder views within care homes.

Aim
To inform the development of a deprescribing approach that can be implemented in care homes.

Methods
The findings from two qualitative work packages of the STOPPING project[1,2] were synthesised to develop a better deprescribing practice approach within care homes, considering different views and environments, and recommendations for designing a deprescribing approach for care homes. In total, 42 interviews were conducted with 36 participants (residents and their family members/friends, care home staff, and healthcare professionals) from 15 different care homes. A framework analysis approach, informed by the Consolidated Framework for Implementation Research (CFIR), was used to analyse data from both work packages. Similar and divergent determinants spanning all CFIR domains were aggregated. Then how and why key these factors operated were considered from generating relationships using conceptual mapping. Researchers and a family carer representative met regularly to discuss discrepancies and refine the themes.

Results
Key considerations for a deprescribing approach for care homes are: engaging multiple individuals and organisations; recognising their various roles, responsibilities, expertise, and beliefs; information access and sharing; and active monitoring of the impact of deprescribing. The guidance is presented as a cycle to illustrate deprescribing as a process, which then works through four implementation aspects: (1) Plan and coordinate, (2) Communicate and collaborate, (3) Access and share information, and (4) Monitor and evaluate. They are a guide rather than a rigid set of steps, as some activities overlap and feed into each other, and demonstrate how deprescribing for residents should be ongoing and iterative. Proposed actions to encourage deprescribing in care homes are provided for each implementation aspect and presented as questions for consideration. For example, in Plan and coordinate, one of the questions is ‘Are the goals of care with respect to medicine optimisation and deprescribing for residents established?’. The key factor influencing this guidance is the quality of local working relationships between care homes and primary care, which was more crucial than the type of care home organisation management structure.

Conclusion
Communication and collaboration between care homes and healthcare professionals (such as GPs, nurses, and pharmacists) are essential to ensure deprescribing is done well. A strength of the work is the use of a comprehensive, well-recognised implementation science framework; however, a limitation is that most participants were care home staff, so the findings reflect their perspectives and experiences. Further work is needed to develop tools and approaches that address how this can be achieved within current structures and limited resources of health and social care. The guidance, developed from the STOPPING project findings, suggests several courses of action for how to improve future deprescribing in care homes.

References
1. Warmoth K, Rees J, Day J et al. Determinants of implementing deprescribing for older adults in English care homes: a qualitative interview study. BMJ Open. 2023;13: e081305.
2. Warmoth K, Rees J, Day J et al. Assessing deprescribing tools for implementation in care homes: A qualitative study of the views of care home staff. Research in Social and Administrative Pharmacy. 2024;20(4):379–88.