Complexity and creativity: Optimising medicines in care homes

Stephanie Park is a care homes pharmacist in Northern Ireland.  She works as part of the region’s Medicines Optimisation in Older People (MOOP) team as Lead Care Homes Pharmacist, Northern Health and Social Care Trust.

Bethan Warner is a care homes pharmacist in South East London. She works with care homes with nursing in Lambeth and Southwark, leading a team of pharmacists and a pharmacy technician as Principal Pharmacist for Care Homes, Guy’s and St Thomas’ NHS Trust, London. She tweets at @Bethan_Pharm. 

Medicines in care homes

In 2009, the Care Homes Use of Medicines Study (CHUMS1) observed that 70% of people living in a care home encountered at least one error with their medicines. These errors have the potential to exist at the same level today, and stem from a multitude of factors – polypharmacy, multimorbidity, limited medication reviews and the complexities of ordering, storing and administering an average of eight medicines per person. This landmark study spurred numerous initiatives across the UK aimed at providing equity of access to pharmacists and pharmacy technicians for people who live in a care home. We know that these residents can experience worse care simply due to where they live. Care Home Pharmacists carry out important work in addressing this inequality, and aim to move the dial towards the delivery of personalised, “care-home centred” care, which works better for residents and the people who support them. 

Focus on polypharmacy

For many older people in our communities living with frailty, ‘polypharmacy’, the prescribing of multiple medicines, is a well-established practice. Ensuring polypharmacy is reviewed and appropriate for the person is recognised as necessary by the BGS's Joining the dots: A blueprint for preventing and managing frailty in older people. Polypharmacy can be the right choice when medications are being frequently reviewed and prescribing is in line with a common goal shared between the multidisciplinary healthcare team and the person themselves. But all too often, people in care homes are taking medicines that they might not need, or which they would like to stop taking but need support to be empowered to do this. 

Case Study: Stephanie’s Experience as a Care Home Pharmacist 

For the last 7 years I have been carrying out medication reviews and optimisation in care homes across the trust I work in. Traditionally the focus of my role has been reviewing the medications of people over 65 years who live in nursing homes. These clients tend to be living with severe frailty (Clinical Frailty Scale 7-9).  Deprescribing for these clients is common to reduce their medication burden, limit unwanted side effects and ensure positive outcomes to improve their quality of life. Recently I have spent more time reviewing the medications of those in residential homes. These clients tend to be living with mild to moderate frailty (Clinical Frailty Scale 5-6). For those living in residential homes, in addition to the benefits seen for nursing home residents, I have also found medicine optimisation to be beneficial for preventing falls, and possibly limiting the progression of their frailty.

Those who know me know how passionate I am about the importance of medication review and medicine optimisation to prevent harm and improve outcomes for our ageing populations. As someone who struggles to take a supplement daily, or an antibiotic when I need to, I understand the burden daily medications can be for people. There is nothing I like to do more than try to reduce that burden for those living with frailty.” 

Tips for polypharmacy professionals working in care homes

Sharing expertise

Working with care home staff to address learning needs related to medications and the management of specific conditions is a deeply rewarding aspect of the care home pharmacist's role. While medications are typically reviewed on a resident-by-resident basis, educating care home staff enables pharmacy teams to equip them with the skills to recognise when a medication review might be necessary or when side effects may be occurring. This collaborative approach ensures that we can work together to support care home residents in achieving their individual health goals with the most appropriate medications tailored to their needs. 

Targeting populations where medication review is most beneficial

Often there are more residents to be reviewed than time to review them – targeting an “at-risk” population is useful, but we also recognise that care home residents are a complex group of people, with high needs and likely to be prescribed an average of 8 medicines. So if in doubt who to start reviewing, just start! 

Find your network

As Care Home Pharmacists, we are experts in generalist pharmacy care being delivered in the specialist care home setting. Finding your local network of specialist pharmacists, medical professionals, nurses and AHPs is a necessity to be able to review medication in care homes. Decisions about medicines in this under-researched population can be difficult and input from the multidisciplinary team is needed.