Learning from proactive deprescribing experiences within the Care Homes Independent Pharmacist Prescribing Study to develop national policy regarding deprescribing in care homes for older people

Research question What are the individual and system level behaviour change components required to enable the creation of policy to inform and drive effective implementation of proactive deprescribing within the care homes setting?

Background Approximately half of older care home residents are prescribed at least one inappropriate medicine which can predispose them to adverse outcomes such as falls, morbidity and hospitalisation.

It is therefore important that inappropriate medicines are discontinued in a timely manner i.e. interventions implemented which effectively facilitate proactive deprescribing.

The NIHR funded Care Homes Independent Pharmacist Prescribing Study (CHIPPS) was designed to estimate the effectiveness and cost-effectiveness of pharmacist independent prescribers (PIPs) assuming responsibility for medicines optimisation in care homes.

The process evaluation found that proactive deprescribing varied within the 25 pharmacist prescribers from 3 medicines per 20 residents to 28 medicines.

We will use this experience to elucidate the barriers and enablers associated with deprescribing in the care home environment and develop appropriate policy. Aim To develop policy to support effective implementation of proactive deprescribing within care homes.

Objectives Describe the types of medicines commonly proactively deprescribed in CHIPPS and characterise variation in this behaviour within CHIPPS intervention care homes. Identify enablers and barriers to proactive deprescribing within CHIPPS intervention care homes.

Identify the mechanisms of action leading to proactive deprescribing and their linked Behaviour Change Techniques (BCTs).

Develop policy to support creation of the appropriate environment, training and inter-professional and patient relationships to implement proactive deprescribing in care homes.

Methods Phase 1: Secondary analysis of the existing CHIPPS proactive deprescribing data to identify trends and variation in practice.

Phase 2: Identify a purposive sample (according to Phase 1 trends) of CHIPPS practitioners and conduct semi structured interviews, informed by the Theoretical Domains Framework (TDF), to identify and prioritise the barriers, enablers and therefore relevant TDF domains pertinent to proactive care home deprescribing.

Phase 3: Based on Phase 2 data, for each identified TDF domain, identify all possible BCTs, to address the barriers and enablers.

Convene a modified Nominal Group Technique workshop to facilitate target audience selection and characterisation of BCTs to support implementation of proactive care home deprescribing.

Phase 4: Convene a policy development and dissemination working group of national opinion leaders to develop the policy to include guidance for addressing broader structural and system level considerations. Disseminate policy at national, regional and local levels.

Timelines for delivery Months 0-3: Phase 1 Ethical approval obtained Phase 2 Expressions of interest for Phase 2 participants Months 3 to 8: Phase 2 Ethical approval obtained for Phase 3 Participants for Phase 3 identified and recruited Data analysis iterative as data collated Phase 4 meeting organised Month 9 -10: Phase 3 Months 11-12: Phase 4 Policy dissemination to target audiences Dissemination and Impact Dissemination through relevant policy leads such as NHS England and Improvement, Department of Health and Social Care and deprescribing networks.

Impact will be better design of interventions to facilitate proactive deprescribing and ultimately more timely discontinuation of medicines whereby risks outweigh the benefits.