Lending a Hand to Create a Trusting Environment: How Brown Bagging Can Bring Clarity

Brown-bag consults can be essential educational and safety tools to measure and ensure quality care. By asking patients to bring in all of their current medications, including OTC, mail order, specialty, and herbal products, pharmacists can guarantee appropriate and up-to-date care.

Pharmacists are key providers in the continuum of care, consistently helping to identify potential problems and concerns that may require follow-up with prescribers or a medication therapy management (MTM) session. It is essential that a pharmacist’s workflow allow for brown-bag consults, which can do the following:

• Develop the pharmacist—patient relationship to help create better individualized service, forge patient loyalty and trust, and prevent medical errors
• Provide insight into a patient’s lifestyle and quality of care
• Show how well patients understand their conditions and medications

Offering to review medications one-on-one can give the pharmacist an opportunity to personally connect with patients by serving as the trusted professional within the community. Brown bag sessions for patients living with chronic disease states do not have to be time-consuming scheduled events. They can be offered anytime when you feel a patient needs follow-up care after a typical counseling session.

Patients suffering from a chronic disease state such as diabetes can benefit from brown bag sessions and MTM. A pharmacist’s involvement may aid with a patient’s understanding of complex therapy, help enhance adherence, and ultimately affect overall outcomes.

MR is an overweight 67-year-old man who has been coming to the pharmacy for the past 6 months. Over this time, you have seen him become forgetful and noncompliant with various drug regimens, because of his complex toward medications, lack of interest in his care plan, and multiple disease states. MR does not ask questions anymore, has gained weight, and seems negative about his therapy and stressed about the financial impact of his health. You ask if he would be interested in participating in a brown bag session. You explain what happens during a brown bag consult and tell MR that you are interested in reviewing and re-educating him on his medications, which will allow him to maximize their use. It may also have a positive financial impact and ideally improve MR’s overall attitude and health. He smiles, appreciating the opportunity to talk with you in depth, one-on-one. MR schedules a time with you after his upcoming doctor’s appointment to bring in all of his laboratory updates and medications.

Upon reviewing his medication profile at the pharmacy, you find the following:

• Dapagliflozin, 10 mg, every morning
• Furosemide, 40-mg tablet, daily
• Enalapril, 20-mg tablet, daily
• Metformin, 500 mg, twice daily
• OTC enteric-coated aspirin, 81 mg, daily
• Rosuvastatin, 20 mg, daily

When MR comes in for his session, you notice the following additional medications in his brown bag:

• One Touch Verio Flex meter and test strips
• OTC aspirin, 325-mg tablets
• OTC daily multivitamin
• Used insulin (insulin + insulin glargine) vials, expired October 2017, unlabeled
• Various used and expired dapagliflozin samples

After reviewing the medications in MR’s possession, you realize that he would benefit from an MTM session, and you schedule a follow-up appointment. An MTM session will allow you to further communicate with his health care providers, evaluate his medical goals, and review lab values, as well as give you the opportunity to offer in-depth diabetes education, as requested by MR. He admits to having a fear of needles, so he stopped using his insulin; and to being regularly short of breath. This brings up some questions surrounding MR’s medications and suggestions:

He says that he used to have a “breathing inhaler and wants one again to help him move around better and exercise.” MR’s weight makes it very hard for him to “get air.” You ask if he was ever diagnosed with asthma, and he cannot confirm. You offer to contact MR’s primary care provider for immediate follow-up so proper care options can be assessed.

You notice that MR’s dapagliflozin, enalapril, furosemide, and metformin bottles contain many split pills, conflicting with the prescribed dose and directions. He says that he has been cutting all his tablets in half to save money. You also see that his compliance has been off, in your computer system. You ask MR about this, and he says that his providers are unaware of his manipulation. You explain that medications are studied and how dosing medications properly for efficacy is important. You notify the provider immediately after you note that MR’s blood pressure is well above >130/80 mm Hg.

You ask MR about his blood sugar testing regimen and his expired insulin vials. MR says that he stopped using insulin on a regular basis last year, that he does not test his blood sugar on a regular basis because he finds his meter very confusing. He says that the cost of supplies and a his fear of needles and bruising compromises his adherence. You educate MR about the importance of knowing his goals and numbers. You also offer him an opportunity to practice his testing technique so that he gets more comfortable with his meter.

What else would you suggest to MR before his MTM session?

Jill Drury, PharmD, is a clinical pharmacy specialist in Chicago, Illinois, and Milwaukee, Wisconsin. She earned her doctor of pharmacy degree from Midwestern University College of Pharmacy.