You Cannot Beat a Healthy Heart: 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 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 identifying 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 pharmacists the opportunity to connect with patients by serving as trusted medical professionals in 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 a pharmacist thinks that a patient needs follow-up care after a counseling session.

Patients who suffer from chronic conditions may be at a higher risk for medical-related episodes and errors. These patients take many different medica- tions, visit a variety of health care providers, and may use more than 1 pharmacy. Often patients experience long- or short-term changes in their health, which require adjustments in maintenance therapy. Pharmacists can provide the necessary follow-up care. Refill medication counseling is an excellent opportunity for pharmacists to identify vulnerable patients. By asking open-ended questions about possible changes or concerns, pharmacists can easily determine whether further review is necessary. Brown bagging provides a smooth introduction for a pharmacist to participate in and offer extended counseling concepts such as MTM. It is also an essen- tial educational and safety tool the pharmacist can use to measure and ensure quality care within the health care system.

Hypertension is an independent risk factor for coronary artery disease, renal failure, and stroke. It is a silent condition that affects many patients. There are many guidelines to review and understand when treating a patient with hypertension. It is important to discuss blood pressure (BP) goals, dietary habits, and medication regimens during brown bag checkups and counseling and MTM sessions.

MF is a 55-year-old overweight woman who is a regular customer. She has become more aware of her prescribed medications and her weight because of a recent health scare involving a family member. During counseling sessions, MF asks many questions, related particularly to her diet and heart. Today she stops in to pick up her late refill prescription for levothyroxine. You counsel MF about the potential misuse and explain the concept behind a brown bag session. You tell her that because of her chronic disease states, she would be an excellent candidate to participate in a review. You ask MF whether she would be interested in bringing in all her medications and reviewing them with you for proper use. She is happy to have your attention and be under your care. MF says that she is starting to have difficulty keeping her medications straight and feels as if she does not have anyone to talk to about her health concerns. She stresses that she cannot afford a hospitalization like the one her family member recently experienced. MF schedules an appointment to meet with you tomorrow when you have overlap pharmacist coverage.

To prepare for tomorrow’s session, you pull up her pharmacy profile so you can compare it with what is in her brown bag. You find the following in MF’s brown bag:

• Atorvastatin, 20 mg, once daily every eveningu
• Bupropion, 150 mg, once daily
• Furosemide, 20 mg, once daily every morningu
• Levothyroxine, 15 μg, once daily every morninguLosartan, 50 mg, daily
• Metoprolol, 100 mg, twice daily

MF arrives the next day for the appointment and empties her brown bag onto the counter. You notice these additional medications:

• Calcium carbonate, 1000 mg, once daily
• Expired clopidogrel, 75 mg, once daily, last filled at a competitor pharmacy 2 years prioru OTC aspirin, enteric-coated, 81 mg, once daily
• OTC fish oil, 4 capsules dailyu
• OTC omeprazole, 20 mg, once daily

As you review the medications, MF says that she does not always take them as prescribed. She often forgets to take certain ones or fails to follow her prescriber’s directions. You offer a calendar to get MF started and suggest a pillbox. She complains of adverse effects such as coughing and muscle aches. MF also talks about dizziness and having bad dreams and says she gets terrible heartburn after eating and self-medicates. You discuss diet and portion control as a start. MF no longer has a regular primary care provider because she has not found anyone she trusts since her doctor retired last year. She cannot remember the last time she had laboratory work performed. MF has been monitoring her BP more frequently at the pharmacy and has questions about diet and goals. You instruct her on how to take a reliable BP reading. MF would like to purchase an inexpensive cuff for home use. You take a more thorough medical history and discover that she has 3 cardiac stents and has not been seeing a cardiologist. Thus, MF is interested in participating in the MTM session you propose after you put her in touch with the appropriate specialists.

How would you review her medication profile, and what advice could you offer during the brown bag checkup? MF needs to establish care with local providers to help her manage her condi- tions. How can you refer her to the correct professionals?

Editor’s note: Case is not based on an actual patient.

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.