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

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 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 typical counseling session.

Patients who suffer from chronic conditions often go to more than 1 pharmacy, take many medications, and visit a variety of health care providers. They frequently experience long- or short-term changes in their health, where maintenance therapy must be adjusted. Community pharmacists are providers with whom patients may communicate frequently to help provide necessary check-ups or follow-up care. Refill medication counseling provides an excellent opportunity for pharmacists to identify vulnerable patients. By asking open-ended questions about possible changes or concerns, it is easy to determine if further review of chronic care medications is necessary.

AH is a 46-year-old overweight woman who visits the pharmacy often. She is a stay-at-home mother who spends a lot of time volunteering at her child’s school and has a flourishing baking business. AH has become more aware of her health and weight issues and was prescribed medications to treat heart issues about 6 months ago. She stops in to pick up her late refill prescription for levothyroxine. You counsel AH on the potential misuse and explain the concept behind a brown bag session. You tell her that because of her chronic disease states and interest in her health, she would be an excellent candidate for participating in a review. You ask if AH would be interested in bringing in her medications to the pharmacy and reviewing them with you for proper use. She says that it is confusing trying to keep her medications straight. AH has tried pill boxes and is embarrassed to ask questions sometimes, so she turns to the internet instead. She schedules an appointment to meet with you during the hours when you haveoverlap coverage.

To prepare for the session, you pull up AH’s pharmacy profile so you can compare it with what is in her brown bag. You find the following:
  • Amlodipine, 5 mg, once daily
  • Atorvastatin, 10 mg, once every evening
  • Levothyroxine, 112 mcg, once every morning
  • Esomeprazole, 40 mg, once daily
  • Hydrochlorothiazide, 12.5 mg, once every morning

AH arrives for your appointment and empties herbrown bag. You find the following:
  • Amlodipine, 5 mg, once daily
  • Atorvastatin, 10 mg, once every evening
  • Levothyroxine, 112 mcg, once every morning
  • Esomeprazole, 40 mg, once daily
  • Hydrochlorothiazide, 12.5 mg, once every morning

AH arrives for your appointment and empties her brown bag. You notice these additional medications:
  • Adult multivitamin with iron, once daily
  • Calcium carbonate, 1000 mg, once daily
  • Expired Crestor (rosuvastatin) samples
  • OTC enteric-coated aspirin 81 mg, once daily 
  • OTC fish oil, 4 capsules daily
  • OTC omeprazole, 20 mg once daily
  • Various supplements from online vendors to treat gallbladder and gastrointestinal (GI) issues

As you review the medications for accuracy, AH says that she was supposed to have follow-up lab work 3 months after her doctor prescribed her new heart medications. You stress the adverse effects and the importance of finding the right dose when starting new medications and safe medication use. AH says that her medications make her feel dizzy and she often feels achy and tired. She dislikes taking them, feels forgetful, and just cannot get used to taking so many new medications at different times. You explain how some medications work better when taken on an empty stomach or in the morning. Most importantly, you stress consistency. AH listens and says she will get her lab work as soon as possible. She agrees that there is no use in paying for a medication and taking it if she is not using it properly and getting a maximum safe benefit.

AH also has been monitoring her blood pressure (BP) more frequently at your pharmacy using a free kiosk, and she has questions about BP goals and a heart-healthy low-sodium diet. You instruct AH on how to take a proper and reliable BP reading, and she buys a cuff for home use. AH is happy you reviewed this with her, as she has been using the machine incorrectly. You take a more thorough medical history and discover that she has a lot of untreated GI symptoms. Many of these may be a sign of a more serious issue, and her supplements may be causing more confusion and harm than good. You offer to help refer her to a specialist, as she does not know a physician who may help her in this area. AH is interested in participating in the MTM session you offer as
a follow-up.

How would you properly review her medication profile, and what motivating advice could you offer AH during the brown-bag check-up?
 
Jill Drury, PharmD, is a clinical pharmacy specialist in Chicago, Illinois, and Milwaukee, Wisconsin.