NEW ZEALAND NATIONAL PHARMACIST SERVICES FRAMEWORK 2014

 
NEW ZEALAND NATIONAL PHARMACIST SERVICES FRAMEWORK 2014
NEW ZEALAND
NATIONAL PHARMACIST SERVICES
               FRAMEWORK
                        2014
NEW ZEALAND NATIONAL PHARMACIST SERVICES FRAMEWORK 2014
Contents
   Acknowledgements .............................................................................................................................................................................. 2
   Introduction ......................................................................................................................................................................................... 2
   Background .......................................................................................................................................................................................... 3
   Over-arching Principles ........................................................................................................................................................................ 4
   Pharmacy Services Illustrated .............................................................................................................................................................. 5
   Medicines Management Services......................................................................................................................................................... 6
   Health Promotion and Preventative Services ..................................................................................................................................... 11
   Pharmacist Medicines Information Services ...................................................................................................................................... 14
   Pharmacist-Only (Restricted) Medicines ............................................................................................................................................ 15
   Pharmacist Prescribing ....................................................................................................................................................................... 16
   Hospital Clinical Pharmacy Services ................................................................................................................................................... 17
   References.......................................................................................................................................................................................... 22
   Glossary .............................................................................................................................................................................................. 23

Acknowledgements
Pharmaceutical Society of New Zealand Project Team:
Elizabeth Plant, Bob Buckham, Richard Townley

The Pharmaceutical Society of New Zealand appreciates and acknowledges with thanks, the valuable input and feedback
received from the following organisations: Pharmacy Council of New Zealand, New Zealand Hospital Pharmacists
Association, Pharmacy Guild, Clinical Advisory Pharmacists Association, Ngā Kaitiaki o Te Puna Rongoā o Aotearoa (Māori
Pharmacists Association), Green Cross Health, Pharmac, New Zealand Medical Association, General Practice New Zealand,
Royal New Zealand College of General Practitioners, District Health Boards, Midland Community Pharmacy Group,
Midcentral Community Pharmacy Group, Canterbury Medicines Therapy Assessment (MTA) Peer Group, Medwise,
Canterbury Community Pharmacy Group, as well as the many individuals who submitted personal comments and
feedback.

© Pharmaceutical Society of New Zealand Inc. 2014

Introduction
The New Zealand National Pharmacist Services                                                             The National Executive of the Society discussed in-depth
Framework (the Framework) was developed in 2007 by                                                       and provided direction for the service identification and
District Health Boards of New Zealand (DHBNZ) and                                                        content.
intended for review in 2009.
                                                                                                         In response to submissions received and survey analysis to
Following the dissolution of DHBNZ and subsequent                                                        the first consultation round, changes were made to the
discussions with District Health Boards Shared Services                                                  format, language, service descriptions and services in the
(DHBSS), responsibility for the framework passed to the                                                  Framework and were further considered by the key
Pharmaceutical Society of New Zealand Inc. (Society).                                                    stakeholders workshop in May 2014.
The Society undertook to conduct the review of the
Framework services and to re-present it to the health                                                    With numerous new pharmacist services coming into
sector as the pharmacy profession’s Framework of                                                         mainstream provision it is important to have a reference
Services from the Society.                                                                               of up to date service descriptions for funders / payers /
                                                                                                         employers and providers to refer to when choosing to
During 2013 the Society undertook a cross sector                                                         provide selected extended pharmacist services to their
consultation on a first draft of a revised Framework of                                                  populations.
Services. A detailed survey of Medicines Use Review
(MUR) pharmacist practitioners was conducted and                                                         The Framework enables flexible implementation of
feedback was received from individual pharmacists,                                                       pharmacist services on behalf of District Health Boards
National Medical and Pharmacist Organisations, General                                                   (DHBs), Primary Health Organisations (PHOs) or General
Practice Organisations, DHBs and Government Agencies.                                                    Practice Networks, pharmacy entities and other
                                                                                                         Healthcare entities.

                                                                                                                                                                                                                2
The Framework enables:
   o the promotion of optimal medicine-related              There are two scopes of practice for pharmacists: the
       outcomes from medicines; encouragement of            “pharmacist scope” and the “pharmacist prescriber”
       multidisciplinary work practices, primary-primary    scope.
       and     primary-secondary     collaboration    and
       integrated care                                      It is important to have one reference source as a
   o the utilisation of the opportunity for enhanced        Framework of Services for the health sector. All extended
       access that community pharmacy offers for the        services in this Framework – apart from prescribing, can
       promotion of public health and well-being and the    be provided by a pharmacist competent in the pharmacist
       encouragement of self-care;                          scope of practice. Most of these extended services do
   o the optimisation of health by evaluating and           have an extra element of educational qualification and/or
       addressing where possible, the medication            training. Prescribing can only be carried out by a
       management needs of local populations and            pharmacist competent in the pharmacist prescriber scope
       individual patients;                                 of practice.
   o the development of medication management
       services that enhance patient choice, access and     This framework comprehensively defines pharmacist
       convenience and provide a positive experience for    services that are available for primary care and/or
       patients and other providers of healthcare;          secondary care sector use.
   o the provision of a range of clinically effective and   New service areas in the framework are in addition to base
       cost-effective medication management services        mandatory pharmacy services and designed to provide
   o the development of an integrated approach to           national consistency for users of pharmacist extended
       planning and commissioning of innovative             services
       medication management services that contribute
       to the development of primary health care and the    Health practitioner competence requirements dictate that
       optimisation of health outcomes regionally and       all pharmacist services must be provided in line with
       nationally.                                          appropriate standards as defined by the Pharmacy Council
   o alignment of services with specific pharmacist         of New Zealand.
       roles, such as those working in integrated health
       organisations and/or general practices.

Background
In 2007, the Government highlighted the Optimal Use of             medicines risks and benefits and best practice
Medicines as one of the key outcomes of The Medicines              treatment options
New Zealand Strategy. The Strategy noted that:                 -   Make services more available and provide
                                                                   treatment in a way that recognises the needs of
  Optimal use activities are crucial to ensuring that              individuals, including cultural differences
  medicines that are assessed as being high-quality,
 safe and effective, are chosen, delivered and used in      2. Patients taking medicines to:
 a way that ensures their potential to improve health          - Be active participants in their health management
    and prevent illness is maximised. Optimal use              - Be able to make informed decisions about
  activities also reduce wastage, enabling resources              medicines
                  to be used effectively.                      - Understand the best way to use medicines (be
                                                                  ‘health literate’) and know where to go for
The Medicines Strategy also recommended that the
                                                                  information and support
behaviours and practices to support optimal use need:
                                                            3. The medicines system to:
1. Prescribers and other health practitioners to:
                                                               - Monitor and disseminate information to minimise
  - Consider the most suitable and cost-effective
                                                                  the over-use, under-use, misuse and inappropriate
     treatment options, including non-medicinal and
                                                                  disposal of medicines
     non-prescription alternatives
                                                               - Provide effective regulation and post-marketing
  - Consider the safety and appropriateness (including
                                                                  monitoring, in line with international best practice,
     the risks and benefits) of medicine choice in
                                                                  to ensure ongoing assessment of medicines safety
     relation to clinical need
                                                               - Have systems to support optimal medicines use
  - Develop medicines plans that are mutually agreed
                                                                  practices, including safe medicines systems such as
     with their patients
                                                                  child-safe packaging and at-the-bedside medicines
  - Work collaboratively with other health
                                                                  verification systems
     practitioners and services to provide continuity of
                                                               - Monitor and evaluate the outcomes of medicines
     care and share up-to-date information on
                                                                  use

                                                                                                                    3
Actioning Medicines New Zealand, the action plan for              Support initiatives to realise the potential of the
Medicines New Zealand provided a list of the actions which         pharmacist workforce and address the barriers
“can and will be done” to deliver Medicines New Zealand              to the delivery of innovative pharmacy and
outcomes and singled out the pharmacy profession as               pharmacist services, including those identified at
having a key role in achieving the goals of the strategy,           the health sector workshop in August 2009.
stating to:

Over-arching Principles
Māori Health                                                   national health strategies, and the pharmacist must
An overarching aim of the health and disability sector         demonstrate knowledge of and appropriate linkages
is the improvement of health outcomes and reduction            with prescribing practitioners and health and/or welfare
of health inequalities for Māori. Health providers are         organisations, such as Government and non-
expected to provide health services that will contribute to    Government support organisations, and secondary
realising this aim.      This may be achieved through          services, such as:
mechanisms that facilitate Māori access to services,              Primary medical and nursing services, including
provision of appropriate pathways of care, which might               PHO or other local organisation services
include but are not limited to matters such as referrals and      Māori primary and community care providers
discharge planning, ensuring that pharmacist services are         Pacific primary and community care providers
culturally competent and that services are provided that          Consumer advocacy services, including Māori and
meet the health needs of Māori. It is expected that there            Pacific Islands advocacy services
will be Māori participation in the decision making around,        Community support and home nursing services
and delivery of, pharmacist services.                             Non-Government organisations
                                                                  Secondary medical, surgical and rehabilitation
Services Linked with the Healthcare Team                             services
The success of the services is dependent on the                   Specialised services such as Mental Health, Child
development and maintenance of effective therapeutic                 health, Public health, Maternity, Oral health,
partnerships between those providing and those receiving             Private specialists, etc.
the service. Service provision is consistent with local and

                                                                                                                          4
Pharmacy Services Illustrated
 Medicines Management Services:
    Medicines Adherence                       Medicines Optimisation
 CMM: Comprehensive Medicines Management
 MTA: Medicines Therapy Assessment
 CPAMS: Community Pharmacy Anticoagulation Management Service
 MUR: Medicines Use Review
 LTC: Pharmacy Long Term Conditions Service
                                                                    CMM
                                                For patients with complex clinical medication
                                              management needs under the care of an integrated
                                                health centre or primary health organisation

                                                                 MTA Service
                                             For patients where there are potential clinical concerns
                                              related to safety or efficacy of prescribed medications

                                                                   CPAMS

                                                                MUR Service
                                                     For patients with complex difficulties in
                                                         understanding and adhering to
                                                             prescribed medications

                                                                 LTC Service
                                                      For eligible patients to optimise the
                                                    supply & use of prescribed medications
                                                           and to support adherence

                                                           Standard core dispensing
                                                             and over the counter
                                                             services with self-care
                                                           advice (Incl. pharmacist-
                                                            only, pharmacy, general
                                                           sale classified medicines)

 Other Services / Roles:

                        Medicines Information                                        Pharmacist-Only (Restricted) Medicines

                    Hospital Clinical Pharmacy                                                   Pharmacist Prescribing

     Health Promotion and Preventative Services:

               Health Education                                 Immunisation                            Screening and Intervention

                                                                                                                                     5
Medicines Management Services
Patient-specific services that aim to ensure prescribed pharmacotherapy is understood and                  range of activities to improve utilisation and manage potential and/or actual harm from their
taken for optimal safety and efficacy.                                                                     use or misuse. Issues identified through delivering medicines management services are reported
                                                                                                           back to prescribers, and those that are outside of the scope of the service or capacity/capability
The focus of medicines management services is to optimise the benefits and reduce harm from                of the pharmacist, are referred promptly on to other health professionals for management, as
medicines. They involve a discussion with the patient about their medicines and delivering a               appropriate.

                                           MEDICINES ADHERENCE                                                                                 MEDICINES OPTIMISATION
                      Medicines Adherence LEVEL 1             Medicines Adherence LEVEL 2 Medicines Optimisation LEVEL 1 Medicines Optimisation LEVEL 2 Optimising Specific Medicines
                         Long-Term Conditions                    Medicines Use Review                      Medicines Therapy                   Comprehensive Medicines                E.g. Community Pharmacy
                                 LTC                                    MUR                                Assessment - MTA                      Management - CMM                           Anti-coagulation
                           Optimise supply and use                  Optimise medication                 Optimise medication efficacy               Optimise management of               Management Service -
                               of medications                   understanding and adherence                                                         prescribed medications                       CPAMS

                      Currently funded under the Pharmacy     A comprehensive, systematic,            A systematic, patient-centred clinical   An autonomous pharmacist               Specific medicines may be targeted
 Definition
                      Services Agreement. Pharmacists will    evaluation of a patient’s               assessment of all medicines currently    integrated in the healthcare team      for optimisation, guided by defined
                      assist in the focussed management of    understanding of and adherence to       taken by a patient, identifying,         providing support and advice on all    testing/assessment criteria and
                      eligible patients to optimise the       prescribed medication treatment.        resolving and preventing medication-     matters related to the medication      standing orders as appropriate.
                      supply and use of prescribed                                                    related problems as well as              management of patients with
                      medicines and to support adherence.     Pharmacist aims to improve              optimising the effectiveness of          complex clinical needs.                Example in current practice: CPAMS
                                                              understanding of and adherence to       medication treatment.
                                                              medicines; identifying and addressing                                            May or may not include Pharmacist      The provision of INR point-of-care
                                                              factors linked to non-adherence                                                  Prescriber Scope of Practice (see      testing by accredited community
                                                              behaviours as well as minimising                                                 Pharmacist Prescriber section).        pharmacists and adjustment of
                                                              pharmaceutical waste.                                                                                                   warfarin doses within a defined range
                                                                                                                                                                                      with the aid of an approved decision-
                                                                                                                                                                                      support system.

 For the patient      Eligible patients with chronic          [In addition to Level 1 goals]          [In addition to MUR goals]               Patients with complex clinical         The patient receives timely,
                      conditions who are prescribed regular                                                                                    management needs will, as part of an   convenient and accessible
                      medication treatment will receive       Patients with complex difficulties in   Patients who may have concerns           integrated healthcare environment,     management of their warfarin
                      targeted assistance to ensure they      understanding and adhering to           about the effectiveness of their         have prescribed medication             treatment by a community
                      know what medications they are          medications (and their                  medications, or may be experiencing      treatment continually monitored        pharmacist working collaboratively
                      prescribed, what they are prescribed    family/whanau) receive personalised     adverse effects, will be reviewed by a   against treatment goals and regimen    with the patient’s GP.
                      for and the directions for taking       education and support to improve        clinically experienced pharmacist.       refined as required.
                      them.                                   self-management. This is achieved
                                                              through tailored education for          Patient’s medication-related
                      The patient has available a range of    greater understanding of what their     problems will be identified and
                      services to assist the collection and   prescribed medications are through      managed either directly by the
                      organisation of prescribed medicines,   an agreed action plan to address        pharmacist, or collaboratively with
                      and to manage any changes.              adherence issues.                       the prescriber.

                                                                                                                                                                                                                   6
Pharmacist is able to synchronise         The patient is able to discuss with the
                   prescriptions and adjust the              pharmacist:
                   frequency of dispensing to suit the        Concerns or understanding of
                   patient’s needs and abilities.              medicines
                                                              Access to and administration of
                                                               medicines
                                                              Adherence to medication
                                                               treatment.

For the            Barriers to the prescribing, dispensing   Supports patients to better               Patient’s prescribed medication          The pharmacist is an integrated             The pharmacist actively contributes
                   and administration of prescribed          understand and adhere to the              regimen is collaboratively reviewed      member of the prescriber’s wider            to the primary care of patients by
prescriber /
                   medicines are identified and a plan       prescribed regimen. Targeted to           against treatment goals with the         healthcare team and works                   reducing the burden of
health-system      made to resolve these.                    patients who are experiencing             prescriber, in the context of            autonomously within the team                anticoagulation management whilst
                                                             difficulties in understanding the         identifying, resolving and preventing    providing medicines management              keeping the GP fully informed of
                   In conjunction with prescribers where     purpose of and/or adhering to,            medication-related problems; and         support and advice at an individual         results obtained and dosing
                   appropriate, assistance given to          prescribed treatment are provided         optimising the therapeutic benefits of   and practice population level.              management provided. Prescriber is
                   medicines reconciliation,                 with additional education and             prescribed medication.                                                               notified directly of any patients with
                   synchronous prescribing and               assistance with management; and/or                                                                                             results falling outside set
                   dispensing of medication. Minimises       patients initiated on new or high-risk    Pharmacist discusses aspects of                                                      parameters.
                   duplicate prescribing and resupply of     medicines.                                adherence and utilisation of
                   treatment occurs on a regular, rather                                               prescribed therapy with the patient.                                                 Provides improved accessibility and
                   than ad-hoc basis.                        Health beliefs or behaviours              This is summarised and a care plan is                                                convenience for patients.
                                                             contributing to non-adherence are         developed with the prescriber based                                                  Improved multidisciplinary
                                                             identified and an agreed action plan      on therapeutic priorities.                                                           management of patients taking
                                                             is developed with the patient to                                                                                               warfarin.
                                                             address these.
                                                                                                                                                                                            Improve multidisciplinary
                                                                                                                                                                                            management of patients prescribed
                                                                                                                                                                                            warfarin in the community
Training /         Registered Pharmacist with no             Standards-based Medicines Use             Portfolio of evidence submitted for      MTA Standards minimum level                 Formally assessed accreditation
                   additional qualification or training      Review training & accreditation.          accreditation and formally assessed      expected.                                   training.
Accreditation
                   required.                                 Formally Assessed against Pharmacy        against PSNZ Medicines Therapy                                                       Biennial recertification
                                                             Council Medicines Use Review              Assessment Standards.                    Experience, qualifications, skills and
                   Some activities may be completed          Standards.                                                                         knowledge as considered appropriate
                   within an Intern Pharmacist Scope of                                                MTA Standards require pharmacists        to the role being fulfilled as a clinical
                   Practice.                                 MUR pharmacists require knowledge         to have defined pharmacotherapeutic      pharmacist employed as an
                                                             and skills in behavioural change          knowledge and skills at a minimum        integrated member of a healthcare
                                                             management.                               post-graduate certificate level (or      team.
                                                                                                       equivalent) plus at least TWO years
                                                                                                       patient orientated experience in a
                                                                                                       hospital, community or primary care
                                                                                                       setting post- registration.
Specific Service   Pharmacy Council of New Zealand           Medicines Use Review Competence           PSNZ Pharmacist Medicines Therapy        MTA Standards in addition to any            Standard Operating Procedure
                   Competence Standards.                     Standards set by the Pharmacy             Assessment Standards (endorsed by        defined in accordance with                  CPAMS Standing Order
Standards
                                                             Council of New Zealand.                   the Pharmacy Council of New              employment agreement with
                   Service delivered by all pharmacies as                                              Zealand).                                healthcare practice                         Delivered as per the Community
                   per the Community Pharmacy                                                                                                                                               Pharmacy Services Agreement.
                   Services Agreement.

                                                                                                                                                                                                                         7
Eligibility      Patients who:                             Patients living independently in the    Patients who have one or more            None specified. Patient population       Patients are referred by a Medical
                  Have a diagnosed long-term              community who have one or more          chronic disease states; two or more      service by the practice.                 Practitioner and consent to
                    condition as described in the LTC      chronic disease states and meet one     co-morbidities; and meet one or                                                   registration in the Community
                    Service Patient Eligibility            or more of the following conditions:    more of the following conditions:                                                 Pharmacy Anti- coagulation
                    Assessment Form                         Taking three or more medicines         Taking four or more medicines                                                   Management Service. Stable and
                  Does not adhere or genuinely has          and/or 12+ doses per day                and/or 12+ doses per day                                                        Unstable INRs may be managed.
                    difficulty adhering to their            Have multiple prescribers              At increased risk of medicine-
                    medicines regime, either because        Have had a recent admission to          related problems                                                                Patients must:
                    of the complexity of that regime         hospital (especially if there was a    Are experiencing or are at risk of                                               be referred by a Medical
                    or because of their personal or          medicine change)                        experiencing sub-optimal response                                                  Practitioner who delegates point-
                    long-term condition’s                   Are taking or about to commence         to pharmacotherapy                                                                 of-care testing to a community
                    characteristics; and                     taking medicine(s) with a high risk    Have experienced significant                                                       pharmacy service; and either:
                  Have a score of at least [20]             of adverse effects, narrow              changes in their medicine regimen                                                   be taking warfarin medication; or
                    following assessment using the           therapeutic index and/or requires       during the last 3 months                                                            be requiring warfarin loading and
                    LTC Service Patient Eligibility          therapeutic monitoring, or is          Taking or about to commence                                                          initial stabilisation; or
                    Assessment Form.                         suspected of being inappropriately      taking one or more medicines with                                                   be overlapping warfarin
                                                             used.                                   a high risk of adverse effects                                                       medication with low molecular
                                                            Have a particular medicine related     Have signs/symptoms of a                                                             weight heparin (LMWH);
                                                             problem e.g. adverse reaction, non-     medicine adverse effect                                                          be mobile and able to access the
                                                             adherence.                             Are taking medicine(s) with a                                                      services
                                                            Are non-adherent or unable to           narrow therapeutic index and/or
                                                             manage their medicines                  requires therapeutic monitoring,                                                Exclusions:
                                                            Have literacy or language               where sub-therapeutic or toxic                                                  Patients with acquired or congenital
                                                             difficulties, dexterity problems,       effects are suspected.                                                          coagulation disorders (such as anti-
                                                             impaired sight, or cognitive                                                                                            phospholipid syndrome, Protein C
                                                             deficiencies that impact on their                                                                                       deficiency) and/or those receiving
                                                             ability to manage medicines.                                                                                            active anti-neoplastic treatment. Refer
                                                                                                                                                                                     to service specification.

                                                                                                                                                                                     Patients who are non-compliant
                                                                                                                                                                                     and/or have not attended the service
                                                                                                                                                                                     without appropriate explanation
                                                                                                                                                                                     within 6 weeks.

Restrictions /   As per LTC Access Criteria                As per eligibility criteria.            Medicines Review Service Standards                                                Standing Order parameters.
                 Aged residential care excluded.           Issues identified that are beyond the   require pharmacists to recognise
Limitations
                 Activities to address adherence and       adherence and education scope of        personal limitations, to work within                                              Mandatory review by Medical
                 understanding focus at the time of        the service and/or capability of the    these and to recognise need for, and                                              Practitioner if INR is 4.0
                 dispensing.                               pharmacist to resolve, require          facilitate patient referral to another
                                                           referral to other pharmacist            health professional when
                                                           Medicines Management Services (e.g.     appropriate.
                                                           MTA), or other Health Practitioners.

Service          Regular engagement, as deemed             Patients may self-refer into the        In most cases it is expected that MTA    Referrals not specifically required as    A strong professional relationship
                 appropriate or agreed, with members       service, or referrals may come from     referrals will be initiated from a       the service is delivered by a              must be in place between the
Linkages
                 of the patient’s multidisciplinary care   their usual community pharmacist,       recommendation of a member of the        pharmacist who is a fully integrated       Medical Practitioner and
                 team, in particular, engagement with      prescribers, hospital or primary-       patient’s healthcare team.               member of the healthcare team.
                 their key medical practitioner(s).        secondary care liaison pharmacists,

                                                                                                                                                                                                                    8
Primary Health Care Nurses, Nurse         Pharmacists providing MTA services        Reports and recommendations are            Pharmacy/Pharmacist providing
                                                     Practitioners, and/or other healthcare    often work as part of a                   sent to the GP and where available,        this Service.
                                                     providers.                                multidisciplinary team to optimise the    entered into the shared care record.      The Pharmacy must have the
                                                                                               selection of medicines for and the                                                   appropriate secure IT connection to
                                                     For the provision of Medicines            utilisation of medicines by individual                                               allow electronic linkage with
                                                     Adherence Services there will not         patients, with reports and                                                           general practice.
                                                     necessarily be access to clinical         recommendations going to the GP
                                                     information and the interaction           and where available, entered into the
                                                                                                                                                                                   In addition to the calibration
                                                                                                                                                                                    supplied by the manufacturer the
                                                     and intervention is largely with          shared care record.
                                                                                                                                                                                    pharmacy arranges quality
                                                     patients rather than providers.
                                                                                                                                                                                    assurance reviews with an agreed
                                                                                               Service is dependent on the
                                                                                                                                                                                    local laboratory in each DHB and/or
                                                     Pharmacists must demonstrate              development and maintenance of
                                                                                                                                                                                    an external quality assurance
                                                     knowledge of and appropriate              effective therapeutic partnerships
                                                                                                                                                                                    provider.
                                                     linkages with prescribing practitioners   between the various health
                                                     and health and/or welfare                 professionals involved in an individual
                                                     organisations, such as Government         patient’s care along with the patient
                                                     and non-Government support                themselves and their family / whanau
                                                     organisations, and secondary              / caregivers.
                                                     services.
                                                                                               The MTA pharmacist will recognise
                                                                                               national and regional healthcare
                                                                                               priorities and strategies and deliver
                                                                                               MTA services within the context of
                                                                                               these.

Setting     Community Pharmacy                       Community Pharmacy                        Community Pharmacy                        Integrated Health Centre                 Community Pharmacy
                                                     Hospital Pharmacy                         Hospital Pharmacy                         Primary Health Organisation              Must be provided from premises that
                                                     PHO/Integrated Health-based               PHO/Integrated Health-based               General Practice                         conform to relevant standards issued
                                                     Pharmacists                               Pharmacists                               Private consultant practitioners         by the Ministry of Health or PSNZ.
                                                     Private consultant practitioners          Private consultant practitioners          Service may be delivered in other
                                                     Service may be delivered in other         Service may be delivered in other         settings as appropriate to the patient
                                                     settings as appropriate to the patient    settings as appropriate to the patient    e.g. Patient’s home, marae, ‘clinics’
                                                     e.g. Patient’s home, marae, ‘clinics’     e.g. Patient’s home, marae, ‘clinics’

Reporting   Regular engagement (as deemed            Provision of a record of all current      Pharmacist is expected to have access     Reporting into the integrated health      INR results and dosing
            appropriate), with members of the        medicines to the prescriber; and to       to patient clinical records and will      record In accordance with practice         recommendations reported to
            multidisciplinary care team in           the patient unless practical              contribute to these and/or report         policies.                                  prescriber via decision support
            particular medical practitioner(s), in   circumstances dictate that it would       into the integrated health record as                                                 software (i.e. ‘INR Online’).
            order to provide members with            not be beneficial                         appropriate.                                                                        Pharmacy reports information in
            information about the patient’s                                                                                                                                         accordance with the
            progress in improving management         Reporting of suspected significant        MTA Standards require pharmacists                                                    Pharmaceutical Transactions Data
            of their medications.                    adverse medicine effects or               to practise effective working                                                        Specification, the Procedures
                                                     therapeutic issues to prescribers         relationships within the                                                             Manual, and the terms and
            Reporting into integrated health         and/or entered into the shared care       multidisciplinary healthcare team.                                                   conditions set out in the service
            record as appropriate.                   record where available.                                                                                                        agreement.
                                                                                                                                                                                   Quarterly Reporting

                                                                                                                                                                                                              9
Service        Medicines Information: Provide           Includes that as described for LTC      As for MUR Services, in addition:        As for MTA Services, in addition to        Assess patient history / symptoms,
               information about prescribed             Services with the exception of                                                   any applicable criteria described in an     or factors that may influence the
Activities /
               medicines to supplement dispensing       dispensing services.                     Assessment of the level of             employment agreement.                       results (e.g. a missed dose of
Outputs        advice.                                                                            adherence in the context of the                                                    warfarin)
                                                        Detailed assessment of level of           potential effect on clinical            Comprehensive clinical                   perform INR test as per device and
               Medicines reconciliation: Obtaining      understanding of prescribed               outcomes.                                assessment of the safety and              decision support instructions
               the most accurate list of medicines,     treatment and supplementing              Assess clinical status based on all      efficacy of medication treatment         warfarin dose adjustment
               allergies and adverse drug reactions     knowledge gaps as required.               available information, including         against therapeutic goals and in          supported by decision support tool
               and comparing this with the                                                        clinical notes.                          accordance with applicable               advise patient of INR result and
               prescribed medicines and                 Assessment of level of adherence to      Review appropriateness of therapy        guidelines and/or best practice.          new dose of warfarin
               documented allergies and adverse         prescribed medications and reasons        and compare against alternative         Proactive advice to prescribers          provide counselling and education
               drug reactions. Any discrepancies are    or behaviours behind non-adherence.       therapy options as appropriate           and the healthcare team on                about warfarin
               documented and reconciled.                                                        Review cost-effectiveness of             medication management options            provide the Medical Practitioner
                                                        Formulation of an agreed action plan      therapy                                  including appropriate monitoring          with results and changes to the
               Synchronisation: Pharmacist helps        with the patient to address adherence    Identify and evaluate actual and         of treatment                              warfarin regime.
               coordinate prescribing written by all    issues.                                   potential medicine therapy              As applicable, support in the            Request medical review by
               prescribers who have the care of the                                               problems                                 prescribing of medications in             Medical Practitioner if INR exceeds
               patient to assist regular supply of      Formal referral and report to other     • Negotiate treatment goals and            accordance with Pharmacist                limits of advice
               medicines and accommodation of           health professionals, of issues           timelines for attainment of goals        Prescriber scope and area of             contacting Medical Practitioner
               regimen changes.                         identified beyond the scope of the        with both patient and medical            practice.                                 directly if concerned about the
                                                        service or pharmacist.                    practitioner.                           Provision of medicines                    patient’s symptoms, results, or the
               Reminders: Utilisation and                                                       • Reporting of suspected significant       information services, as applicable       dose recommendation;
               individualisation of various             Removal of out of date medicines and      adverse medicine effects                 to role.                                 maintain record of care &
               technologies and services aimed at       medicines that are no longer required    Formulate and document a                                                           management plan
               assisting patients’ adherence.           (with permission)                         pharmaceutical care plan                                                          participation in quality assurance
                                                                                                 Contribute to multidisciplinary                                                    programme;
               Adherence support: assists the           Provision of health behaviour             team on the formulation and                                                       audit anticoagulant management
               patient to adhere to and persevere       changing strategies aimed at              documentation of a comprehensive                                                  auditing compliance for timeliness
               with their medicines regime and to       improving lifestyle factors.              care plan, and to assist the team in                                               of testing to identify Patients with
               manage any prescribed changes.                                                     modifying the care plan based on                                                   compliance issues
                                                                                                  regular assessment of the patient’s                                               record incidence of adverse events
               Medication Management Plan: a                                                      status.                                                                            (in particular the incidence of
               living, long term record that outlines                                            Provision of health behaviour                                                      bleeding) including hospital
               how the pharmacist is working with                                                 changing strategies aimed at                                                       admissions.
               the patient to improve medicines                                                   improving lifestyle
               adherence over time.                                                              Recommend therapeutic medicine
                                                                                                  monitoring using target
               Dispensing services, with dispensing                                               concentration intervention as
               frequency tailored to need:                                                        appropriate.
               Pharmacists manage the frequency of
                                                                                                 Provide accurate and timely
               dispensing in such a way to assist
                                                                                                  medicines information to health
               adherence, convenience (to the
                                                                                                  professionals and patients.
               patient and prescriber(s) and allows
               regular treatment monitoring and
               clinic appointments.

                                                                                                                                                                                                               10
Health Promotion and Preventative Services
Services for individuals and/or populations utilising the accessibility and knowledge of pharmacists to improve understanding of medicines and to contribute to public health programmes and/or
health targets.

                                    Health Education Services                                           Immunisation Services                                    Screening and Intervention Services
  Definition          Services provided to individuals or populations of patients in     Pharmacist vaccinators contribute to and enhance the success      Targeted health screening/monitoring utilising testing
                      specified/targeted health areas as part of locally or nationally   of local and national immunisation programmes through             procedures available and appropriate for a pharmacy setting,
                      coordinated DHB, PHO or Ministry approved public health            utilising their public accessibility to:                          that integrates with national and/or local health promotion
                      programmes.                                                         Administer funded and unfunded vaccines to eligible people.     activities and strategies (as available).
                                                                                          Reduce demand on other primary healthcare providers for
                      Pharmacist-provided health education services may include the         vaccination services for people ineligible for funded          Examples may include: cholesterol, gout, glycated
                      identification of individual or groups of patients to whom            vaccines.                                                      haemoglobin, blood glucose, blood pressure measurements,
                      specified health information should be provided.                    Increase population uptake of immunisation.                     and screening for infectious disease (e.g., Group A
                                                                                                                                                           Streptococcus, chlamydia), among others.
                      Specifications for any individual service would be developed in    A pharmacist vaccinator has successfully completed a Ministry
                      accordance with delivery requirements and service aims.            of Health-approved vaccinator training course and subsequent      Result of screening measurement tool directs course of action
                                                                                         independent clinical assessment in accordance with the            which may include:
                      Examples of such services might include immunisation               Immunisation Standards.                                            referral for full medical assessment/management
                      promotion, smoking cessation, self-care of medicines, cardiac                                                                         provision of a pharmacist-only medicine
                      rehabilitation (focussed on medicines use), brand switch           Pharmacist vaccinators undertake the same training and             provision of a prescription medicine in accordance with a
                      counselling, diabetes medication use, mental health                accreditation as other authorised vaccinators but may               standing order, or
                      medication use, administration requirements for medications        administer those vaccines which have been classified as being      data collected provided into a multidisciplinary shared-care
                      (e.g. use of insulin pens, asthma inhalers and spacers etc.),      able to be administered by a registered pharmacist who has          plan
                      marae-based medication/health education for Māori.                 successfully completed a vaccinator training course approved
                                                                                         by the Ministry of Health and who is complying with the
                                                                                         immunisation standards of the Ministry of Health, without the     Specifications for any individual service would be developed in
                                                                                         need for a prescription or standing order.                        accordance with delivery requirements and service aims while
                                                                                                                                                           also considering the National Screening Unit’s Principles of
                                                                                         Documentation of immunisation, reporting and notification in      screening and screening assessment criteria.
                                                                                         accordance with the Immunisation Standards and patient
                                                                                         confidentiality requirements.                                     Services will be delivered in accordance with the HDC Code of
                                                                                                                                                           Health and Disability Services Consumers' Rights, including the
                                                                                                                                                           right to make an informed choice and give informed consent.

  For the patient     Patient receives targeted education and advice on the              Patient benefits from convenience and accessibility of            Individuals or targeted populations receive evidence-based
                      presentation and management of specific health topics,             pharmacists and receives immunisation(s) for the prevention       health screening for specific health conditions which present a
                      utilising the accessibility and knowledge of their pharmacist.     of disease in accordance with health needs.                       risk of harm. Results are managed in accordance with
                                                                                                                                                           appropriately developed guidance and/or standing orders in
                                                                                         Populations and individuals attending a pharmacy will receive     order to mitigate that harm.
                                                                                         health promotion information on the benefits of immunisation
                                                                                         in general, for the prevention of disease.

                                                                                         Where immunisation needs are outside of the pharmacist-
                                                                                         delivered immunisation service, pharmacists will refer patients
                                                                                         to their GP.
                                                                                                                                                                                                                       11
For the            Minimise barriers to achieving health goals by utilising the         Pharmacist vaccinator workforce actively contributes to            Pharmacist workforce actively contributes to national and local
                   accessibility and knowledge of pharmacists, individuals or           national and local immunisation targets through increasing         health screening activities. Where appropriate, such services
prescriber /
                   populations of a target group receive specific education aimed       accessibility of vaccines. Pharmacists also actively contribute    may include aspects of management and/or referral to other
health system      to improve understanding and ultimately health outcomes.             to immunisation promotion and are a readily accessible health-     practitioner.
                                                                                        professional source of information and advice on vaccine-
                                                                                        preventable disease.
Training /         None specified.                                                      Pharmacist vaccinators must successfully complete a Ministry       As appropriate to the service, in accordance with scope and
                   As appropriate to the service, in accordance with scope and          of Health-approved vaccinator training course and subsequent       standards of practice.
Accreditation
                   standards of practice.                                               independent clinical assessment, then maintain their
                                                                                        authorisation in accordance with the Immunisation Standards.

                                                                                        The Pharmacy Council Statement on Pharmacist Vaccinators
                                                                                        states that pharmacists who offer a vaccination service must
                                                                                        undertake resuscitation training equivalent to that of NZRC
                                                                                        Rescuer Level 4. The following five skills must be included in
                                                                                        the training: infant, child and adult Cardiac Pulmonary
                                                                                        Resuscitation (CPR) including mouth-to-mouth, mouth-to-mask
                                                                                        and the management of choking

Specific Service   Standards for any individual service would be developed in           Ministry of Health Immunisation Standards                          Standards for any individual service would be developed in
                   accordance with service aims and delivery requirements.              National Guidelines for Vaccine Storage and Distribution           accordance with service aims and delivery requirements.
Standards
                                                                                        Pharmacy Council Statement on Pharmacist Vaccinators
                                                                                        Guidance described in the Ministry of Health Immunisation          Pharmacist screening and intervention services will be
                                                                                        Handbook                                                           evidence-based and any medical devices used will be of
                                                                                                                                                           appropriate standard and quality.
Service Users      Target population or patient groups as defined by DHBs, PHOs,        Target population or patient groups as defined by the National     Target population or patient groups as defined by DHBs, PHOs,
                   Ministry of Health and/or other local or national public health      Immunisation Schedule and those self-referred patients who         Ministry of Health and/or other local or national public health
                   programmes.                                                          are eligible for vaccination.                                      programmes.

Eligibility        Eligibility criteria for any individual service would be developed   As per Immunisation Standards, the indications for the             Eligibility criteria for any individual service would be developed
                   in accordance with service aims and delivery requirements.           respective vaccinations, and as per the medicines classification   in accordance with service aims and delivery requirements.
                                                                                        for those vaccines classified as able to be administer by
                                                                                        pharmacist vaccinators.

Service            To be defined in accordance with service aims and delivery           Pharmacists to have effective links with the following services:   Screening and intervention programmes delivered in a
Linkages           requirements.                                                         Local immunisation coordinators                                  collaborative manner through strong links to general practice
                                                                                         The Immunisation Advisory Centre (IMAC)                          and the wider multidisciplinary team where appropriate.
                   Examples of service linkages may include:                             General practice
                    Consumer advocacy services, including Māori and Pacific             Local Medical Officers of Health                                 Pharmacists will have defined outcomes that are managed
                     Island advocacy services.                                           Local DHB                                                        appropriately within the service (e.g. through the provision of
                    DHB public/population health services, Ministry of Health           Pharmac                                                          treatment), or will refer to other services for comprehensive
                     public health campaigns, PHO health promotion                                                                                         assessment or management as agreed with relevant members
                     programmes.                                                        Pharmacists to notify the patient’s general practitioner of        of the wider healthcare team.
                    Pharmac, Māori Health providers, GPNZ or similar.                  administration of vaccines, with the consent of the patient.

                                                                                        Pharmacists will record information in the National
                                                                                        Immunisation Register as this becomes available.

                                                                                                                                                                                                                          12
Setting         Services will be delivered in a facility and setting            Community pharmacy and/or offsite from a community                Delivered in a facility and/or settings appropriate to the target
                 appropriate to the target patient or population groups.         pharmacy when provided in accordance with relevant guidance       patient or population groups and in accordance with any
                A private area must be utilised for discussions with patients   and standards                                                     standards or codes of practice.
                 and their family/whanau.
                Services may be delivered by pharmacists working in             Pharmacist Immunisation Services must be provided from
                 community or hospital pharmacy, PHO/Integrated Health-          premises conforming to relevant standards issued by the
                 centres or as private consultant practitioners.                 Ministry of Health and/or The Pharmacy Council of New
                                                                                 Zealand.

                                                                                 Facilities at which vaccines will be stored and administered by
                                                                                 the pharmacist will provide for cold chain storage as well as
                                                                                 privacy and management of adverse events (including
                                                                                 anaphylaxis). Facilities will comply with the requirements of
                                                                                 the Immunisation Standards and Guidelines for Vaccine
                                                                                 Storage and Distribution.

                                                                                 Pharmacists will provide the service in a manner that enables
                                                                                 the patient to understand evidence-based information about
                                                                                 vaccines and the illnesses they prevent.

                                                                                 Pharmacists will obtain and document informed consent to
                                                                                 administer vaccines on that basis and in accordance with the
                                                                                 individual requirements of the vaccine(s).

Reporting      Requirements developed in accordance with specific service        General practice to be notified of the administration of a        Requirements developed in accordance with specific service
               aims and delivery requirements.                                   vaccine under the service, with the consent of the patient.       aims and delivery requirements, in consultation with all
                                                                                                                                                   members of the healthcare team with service linkages.
                                                                                 National immunisation register as available.

                                                                                 Documentation of the consent, administration, storage and
                                                                                 transport of all immunisations in accordance with Ministry of
                                                                                 Health requirements.

Service        • Provision of generic, non-specific population-based             Safe provision and administration of approved vaccines to         Provision of targeted screening and intervention for diseases or
                 education to patients or other health professionals             patients.                                                         illnesses in accordance with defined national or local public
Activities /
               • Provision of specific education targeted at eligible                                                                              health strategies or initiatives and following appropriate
Outputs          individuals                                                     Active participation in the promotion and education of            guidelines and best practice.
               • Provision of health behaviour changing strategies aimed at      immunisation as a public health benefit.
                 improving lifestyles of individual patients.
                                                                                 Documentation of vaccination, reporting and notification in
                                                                                 accordance with patient confidentiality requirements.

                                                                                 Enhanced national uptake of immunisation.

                                                                                                                                                                                                                 13
Pharmacist Medicines Information Services
Services utilising pharmacists’ specialised knowledge of pharmacotherapy to support patients, health professionals, and health providers
with the optimal use of medicines.

                                                    Pharmacist Medicines Information Services
 Definition           Medicines Information is the provision of evidence-based information about medicines and advice on their therapeutic use.

                      The focus of Pharmacist Medicines Information Services is on information provision to healthcare providers that enables
                      those providers to optimise their effective utilisation of pharmaceuticals.

                      Medicines information services aim to:
                       • assist providers with the rational and quality use of medicines for a given patient, patient group or population
                       • locally implement national or regional appropriate use of medicines campaigns that aim to impact on the demand for
                         certain medicines or classes of medicines
                       • reduce the risk of adverse medicine events associated with the transition between providers of health services
                       • provide independent, accurate and relevant medicines information to health professionals, thus contributing to patient
                         care and the optimal use of medications

                      Medicines information services may reactively respond to specific requests for advice, as well as proactively provide
                      guidance on specific topics.

 For the              Prescribers and other healthcare professionals are provided with independent, evidence-based information about
                      medications and advice on their therapeutic use and optimisation.
 prescriber /
 health-system
 Training /           New Zealand Hospital Pharmacists Association. Medicines Information Group: Medicines Information Training Manual
                      Recommended: Post-Graduate Certificate in Pharmacy (Endorsed in Medicines Management)
 Accreditation
                      Pharmacists providing this service will have relevant post-graduate clinical qualification(s) or work experience to
                      demonstrate general pharmaceutical knowledge in core areas and/or specialist pharmaceutical knowledge in one or more
                      defined areas.

 Service Users        General practitioners, specialists, registrars, house officers, midwives, dentists, veterinarians, optometrists, nurse
                      practitioners and any other prescribers or health professionals.
                      Health service providers concerned with the optimal and cost-effective use of medicines.

 Restrictions /       In accordance with specific service aims and delivery requirements.
 Limitations
 Service              It is intended that Pharmacists will provide Medicines Information Services that are consistent with Government health
                      strategies.
 Linkages
                      As appropriate, the service may provide links between members of the multidisciplinary healthcare team, and/or identify
                      clinical situations requiring more advanced assessment or interpretation.

 Setting              Specialist hospital medicines information centres
                      Hospital pharmacies
                      PHOs/Integrated health centres utilising appropriately qualified pharmacists (e.g. specific MI pharmacist, CMM pharmacists)
                      Private consultant practitioners
 Reporting            Quality assurance procedures to be in place to help ensure services are of a sufficiently high standard.
                      Examples include standard operating procedures, proactive peer review prior to provision of information, induction training
                      for new staff, retrospective audits
 Service              Non-exhaustive list of activities may include:
                      Provision of information and advice either retrospectively in response to a direct enquiry, or prospectively by issuing general
 Activities /
                      guidance on a particular topic. Pharmacists providing this service interpret and apply evidence-based information on a
 Outputs              population or individual patient basis to:
                       • Outline the appropriateness of medicine options for a patient according to their individual clinical status
                       • Provide advice on the cost effectiveness of medicine options
                       • Facilitate best practice medicines utilisation through the development and/or implementation of localised guidelines,
                           analysis and feedback of medicines utilisation data, educational interaction with prescribers and other providers of
                           healthcare, and the provision of objective, comparative and unbiased medicines information
                       • Facilitate the smooth transition between providers of health services.

                      As appropriate, pharmacists providing the service may generate and utilise reports (e.g. medicine utilisation/dispensing
                      history) to assist:
                       • Other providers of healthcare with individual patient management and quality use of medicines
                       • Hospital admission and/or discharge management, including managing prescriptions from multiple providers for
                           individual patients.
                      Appropriate use of medicines campaign participation
                      Pharmacists providing the service to actively participate in national or regional appropriate use of medicines campaigns to
                      address the demand for certain medicines, as determined by the DHB or PHOs.

                                                                                                                                                        14
Pharmacist-Only (Restricted) Medicines
Pharmacist-only medicines are available for those patients assessed as appropriate for supply and are mostly unfunded if not supplied in
accordance with a prescription. Opportunities are available for specific medicines to be funded for those patients meeting appropriate
assessment criteria, in accordance with a nationally or locally delivered health programme.

                                                         Pharmacist-Only (Restricted) Medicines
 Definition           A pharmacist-only (restricted) medicine is a medicine classified as such under the Medicines Regulations that may only be sold
                      by retail by a pharmacist in a pharmacy or hospital; or in accordance with a standing order. Pharmacist-Only Medicines are
                      regarded within the profession as pharmacist-prescribed medicines. Accordingly, the pharmacist is expected to undertake an
                      appropriate consultation with the patient, fully considering any specific practice guidelines or protocols prior to making the
                      decision to supply a pharmacist-only medicine.

                      References to ‘pharmacist-only’ medicines also includes those medicines which are classified as prescription medicines “except
                      when supplied by a registered pharmacist…” or words to similar effect. Such medicines remain classified as ‘prescription
                      medicines’ but may be supplied by pharmacists under conditions defined in the classification statement for that medicine.

                      Pharmacists have special legislative and professional responsibilities in controlling the supply, storage, recording and advertising
                      of these medicines. Pharmacist-only medicines are not usually funded by the health system unless listed in the Pharmaceutical
                      Schedule and prescribed by an authorised prescriber; or specific medicines are funded as part of a local healthcare initiative
                      (such as the Emergency Contraceptive Pill).

 For the patient      Patients have the ability to obtain readily-accessible, efficacious medicines, where the sale is supervised by a health professional
                      who identifies the need and appropriateness for the medicine, and gives individualised information and advice. Patients are
                      referred to their general practitioner where management using a pharmacist-only or other over the counter medicine would be
                      inappropriate.

 For the              Ailments suitable for management through advice and/or the use of a pharmacist-only medicine can be cared for by
                      pharmacists. However more serious ailments beyond the scope of over the counter management are referred for medical
 prescriber /
                      assessment.
 health system
 Training /           Registration within the Pharmacist Scope of Practice (or Intern Pharmacist Scope of Practice when under the supervision of a
                      Pharmacist)
 Accreditation
                      Training must be successfully completed where the classification of a medicine, or Pharmacy Council standards requires it.
                      Training and accreditation is a mandatory requirement for the provision of trimethoprim, levonorgestrel (emergency
                      contraception) and vaccines by pharmacists.

 Specific Service     • Pharmacy Council Code of Ethics for Pharmacists
                      • PSNZ Pharmacy Practice Handbook
 Standards
                      • Standards, Guidelines and/or Protocols for the supply of specific pharmacist-only medicines as available when defined by the
                        Pharmacy Council and/or Pharmaceutical Society of NZ.
                      • Pharmacy Council Protocol for the Sale or Supply of Pharmacist-Only Medicines for Chronic Conditions (POMCC)

                      Pharmacists must have procedures to ensure that pharmacy staff always refer patients to the pharmacist when:
                      • a Pharmacist-Only Medicine is requested; or
                      • a Pharmacist-Only Medicine could be a suitable treatment for symptoms described by the patient.

 Service              Refer to or consult with the patient's medical practitioner and/or other health professionals as appropriate and agreed to by the
                      patient.
 Linkages
 Setting /            Sales of Pharmacist-Only Medicines may only be made from a registered pharmacy or from a hospital.
                      A private area that enables confidential patient consultations to be undertaken is required.
 Facilities
 Reporting            Medicines Regulations require the documentation of the sale of pharmacist-only (restricted) medicines and set out the details
                      which must be recorded in the register of pharmacist-only medicines.
                      Pharmacists are encouraged to record provision of pharmacist-only medicines using electronic methods and process the sale
                      through their computers as they would when dispensing a prescription. The Medicines Regulations require recording of the
                      following information:
                        • date of transaction; name and address of purchaser (if the purchaser is not the patient, it is recommended that the details of
                           the sale are also recorded in the patient's history); name and quantity of medicine sold; name of pharmacist making the sale.

 Service              Assessment of the condition to be treated:
                      • history of the signs/symptoms or disease process
 Activities /
                      • current medications and any other treatments
 Outputs              • patient’s known risk factors e.g. allergies, pregnancy, contraindications and precautions of the medication

                      Assessment of the appropriateness of the pharmacist-only medicine supply considering potential adverse reactions, interactions
                      and side effects; while also considering possible non-medication therapy or referral for further medical attention.

                      Provision of patient-individualised advice using verbal and written information on: adverse effects; precautions; correct use and
                      storage of the medicine; when the patient should seek medical advice; and the availability of the pharmacist for further
                      information if required.
                                                                                                                                                       15
You can also read
NEXT SLIDES ... Cancel