Resources, Training, Tools
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ElevatingHome has identified tools, training programs, and reference material to support home-based care organizations in developing effective programs that move home care towards the Quadruple Aim: improved health of people and communities, added value, and satisfied patients and providers.
Use the links in the table of contents here navigate to specific types of resources - or browse the page to identify topics of interest. Most resources also include tools and training information and we recommend you start with Resources. Visit 'additional' for more information.
For All Patients |
- National Alliance for Caregiving - Caregiver data, information, advocacy
- CaringInfo-National Hospice and Palliative Care Organization
- Roslyn Carter Institute for Caregiving - Caregiver training, education information, and best practices
- Selected Caregiver Assessment Measures: A Resource Inventory for Practitioners – Family Caregiver Alliance
- Managing Older Patients with Cognitive Impairment: A Quick Guide for Primary Care Physicians. National Institutes of Health - includes a resources and references section along with clinical information.
- Cognitive Changes in the Elderly - National Institutes of Health
- Guidelines for Prevention and Treatment of Cognitive Impairment in the Elderly
- (2015)
- American Geriatrics Society Clinical Practice Guideline for Postoperative Delirium in Older Adults (2014)
- Mild Cognitive Impairment Patient Information on Medline Plus
Cognitive Change Assessment Tools:
St. Louis University Mental Status Exam (SLUMS)
Mini Mental State Examination (MMSE)
Montreal Cognitive Assessment
Community Resources
St. Louis University Mental Status Exam (SLUMS)
Mini Mental State Examination (MMSE)
Montreal Cognitive Assessment
- Aging and Disability Resource Centers (ADRCs) are a program of the Federal Administration for Community Living. They serve as single points of entry into the long-term services and supports (LTSS) system for older adults, people with disabilities, caregivers, veterans and families. Use the link here to find a local ADRC.
- U.S. Administration on Aging: provides home and community-based services to older persons including transportation, adult day care, caregiver supports and health promotion programs.
- Aging / Area Agencies on Aging Finder Tool: AoA’s and units administer programs for seniors with funds from the Administration on Community Living (ACL)
- Eldercare Locator offers a searchable database for older adults and their families on services including behavioral health, nutrition, financial assistance, transportation and other resources.
- Nutrition.gov A federal resource that provides easy access to all online federal government information on nutrition. The site also includes a page with specific nutrition resources for seniors.
- The Senior Corps is a network of programs that tap the experience, skills, and talents of older citizens.
- Supplemental Nutrition Assistance Program (SNAP): eligibility and application information.
- National Association of Area Agencies on Aging (N4A): community based organizations that support elders and people with disabilities
- Disaster Safety for People with Disabilities: What to Do When Emergency Weather Strikes
- Disaster Preparedness for Seniors by Seniors
- Grants for Home Modification: 16 Resources for Homeowners with Disabilities
- Safe travels: Disaster preparedness on the road
- Family Communication Plan for Parents
- Emergency Power Planning for People Who Use Electricity and Battery-Dependent Assistive Technology
- Emergency Preparedness for People with Disabilities — Guide and Checklist
- End of Life Palliative Care Resource Center (EPERC): This RWJ Foundation funded resource center includes a portfolio of educational materials and training programs.
- The End of Life Curriculum Project includes a comprehensive training module on dyspnea assessment and management
Dyspnea Tools
Modified Borg Scale – uses descriptive terms to measure dyspnea with activity.
Edmonton Symptom Assessment System (ESAS)
Memorial Symptom Assessment Tool-Short Form
Visual Analog Scale as a Measure of Clinical Dyspnea
Respiratory Distress Observation Scale (RDOS)
Falls Prevention
Modified Borg Scale – uses descriptive terms to measure dyspnea with activity.
Edmonton Symptom Assessment System (ESAS)
Memorial Symptom Assessment Tool-Short Form
Visual Analog Scale as a Measure of Clinical Dyspnea
Respiratory Distress Observation Scale (RDOS)
- Preventing Falls Among Older Adults Centers for Disease Control and Prevention
- CDC Compendium of Effective Fall Interventions: What Works for Community-Dwelling Older Adults, 3rd Edition
- National Council on Aging – Falls Prevention Resources
- Preventing Falls Among Older Adults Centers for Disease Control and Prevention
- Preventing Falls: A Guide to Implementing Effective Community-Based Fall Prevention Programs - Centers for Disease Control and Prevention
- CMS Partnership for Patients – Falls Resources
- Stop Falls – Falls Prevention Center of Excellence for patients, families, providers and researchers
- Hip Pain and Mobility Deficits – Hip Osteoarthritis: Clinical Practice Guidelines
- Rehabilitation Measures Database
- Geriatric Examination Toolkit (includes many functional status tools)
Functional Status Assessment Tools
Timed Up & Go (TUG) - recommended by APTA post TKR
Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)
Tinetti Assessment tool -for balance
Tinetti Performance Oriented Mobility Assessment (POMA)
30?Second Chair Stand Test (30CST)
Knee Injury and Osteoarthritis Outcome Score (KOOS)
MAHC 10 - Fall Risk Assessment Tool
6-Minute Walk Test (6MWT)
Timed Up & Go (TUG) - recommended by APTA post TKR
Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)
Tinetti Assessment tool -for balance
Tinetti Performance Oriented Mobility Assessment (POMA)
30?Second Chair Stand Test (30CST)
Knee Injury and Osteoarthritis Outcome Score (KOOS)
MAHC 10 - Fall Risk Assessment Tool
6-Minute Walk Test (6MWT)
Immunizations
- Centers for Disease Control and Prevention: Key Facts About Seasonal Flu Vaccine
- Influenza Vaccination Information for Health Care Workers
- Immunization Action Coalition (CDC-funded patient and provider information)
- Centers for Disease Control and Prevention: Key Facts About Seasonal Flu Vaccine
- Centers for Disease Control and Prevention: Pneumococcal Vaccination
- Institute for Safe Medication Practices – includes FDA alerts, ‘no-crush’ and high-risk medication lists, and other tools
High-Alert Medications In Community/Ambulatory Healthcare – Institute for Safe Medication Practices - Home Health Quality Improvement University-- free course on medication management; requires registration and includes continuing education credits.
- Medication Reconciliation at Transitions - Institute for Healthcare Improvement
- Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation - AHRQ
- Safe Medication Consumer Website – includes medication list template and other consumer information
- American Pain Society Guideline
- American Society for Pain Management Nursing
- ESMO Management of Cancer Pain Guideline
- Improving the Quality of Care Through Pain Assessment and Management – from Patient Safety and Quality: An Evidence-Based Handbook for Nurses
- University of Iowa GeriatricPain Website – assessment, management, and QI tools
- The National Cancer Institute - PDQ Pain Information NCI offers detailed information on pain assessment and management for cancer related pain.
- Cancer Care Ontario - CCO is a Canadian Ontario government agency that has developed comprehensive symptom assessment and management guides for symptoms associated with cancer at end of life (applicable to other end of life conditions).
- City of Hope Pain &Palliative Care Resource Center very robust resource information.
- AMDA Pain Corner
Pain Assessment Tools (see Pain module for more tools)
The Faces Pain Scale-Revised or FPS-R - patient visual
Verbal Descriptor Scale
10 Point Scale
Wong-Baker FACES Pain Scale - patient visual for children
FLACC for assessment for young children (patient visual)
Brief Pain Inventory (BPI) and BPI User Guide
McGill Pain Inventory Short Form
Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC)(staff observation)
Pain Assessment in Advanced Dementia (PAIN-AD) (staff observation)
Pain Thermometer - Visual tool
Symptom Distress Scale
CNA Pain Assessment Tool (CPAT)
Elderly Pain Caring Assessment 2 (EPCA-2) - Observational assessment
Memorial Symptom Assessment Scale (MSAS)
Non-Communicative Patient’s Pain Assessment Instrument (NOPPAIN) - Observational assessment
Discomfort Behavior Scale - Observational assessment
Checklist of Nonverbal Pain Indicators
The Faces Pain Scale-Revised or FPS-R - patient visual
Verbal Descriptor Scale
10 Point Scale
Wong-Baker FACES Pain Scale - patient visual for children
FLACC for assessment for young children (patient visual)
Brief Pain Inventory (BPI) and BPI User Guide
McGill Pain Inventory Short Form
Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC)(staff observation)
Pain Assessment in Advanced Dementia (PAIN-AD) (staff observation)
Pain Thermometer - Visual tool
Symptom Distress Scale
CNA Pain Assessment Tool (CPAT)
Elderly Pain Caring Assessment 2 (EPCA-2) - Observational assessment
Memorial Symptom Assessment Scale (MSAS)
Non-Communicative Patient’s Pain Assessment Instrument (NOPPAIN) - Observational assessment
Discomfort Behavior Scale - Observational assessment
Checklist of Nonverbal Pain Indicators
Patient Engagement and Health Literacy
- AHRQ Health Literacy Universal Precautions Toolkit – Agency for Healthcare Research and Quality
- Ask Me 3 - Words To Watch.pdf – National Patient Safety Foundation
- Health Resources and Services Administration Health Literacy Resource Center
- SMART Goals – Center for Healthcare Communication
- Sutter Health's Center for Integrated Care (SCIC) – case study on personal health records
- Teach Back Method Training and Toolkit – part of AHRQ Health Literacy Universal Precautions training
- Patient Self-Management Best Practice Improvement Project - - HHQI
- Agency for Healthcare Quality and Research (AHRQ) – Preventing Avoidable Re-admissions
- AHRQ Toolkit to Engage High-Risk Patients In Safe Transitions Across Ambulatory Settings
- AHRQ - Interventions to Prevent Readmissions for People with Heart Failure
- CMS Guide to Preventing Readmissions among Racially and Ethnically Diverse Medicare Beneficiaries
- Center for Health Care Quality and Payment Reform – Preventing Readmissions
- HHQI Fundamentals of Reducing Acute Care Hospitalizations - tools and patient education
- Improving Care Transitions Between Hospital and Home Health: A Home Health Model of Care Transitions
- Institute for Healthcare Improvement – Reduce Avoidable Readmissions
- National Transitions of Care Coalition
- Transitions of Care Resources and Tools - The Joint Commission
- Transitions of Care from Hospital to Home: An Overview of Systematic Reviews and Recommendations for Improving Transitional Care in the Veterans Health Administration
- Risk Assessment - 8P Project BOOST® Implementation Toolkit – Society for Hospital Medicine
Clinical Interventions |
- Management of COPD exacerbations: a European Respiratory Society/American Thoracic Society guideline
- Living with lung disease. Strategies for breathing easier. COPD patient education from VNA of the Middlesex-East handbook for patients with chronic obstructive pulmonary disease (COPD)
COPD Tools
CAT – COPD Assessment Test
COPD Control Questionnaire-CCQ
Modified Borg Scale
Respiratory Distress Observation Scale (RDOS)
Visual Analog Scale
6 Minute Walk Test
CAT – COPD Assessment Test
COPD Control Questionnaire-CCQ
Modified Borg Scale
Respiratory Distress Observation Scale (RDOS)
Visual Analog Scale
6 Minute Walk Test
Depression Screening and Management
- Depression Management BPIP – Home Health Quality Institute
- National Institute of Mental Health - Depression
Depression Screeing Tools
Geriatric Depression Scale (GDS) – – a 15 item scale asking patients to answer yes/no to a series of questions.
Patient Health Questionnaire 2 (PHQ2) – - Utilized in OASIS (M1730) to quickly screen for depression.
PHQ9 – Expanded version of the Patient Health Questionnaire that probes for specific possible symptoms.
Geriatric Depression Scale (GDS) – – a 15 item scale asking patients to answer yes/no to a series of questions.
Patient Health Questionnaire 2 (PHQ2) – - Utilized in OASIS (M1730) to quickly screen for depression.
PHQ9 – Expanded version of the Patient Health Questionnaire that probes for specific possible symptoms.
Heart Failure
- American Heart Association. (2014). Smoking and cardiovascular disease.
- Heart Failure Society of America. Patient Education modules
- Home Health Quality Improvement Program - Heart Failure Quality Improvement
- Qualidigm. Heart talk videos: Evidence-based educational video series about heart failure
- Prevention of VTE in orthopedic surgery patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. (2012)
- Updated Guidelines on Outpatient Anticoagulation (2013)
- International Congress for Joint Reconstruction: Evaluation and Management of the Stiff Knee
Tools-See Functional Status
Pressure Ulcer Treatment and Prevention
- Prevention and Treatment of Pressure Ulcers: Quick Reference Guide -
- Guideline for Prevention and Management of Pressure Ulcers - The WOCN Society 2016 (purchase required).
- Wound healing society 2015 update on guidelines for pressure ulcers (2015)
- Agency for Healthcare Research and Quality Guideline Clearinghouse: wound care guideline summary
Pressure Ulcer Prevention and Treatment
- Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving Quality of Care from the Agency for Healthcare Research and Quality.
- Cross-Setting Pressure Ulcer Measurement & Quality Improvement CMS webpage.
- National Pressure Ulcer Advisory Panel (NPUAP) , NPUAP White Papers and NPUAP Position Statements
- Wound, Ostomy and Continence Nurses
- Wound care treatment algorithms – summarized on the AHRQ Guideline website, and include citations.
- WOCN Support Surface Selection algorithm
- VNAA Clinical Procedure Manual, 19th edition.
- Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance
Pressure Ulcer Patient Education
- American Nurses Credentialing Center Principles of Education
- MedScape: an Overview of Adult Learning Processes
- Home Health Quality Improvement Institute: Includes Zone Tools for patient education on wound care. (Free but requires login)
- AAWC Wound Patient/Caregiver Resources: Patient education materials in English and Spanish
- Intermountain Healthcare Wound Care Patient Education Booklet: This is a helpful template for information to address in patient education materials.
- AAWC Wound Patient/Caregiver Resources(patient education materials in English and Spanish)
Pressure Ulcer Tools
Braden Scale
Norton Scale for Assessing Risk of Pressure Ulcers: Another common standardized tool for assessing risk.
Intervention Protocols For Braden Scale Subscales: nursing interventions linked to Braden Scale scores.
NPUAP Presentation on Risk Assessment tools and Approaches (2015)
NPUAP PUSH Tool for pressure ulcer measurement
National Pressure Ulcer Advisory Panel - PUSH Tool 3.0 (web version)
Norton Scale for Assessing Risk of Pressure Ulcers: Another common standardized tool for assessing risk.
Intervention Protocols For Braden Scale Subscales: nursing interventions linked to Braden Scale scores.
NPUAP Presentation on Risk Assessment tools and Approaches (2015)
NPUAP PUSH Tool for pressure ulcer measurement
National Pressure Ulcer Advisory Panel - PUSH Tool 3.0 (web version)
| High Performing Agencies |
- Institute for Healthcare Improvement (IHI) "How to Improve" Model for Quality Improvement" - IHI Modules include: Introduction; Forming the Team; Setting Aims; Establishing Measures; Selecting Changes; Testing Changes; Implementing Changes; Spreading Changes
- Health Resources and Services Administration Quality Improvement Methodology Toolkit - HRSA Modules included:
- The Home Health Quality Improvement University is free with registration and includes online education with continuing education credits. Modules include: QAPI 101; PIPs to reduce hospitalizations; PIPs for medication management; PIPs for cardiovascular health
- IHI SBAR (Situation, Background, Assessment, Recommendation) Toolkit
- Alliance for Home Health Quality and Innovation Future of Home Health Project
- CMS Home Health Quality Improvement Initiative
- CMS Pressure Ulcer Measure Development and Quality Improvement Resources
- Home Health Quality Improvement Campaign
- Institute for Healthcare Improvement - Training and strategy on improving quality, patient safety, patient experience, and health care value
- Institute for Healthcare Improvement Getting Started Always Event Kit
- Recorded Webinar "It Takes a Village to Stay Home Safely" - Christiana Care Health System case conferencing approach to reducing readmissions.
- Creating High Reliability in Health Care Organizations (seminal article)
- Robert Wood Johnson Foundation – Tools for Continuous Quality Improvement
- Home Health Value-Based Purchasing Model - CMS
- Home Care Home Base Information on VBP
- Catalyst for Payment Reform
- AHRQ Patient Education Materials Assessment Tool (PEMAT) and User’s Guide
- HHQI Fundamentals of Reducing Acute Care Hospitalizations - tools and patient education
- 4 Patient Education Strategies that Drive Patient Activation
- Patient Experience with Care - Inventory of Resources (not home health specific)
- Patient Experience Observation Exercise – IHI exercise to improve quality of patient experience
- NIH PROMIS The Patient Reported Outcomes Measurement Information System tools measure what patients are able to do and how they feel by asking questions.
- IHI SBAR (Situation, Background, Assessment, Recommendation) Toolkit – requires login
- Joint Commission – Situation, Background, Assessment and Recommendation (SBAR) Information
| Hospice and Palliative Care |
Hospice Care Initiation
- National Consensus Project’s Clinical Practice Guidelines for Quality Palliative Care (2013 version; new Guideline scheduled for release in 2018)
- Seven Stages of Dementia – Tools and Information
Hospice Care Initiation Tools
MAHC 10 - Fall Risk Assessment Tool
standardized questionnaire that scores the patient in 10 areas to come up with a risk level
PPS – Palliative Performance Scale (Copyright 2001 Victoria Hospice Society)
FAST (©Barry Reisberg, MD, 1984) - Functional Assessment Staging for dementia
Braden Scale - A widely used tool to predict the risk of pressure ulcers. Six criteria are examined: Sensory perception; Moisture; Activity; Mobility; Nutrition and Friction and Shear.
ECOG and Karnofsky Performance Status Tools -
GCS – Glasgow Coma Scale aims to give a reliable, objective way of recording the conscious state of a person. Used in monitoring chronic patients in intensive care.
MNA® – Mini Nutritional Assessment – reflects the patient’s nutritional condition among other domains and is predictive of patient’s outcome (death or survival)
NYHA – New York Heart Association Functional Classification of Heart Failure - provides a simple way of classifying the extent of heart failure
Caregiver Support (link to home health)
MAHC 10 - Fall Risk Assessment Tool
standardized questionnaire that scores the patient in 10 areas to come up with a risk level
PPS – Palliative Performance Scale (Copyright 2001 Victoria Hospice Society)
FAST (©Barry Reisberg, MD, 1984) - Functional Assessment Staging for dementia
Braden Scale - A widely used tool to predict the risk of pressure ulcers. Six criteria are examined: Sensory perception; Moisture; Activity; Mobility; Nutrition and Friction and Shear.
ECOG and Karnofsky Performance Status Tools -
GCS – Glasgow Coma Scale aims to give a reliable, objective way of recording the conscious state of a person. Used in monitoring chronic patients in intensive care.
MNA® – Mini Nutritional Assessment – reflects the patient’s nutritional condition among other domains and is predictive of patient’s outcome (death or survival)
NYHA – New York Heart Association Functional Classification of Heart Failure - provides a simple way of classifying the extent of heart failure
Caregiver Support (link to home health)
Palliative Care/End of Life
- Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life (2015). Institute of Medicine Report. Free downloadable PDF
- Medicare Advance Care Planning benefit rules
- CAPC report on community based palliative care
- Center to Advance Palliative Care
- CAPC-Training
- NHPCO Care Continuum Resources
- Illinois Homecare & Hospice Council (IHHC) Palliative Care MOOC (massive open online course)
- California Health Care Foundation’s Community-Based Palliative Care (CBPC) Resource Center. resources to support development of community based palliative care programs.
- Coalition for Compassionate Choices in California: Information and materials to assist organizations in developing community based palliative care programs.
- COMFORT Communication training - interdisciplinary team training for palliative care (California focused)
- Respecting Choices – Advanced Care Planning: A program of the Gunderson Health System to support providers and patients in making decisions about end of life, and to get leadership buy in for a system wide initiative.
- National Hospice and Palliative Care Organization’s CaringInfo: Includes materials for patients and caregivers on advance care planning, hospice and palliative care, and grief.
- The Conversation Project: A website that includes information and a kit to help people start talking about their end of life wishes
- Physician Orders for Life Sustaining Treatment (POLST): An approach to end-of-life planning based on conversations between patients, loved ones, and health care professionals
- Roslyn Carter Institute for Caregiving
- National Palliative Care Resource Center – includes multiple needs assessment tools
- Needs at the End of Life Screening Tool (NEST) at NPCRC– This tool is a numeric rating scale that addresses issues such as religious beliefs, sense of purpose, trust in health care professionals, and evaluation of care compared to the individual’s health care goals.
- CAPC – Center to Advance Palliative Care “Policies and Tools for Hospital Palliative Care Programs” – a hospital specific document that includes a Spiritual Care Assessment tool.
- FICA (acronym for the four aspects of healthy spiritual conversations between clinicians and patients) – Facilitates and encourages health care professionals to have spiritual conversations with patients and to identify spiritual issues patients face, spiritual distress, and patient’s spiritual resources of strength.
- Cancer Care Ontario Symptom Management - Comprehensive symptom assessment and management guides for symptoms associated with cancer at end of life (applicable to other end of life conditions).
- National Institutes of Health PDQ® Cancer Information Summaries: Supportive and Palliative Care – evidence based recommendations for symptom management for multiple conditions
- Crisis Management in Hospice Patients – Presentation from the Virginia Association of Hospice and Palliative Care (2015)
Tools
Edmonton Symptom Assessment Tool (ESAS) at NPCRC – This is a multi-symptom assessment tool used to evaluate for the presence and severity of symptoms
Edmonton Symptom Assessment Tool (ESAS) at NPCRC – This is a multi-symptom assessment tool used to evaluate for the presence and severity of symptoms
Hospice Treatment Preferences
- Establishing Therapeutic Relationships - Nursing Best Practice Guideline - Registered Nurse Association of Ontario. July 2002, revised 2006.
- The Conversation Project- The Conversation Project encourages people to have conversations with their loved ones about end of life preferences, and provides tools to support those conversations.
- Physician Orders for Life Sustaining Treatment - POLST is a national initiative to promote end of life planning for people with serious illness or facility. POLST initiatives have been developed in multiple states in order to ensure compliance with state laws on advance care planning.
- Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life
- MEDPAC, 2013
- COMFORT Communication training - interdisciplinary team training for palliative care (California focused)
Policy and Performance Reporting Requirements and Concepts |
- CMS IMPACT Act website
- IMPACT Act of 2014
- CMS Measures Management Home Page
- CMS Home Health Star Ratings Information
- CMS 'Spotlight' Page with news and information on measures and reporting
- Home Health Compare Website
- Home Health Conditions of Participation (2017)
- Hospice Quality Reporting Program
- Hospice Quality Reporting Measures used for Hospice Compare (as of November, 2017)
- Hospice Compare
- Hospice Conditions of Participation FInal Rule for 2018
- CMS Hospice Experience of Care Survey (CAHPS)
- Palliative Care Measures Menu: The California Health Care Foundation
- AAHPM Measuring What Matters
- National Quality Forum Palliative and End of Life Measures
- Joint Commission recommendations on palliative care measures
- Center to Advance Palliative Care (CAPC) recommendations for palliative care measures
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| Partner with referring clinicians and hospitals to develop programs and strategies to improve health outcomes and patient experience, and to help them meet accountability goals. | ||
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| By effectively engaging patients and caregivers as partners in care, home-based care organizations improve experience, activation, and ultimately, outcomes. | ||
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| Educate payers on opportunity to improve outcomes by more effectively caring for people in their homes. Drive smarter spending by preventing admissions and avoidable ED use. | ||
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| Support clinicians and staff to practice in teams and at the top of their licenses, train for excellence, and recognize achievement. |