Health literacy, cognition, and urinary incontinence among geriatric inpatients discharged to skilled nursing facilities

AIMS

To investigate the association between health literacy and cognition and nursing and patient-reported incontinence in a geriatric inpatient population transitioning to skilled nursing facilities (SNF).

METHODS

Health literacy, depression, and cognition were assessed via the Brief Health Literacy Screen (BHLS), Geriatric Depression Scale 5-item (GDS) and Brief Interview for Mental Status (BIMS), respectively. Multivariable logistic regression assessed the association between BHLS score and incontinence by: (1) nursing-reported urinary incontinence during hospitalization; and (2) patient self-reported "bladder accidents" in the post-enrollment study interview.

RESULTS

A total of 1556 hospitalized patients aged 65 and older met inclusion criteria, of whom 922 (59.3%) were women and 1480 had available BHLS scores. A total of 464 (29.8%) and 515 (33.1%) patients had nursing-reported and self-reported urinary incontinence, respectively. Nursing-reported incontinence was significantly associated with lower BHLS (ie, poorer health literacy) (aOR 0.93, 95%CI 0.89-0.99) and BIMS (ie, poorer cognition) (aOR 0.90, 95%CI 0.83-0.97) scores and need for assistance with toileting (aOR 7.08, 95%CI 2.16-23.21). Patient-reported incontinence was significantly associated with female sex (aOR 1.62, 95%CI 1.19-2.21), increased GDS score (ie, greater likelihood of depression) (aOR 1.22, 95%CI 1.10-1.36) and need for assistance with toileting (aOR 2.46, 95%CI 1.26-4.79).

CONCLUSIONS

Poorer health literacy and cognition are independently associated with an increased likelihood of nursing-reported urinary incontinence among geriatric inpatients transitioning to SNF. Practitioners should consider assessment of health literacy and cognition in frail patients at risk for urinary incontinence and that patient and nursing assessment may be required to capture the diagnosis.

Potentially Avoidable Readmissions of Patients Discharged to Post-Acute Care: Perspectives of Hospital and Skilled Nursing Facility Staff

BACKGROUND

Hospital readmissions from skilled nursing facilities (SNFs) are common. Previous research has not examined how assessments of avoidable readmissions differ between hospital and SNF perspectives.

OBJECTIVES

To determine the percentage of readmissions from post-acute care that are considered potentially avoidable from hospital and SNF perspectives.

DESIGN

Prospective cohort study.

SETTING

One academic medical center and 23 SNFs.

PARTICIPANTS

We included patients from a quality improvement trial aimed at reducing hospital readmissions among patients discharged to SNFs. We included Medicare patients who were discharged to one of 23 regional SNFs between January 2013 and January 2015, and readmitted to the hospital within 30 days.

MEASUREMENTS

Hospital-based physicians and SNF-based staff performed structured root-cause analyses (RCA) on a sample of readmissions from a participating SNF to the index hospital. RCAs reported avoidability and factors contributing to readmissions.

RESULTS

The 30-day unplanned readmission rate to the index hospital from SNFs was 14.5% (262 hospital readmissions of 1,808 discharges). Of the readmissions, 120 had RCA from both the hospital and SNF. The percentage of readmissions rated as potentially avoidable was 30.0% and 13.3% according to hospital and SNF staff, respectively. Hospital and SNF ratings of potential avoidability agreed for 73.3% (88 of the 120 readmissions), but readmission factors varied between settings. Diagnostic problems and improved management of changes in conditions were the most common avoidable readmission factors by hospitals and SNFs, respectively.

CONCLUSION

A substantial percentage of hospital readmissions from SNFs are rated as potentially avoidable. The ratings and factors underlying avoidability differ between hospital and SNF staff. These data support the need for joint accountability and collaboration for future readmission reduction efforts between hospitals and their SNF partners.

Training Nonnursing Staff to Assist with Nutritional Care Delivery in Nursing Homes: A Cost-Effectiveness Analysis

OBJECTIVES

To determine the effect and cost-effectiveness of training nonnursing staff to provide feeding assistance for nutritionally at-risk nursing home (NH) residents.

DESIGN

Randomized, controlled trial.

SETTING

Five community NHs.

PARTICIPANTS

Long-stay NH residents with an order for caloric supplementation (N = 122).

INTERVENTION

Research staff provided an 8-hour training curriculum to nonnursing staff. Trained staff were assigned to between-meal supplement or snack delivery for the intervention group; the control group received usual care.

MEASUREMENTS

Research staff used standardized observations and weighed-intake methods to measure frequency of between-meal delivery, staff assistance time, and resident caloric intake.

RESULTS

Fifty staff (mean 10 per site) completed training. The intervention had a significant effect on between-meal caloric intake (F = 56.29, P < .001), with the intervention group consuming, on average, 163.33 (95% CI = 120.19-206.47) calories per person per day more than the usual care control group. The intervention costs were $1.27 per person per day higher than usual care (P < .001). The incremental cost-effectiveness ratio for the intervention was 134 kcal per dollar. The increase in cost was due to the higher frequency and number of snack items given per person per day and the associated staff time to provide assistance.

CONCLUSION

It is cost effective to train nonnursing staff to provide caloric supplementation, and this practice has a positive effect on residents' between-meal intake.

Medications associated with geriatric syndromes and their prevalence in older hospitalized adults discharged to skilled nursing facilities

BACKGROUND

More than half of the hospitalized older adults discharged to skilled nursing facilities (SNFs) have more than 3 geriatric syndromes. Pharmacotherapy may be contributing to geriatric syndromes in this population.

OBJECTIVES

Develop a list of medications associated with geriatric syndromes and describe their prevalence in patients discharged from acute care to SNFs.

DESIGN

Literature review and multidisciplinary expert panel discussion, followed by cross-sectional analysis.

SETTING

Academic medical center in the United States PARTICIPANTS: One hundred fifty-four hospitalized Medicare beneficiaries discharged to SNFs.

MEASUREMENTS

Development of a list of medications that are associated with 6 geriatric syndromes. Prevalence of the medications associated with geriatric syndromes was examined in the hospital discharge sample.

RESULTS

A list of 513 medications was developed as potentially contributing to 6 geriatric syndromes: cognitive impairment, delirium, falls, reduced appetite or weight loss, urinary incontinence, and depression. Medications included 18 categories. Antiepileptics were associated with all syndromes, whereas antipsychotics, antidepressants, antiparkinsonism, and opioid agonists were associated with 5 geriatric syndromes. In the prevalence sample, patients were discharged to SNFs with an overall average of 14.0 (±4.7) medications, including an average of 5.9 (±2.2) medications that could contribute to geriatric syndromes, with falls having the most associated medications at discharge at 5.5 (±2.2).

CONCLUSIONS

Many commonly prescribed medications are associated with geriatric syndromes. Over 40% of all medications ordered upon discharge to SNFs were associated with geriatric syndromes and could be contributing to the high prevalence of geriatric syndromes experienced by this population. Journal of Hospital Medicine 2016;11:694-700. © 2016 Society of Hospital Medicine.

Comparison Between Quality of Care Provided by Trained Feeding Assistants and Certified Nursing Assistants During Between-Meal Supplementation in Long-Term Care Settings

The purpose of this study was to compare the quality of feeding assistance provided by trained non-nursing staff with care provided by certified nursing assistants (CNAs). Research staff provided an 8-hr training course that met federal and state requirements to non-nursing staff in five community long-term care facilities. Trained staff were assigned to between-meal supplement and/or snack delivery for 24 weeks. Using standardized observations, research staff measured feeding assistance care processes between meals across all study weeks. Trained staff, nurse aides, and upper level staff were interviewed at 24 weeks to assess staff perceptions of program impact. Trained staff performed significantly better than CNAs for 12 of 13 care process measures. Residents also consumed significantly more calories per snack offer from trained staff ( M = 130 ± 126 [ SD] kcal) compared with CNAs ( M = 77 ± 94 [ SD] kcal). The majority of staff reported a positive impact of the training program.

Stability of Geriatric Syndromes in Hospitalized Medicare Beneficiaries Discharged to Skilled Nursing Facilities

OBJECTIVES

To assess multiple geriatric syndromes in a sample of older hospitalized adults discharged to skilled nursing facilities (SNFs) and subsequently to home to determine the prevalence and stability of each geriatric syndrome at the point of these care transitions.

DESIGN

Descriptive, prospective study.

SETTING

One large university-affiliated hospital and four area SNFs.

PARTICIPANTS

Fifty-eight hospitalized Medicare beneficiaries discharged to SNFs (N = 58).

MEASUREMENTS

Research personnel conducted standardized assessments of the following geriatric syndromes at hospital discharge and 2 weeks after SNF discharge to home: cognitive impairment, depression, incontinence, unintentional weight loss, loss of appetite, pain, pressure ulcers, history of falls, mobility impairment, and polypharmacy.

RESULTS

The average number of geriatric syndromes per participant was 4.4 ± 1.2 at hospital discharge and 3.8 ± 1.5 after SNF discharge. There was low to moderate stability for most syndromes. On average, participants had 2.9 syndromes that persisted across both care settings, 1.4 syndromes that resolved, and 0.7 new syndromes that developed between hospital and SNF discharge.

CONCLUSION

Geriatric syndromes were prevalent at the point of each care transition but also reflected significant within-individual variability. These findings suggest that multiple geriatric syndromes present during a hospital stay are not transient and that most syndromes are not resolved before SNF discharge. These results underscore the importance of conducting standardized screening assessments at the point of each care transition and effectively communicating this information to the next provider to support the management of geriatric conditions.

The Need for Higher Minimum Staffing Standards in U.S. Nursing Homes

Many U.S. nursing homes have serious quality problems, in part, because of inadequate levels of nurse staffing. This commentary focuses on two issues. First, there is a need for higher minimum nurse staffing standards for U.S. nursing homes based on multiple research studies showing a positive relationship between nursing home quality and staffing and the benefits of implementing higher minimum staffing standards. Studies have identified the minimum staffing levels necessary to provide care consistent with the federal regulations, but many U.S. facilities have dangerously low staffing. Second, the barriers to staffing reform are discussed. These include economic concerns about costs and a focus on financial incentives. The enforcement of existing staffing standards has been weak, and strong nursing home industry political opposition has limited efforts to establish higher standards. Researchers should study the ways to improve staffing standards and new payment, regulatory, and political strategies to improve nursing home staffing and quality.

The Need for Higher Minimum Staffing Standards in U.S. Nursing Homes

Many U.S. nursing homes have serious quality problems, in part, because of inadequate levels of nurse staffing. This commentary focuses on two issues. First, there is a need for higher minimum nurse staffing standards for U.S. nursing homes based on multiple research studies showing a positive relationship between nursing home quality and staffing and the benefits of implementing higher minimum staffing standards. Studies have identified the minimum staffing levels necessary to provide care consistent with the federal regulations, but many U.S. facilities have dangerously low staffing. Second, the barriers to staffing reform are discussed. These include economic concerns about costs and a focus on financial incentives. The enforcement of existing staffing standards has been weak, and strong nursing home industry political opposition has limited efforts to establish higher standards. Researchers should study the ways to improve staffing standards and new payment, regulatory, and political strategies to improve nursing home staffing and quality.

Geriatric Syndromes in Hospitalized Older Adults Discharged to Skilled Nursing Facilities

OBJECTIVES

To determine the prevalence, recognition, co-occurrence, and recent onset of geriatric syndromes in individuals transferred from the hospital to a skilled nursing facility (SNF).

DESIGN

Quality improvement project.

SETTING

Acute care academic medical center and 23 regional partner SNFs.

PARTICIPANTS

Medicare beneficiaries hospitalized between January 2013 and April 2014 and referred to SNFs (N = 686).

MEASUREMENTS

Project staff measured nine geriatric syndromes: weight loss, lack of appetite, incontinence, and pain (standardized interview); depression (Geriatric Depression Scale); delirium (Brief Confusion Assessment Method); cognitive impairment (Brief Interview for Mental Status); and falls and pressure ulcers (hospital medical record using hospital-implemented screening tools). Estimated prevalence, new-onset prevalence, and common coexisting clusters were determined. The extent to which treating physicians commonly recognized syndromes and communicated them to SNFs in hospital discharge documentation was evaluated.

RESULTS

Geriatric syndromes were prevalent in more than 90% of hospitalized adults referred to SNFs; 55% met criteria for three or more coexisting syndromes. The most-prevalent syndromes were falls (39%), incontinence (39%), loss of appetite (37%), and weight loss (33%). In individuals who met criteria for three or more syndromes, the most common triad clusters were nutritional syndromes (weight loss, loss of appetite), incontinence, and depression. Treating hospital physicians commonly did not recognize and document geriatric syndromes in discharge summaries, missing 33% to 95% of syndromes present according to research personnel.

CONCLUSION

Geriatric syndromes in hospitalized older adults transferred to SNFs are prevalent and commonly coexist, with the most frequent clusters including nutritional syndromes, depression, and incontinence. Despite the high prevalence, this clinical information is rarely communicated to SNFs on discharge.

Cost-Effectiveness of Nutrition Intervention in Long-Term Care

OBJECTIVES

To determine the cost-effectiveness of two nutrition interventions on food, beverage, and supplement intake and body weight.

DESIGN

Randomized, controlled trial.

SETTING

Five skilled nursing home facilities.

PARTICIPANTS

Long-stay residents with orders for nutrition supplementation (N = 154).

INTERVENTION

Participants were randomized into a usual care control group, an oral liquid nutrition supplement (ONS) intervention group, or a snack intervention group. Research staff provided ONS, according to orders or a variety of snack foods and beverages twice per day between meals, 5 days per week for 24 weeks and assistance to promote consumption.

MEASUREMENTS

Research staff independently weighed residents at baseline and monthly during the 24-week intervention. Resident food, beverage and supplement intake and the amount of staff time spent providing assistance were assessed for 2 days at baseline and 2 days per month during the intervention using standardized observation and weighed intake procedures.

RESULTS

The ONS intervention group took in an average of 265 calories more per day and the snack intervention group an average of 303 calories more per day than the control group. Staff time required to provide each intervention averaged 11 and 14 minutes per person per offer for ONS and snacks, respectively, and 3 minutes for usual care. Both interventions were cost-effective in increasing caloric intake, but neither intervention had a significant effect on body weight, despite positive trends.

CONCLUSION

Oral liquid nutrition supplements and snack offers were efficacious in promoting caloric intake when coupled with assistance to promote consumption and a variety of options, but neither intervention resulted in significant weight gain.

Specific Physician Orders Improve Pain Detection and Pain Reports in Nursing Home Residents: Preliminary Data

Despite evidence that many nursing home residents' pain is poorly managed, reasons for this poor management remain unanswered. The aim of this study was to determine if specific order sets related to pain assessment would improve pain management in nursing home (NH) residents. Outcomes included observed nurse pain assessment queries and resident reports of pain. The pretest/post-test study was performed in a 240-bed for-profit nursing home in the mid-southern region of the United States and participants were 43 nursing home residents capable of self-consent. Medical chart abstraction was performed during a 2-week (14-day) period before the implementation of specific order sets for pain assessment (intervention) and a 2-week (14-day) period after the intervention. Trained research assistants observed medication administration passes and performed participant interviews after each medication pass. One month after intervention implementation, 1 additional day of observations was conducted to determine data reliability. Nurses were observed to ask residents about pain more frequently, and nurses continued to ask about pain at higher rates 1 month after the intervention was discontinued. The proportion of residents who reported pain also significantly increased in response to increased nurse queries (e.g., "Do you have any pain right now?"), which underscores the importance of nurses directly asking residents about pain. Notably 70% of this long-stay NH population only told the nurses about their pain symptoms when asked directly. Findings uncover that using specific pain order sets seems to improve the detection of pain, which should be a routine part of nursing assessment.

Pain and Satisfaction With Pain Management Among Older Patients During the Transition From Acute to Skilled Nursing Care

PURPOSE

Approximately 20% of hospitalized Medicare beneficiaries are discharged from the hospital to skilled nursing facilities (SNFs); and up to 23% of SNF patients return to the hospital within 30 days of hospital discharge, with pain as one of the most common symptoms precipitating hospital readmission. We sought to examine the prevalence of moderate to severe pain at hospital discharge to SNF, the incidence of new moderate to severe pain (relative to prehospitalization), and satisfaction with pain management among older acute care patients discharged to SNF.

DESIGN AND METHODS

Structured patient interviews were conducted with 188 Medicare beneficiaries discharged to 23 area SNFs from an academic medical center. Pain level (0-10) and satisfaction with pain management were assessed upon hospital admission, discharge, and within 1 week after transition to SNF.

RESULTS

There was a high prevalence of moderate to severe pain at each time point including prehospital (51%), hospital discharge (38%), and following SNF admission (53%). Twenty-eight percent of participants reported new moderate to severe pain at hospital discharge, whereas 44% reported new moderate to severe pain following SNF admission. Most participants reported being "satisfied" with their pain treatment, even in the context of moderate to severe pain.

IMPLICATIONS

Moderate to severe pain is a common problem among hospitalized older adults discharged to SNF and continues during their SNF stay. Pain assessment and management should involve a specific, planned process between hospital and SNF clinicians at the point of care transition, even if patients express "satisfaction" with current pain management.

The Impact of Family Visitation on Feeding Assistance Quality in Nursing Homes

The purpose of this study was to determine: (a) the frequency of family visitation during mealtime and (b) whether the presence of family during meals had an impact on the quality of feeding assistance care and resident intake. Participants included 74 nursing home residents from two Veterans Affairs (VA) and four community facilities in one geographic region. Mealtime periods in which family was present were compared with mealtime periods when family was not present for the same resident. Results showed that family visitation was infrequent during mealtime; however, feeding assistance time was significantly higher when visitors were present. Despite the increase in assistance time, there was not a significant difference in intake. Strategies that encourage the involvement of family in mealtime assistance may have additional benefits not directly associated with meal consumption, including providing family members with meaningful activity during a visit and enhancing residents’ quality of life and well-being.

A staff training and management intervention in VA long-term care: impact on feeding assistance care quality

Efforts to translate efficacious interventions into long-term care practice have had limited success due to the lack of consideration of key translational intervention components. A multi-faceted intervention was implemented in two veteran affairs facilities to improve feeding assistance care. There were three study phases: baseline, intervention, and follow-up. During each phase, trained research staff conducted standardized observations of 12 meals/participant to assess feeding assistance care quality. The staff received three initial training sessions followed by six consecutive weeks of feedback sessions wherein the observation-based care process measures were shared with the staff. There were significant, but modest, improvements in mealtime feeding assistance care processes, and most of the improvements were maintained during follow-up. A multi-faceted intervention resulted in significant, but modest, improvements in mealtime feeding assistance care quality. Organizational (staff schedules, communication) and environmental (dining location) barriers were identified that interfered with improvement efforts.

Pain reports and pain medication treatment in nursing home residents with and without dementia

AIM

The purpose of this pilot study was to determine if a diagnosis of dementia influenced pain self-reports and pain medication use in a group of verbally communicative nursing home (NH) residents.

METHODS

The study design was a between groups, cross-sectional chart audit and a seven-question structured pain interview comparing outcomes in residents with and without a diagnosis of dementia. The study was carried out at a large metropolitan NH in the southern USA. The participants consisted of 52 long-stay NH residents capable of self-consent with at least one order for pain medication (opioid or non-narcotic) either pro re nata, scheduled or both. Approximately 40% (n = 20) had a diagnosis of dementia.

RESULTS

Although each group had similar pain-related diagnoses, residents without a dementia diagnosis were significantly more likely to have a medication order for an opioid (OR 4.37,95% CI 1.29-14.73, P = 0.018). Based on self-reported pain interview responses, no statistically significant differences were identified between the groups for chronic pain symptoms. However, among residents who reported current pain, those with a dementia diagnosis reported greater pain intensity (based on a 0-10 numeric rating scale) than did those without dementia (median 8.0 vs 6.0, respectively; P = 0.010).

CONCLUSIONS

Verbally communicative NH residents with mild and moderate cognitive impairment can report their pain symptoms and pain intensity. Nurses in long-term care might assume that residents with dementia cannot reliably self-report their pain; however, suffering from untreated severe pain could exacerbate cognitive impairment, worsen functional impairment and severely impair sleep. A brief, focused pain interview might be one method for increasing the detection of moderate to severe pain in verbally communicative NH residents with dementia.

Fatigability as a function of physical activity energy expenditure in older adults

Increased fatigue is a predictor of morbidity and mortality in older adults. Fatigability defines a change in performance or self-reported fatigue in response to physical activity (PA). However, the relationship of fatigability to PA-related energy expenditure (PAEE) is unknown. Changes in performance, fatigue, and energy expenditure were measured simultaneously in 17 adults (11 females, 74-94 years old) performing eight standardized PA tasks with various energy expenditure requirements in a whole-room indirect calorimeter. Change in performance was objectively measured using a PA movement monitor and change in fatigue was self-reported on a seven-point scale for each task. Performance and perceived fatigability severity scores were calculated as a ratio of change in performance and fatigue, respectively, and PAEE. We found that change in both objective performance and self-reported fatigue were associated with energy expenditure (Spearman rho = -0.72 and -0.68, respectively, p < 0.001) on a task requiring relatively high level of energy expenditure. The performance and perceived fatigability severity scores were significantly correlated (rho = 0.77, p < 0.001) on this task. In summary, results of this proof of concept pilot study show that both perceived and performance fatigability severity scores are related to PAEE-induced fatigue on a task requiring relatively high level of energy expenditure. We conclude that fatigability severity is a valid measure of PAEE-induced fatigue in older adults.

A controlled trial of an intervention to increase resident choice in long term care

OBJECTIVE

The purpose of this study was to evaluate an intervention to improve staff offers of choice to nursing home residents during morning care.

DESIGN

A controlled trial with a delayed intervention design.

SETTING

Four community, for-profit nursing homes.

PARTICIPANTS

A total of 169 long-stay nursing home residents who required staff assistance with morning care and were able to express their care preferences.

INTERVENTION

Research staff held weekly training sessions with nurse aides (NAs) for 12 consecutive weeks focused on how to offer choice during four targeted morning care areas: when to get out of bed, when to get dressed/what to wear, incontinence care (changing and/or toileting), and where to dine. Training sessions consisted of brief video vignettes illustrating staff-resident interactions followed by weekly feedback about how often choice was being provided based on standardized observations of care conducted weekly by research staff.

MEASUREMENTS

Research staff conducted standardized observations during a minimum of 4 consecutive morning hours per participant per week for 12 weeks of baseline and 12 weeks of intervention.

RESULTS

There was a significant increase in the frequency that choice was offered for 3 of the 4 targeted morning care areas from baseline to intervention: (1) out of bed, 21% to 33% (P < .001); dressing, 20% to 32% (P < .001); incontinence care, 18% to 23%, (P < .014). Dining location (8% to 13%) was not significant. There was also a significant increase in the amount of NA staff time to provide care from baseline to intervention (8.01 ± 9.0 to 9.68 ± 9.9 minutes per person, P < .001).

CONCLUSION

A staff training intervention improved the frequency with which NAs offered choice during morning care but also required more time. Despite significant improvements, choice was still offered one-third or less of the time during morning care.

Whom do veteran nursing home residents prefer to talk to about satisfaction with care?: implications for nursing staff

The purpose of this study was to determine whom residents in U.S. Department of Veterans Affairs (VA) nursing homes prefer to talk to about their quality of care. A total of 127 participants in three VA facilities completed a structured, in-person interview. Nearly half (47.6%) reported that they prefer talking with facility staff about their quality of care, with the most preferred staff being licensed nurses and physicians. However, 26% reported being hesitant to express complaints for fear of reprisal. Participants also reported being least comfortable talking to direct care staff (nurse aides) if they saw another resident being mistreated. These findings suggest that licensed nurses and primary care professionals, both of whom are in frequent contact with residents, should routinely ask residents questions about their quality of care so that nursing home residents have ample opportunity to express concerns. Finally, asking satisfaction questions routinely may also enable facilities to address problems as they occur.

Translating research into practice in nursing homes: can we close the gap?

PURPOSE

A gap between research and practice in many nursing home (NH) care areas persists despite efforts by researchers, policy makers, advocacy groups, and NHs themselves to close it. The reasons are many, but two factors that have received scant attention are the dissemination process itself and the work of the disseminators or change agents. This review article examines these two elements through the conceptual lens of Roger's innovation dissemination model.

DESIGN AND METHODS

The application of general principles of innovation dissemination suggests that NHs are characteristically slow to innovate and thus may need more time as well as more contact with outside change agents to adopt improved practices.

RESULTS

A review of the translation strategies used by NH change agents to promote adoption of evidence-based practice in NHs suggests that their strategies inconsistently reflect lessons learned from the broader dissemination literature.

IMPLICATIONS

NH-related research, policy, and practice recommendations for improving dissemination strategies are presented. If we can make better use of the resources currently devoted to disseminating best practices to NHs, we may be able to speed NHs' adoption of these practices.