HoNOS Frequently Asked Questions

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1 HoNOS Frequently Asked Questions The answers in this document are based on the information found on the Royal College of Psychiatrists webpage and policy adopted by Southern health Foundation Trust. If there are issues arising in training that you are unable to resolve please forward them to Liz Vernon-Wilson What is, or are, HoNOS? They are 12 simple scales on which service users with severe mental illness are rated by clinical staff. The idea is that these ratings are stored, and then repeated - say after a course of treatment or some other intervention - and then compared. If the ratings show a difference, then that might mean that the service user's health or social status has changed. They are therefore designed for repeated use, as their name implies, as clinical outcomes measures. What does HoNOS stand for? Health of the Nation Outcome Scales What do the scales cover? A wide range of health and social domains - psychiatric symptoms, physical health, functioning, relationships and housing: 1. Overactive, aggressive, disruptive or agitated behaviour 2. Non-accidental self-injury 3. Problem drinking or drug-taking 4. Cognitive problems 5. Physical illness or disability problems 6. Problems associated with hallucinations and delusions 7. Problems with depressed mood 8. Other mental and behavioural problems 9. Problems with relationships 10. Problems with activities of daily living 11. Problems with living conditions 12. Problems with occupation and activities How are they scored? All scales follow the format: 0 = no problem 1 = minor problem requiring no action 2 = mild problem but definitely present 3 = moderately severe problem 4 = severe to very severe problem Each scale is rated in order from 1 to 12. Do not include information rated in an earlier item except for item 10 which is an overall rating. The rating is made on the basis of all information available to the rater (whatever the source) and is based on the most severe problem that occurred during the period rated (usually the two weeks leading up to the point of rating).

2 The HoNOS system is not a standardised clinical assessment and cannot be a substitute for one. When are HoNOS ratings made? The minimum required is that a rating is made at the start of each episode of care and at the end. HoNOS should also be rated following assessments made for Care Programme Approach review. It is recommended that HoNOS is rated when there is a major change in the patient's status (for instance, an admission to or discharge from hospital, to PICU, to CRHT) and, for long episodes of care, at every 6 months or so. Guidance from Southern Health Foundation Trust states that the care-coordinator is responsible for HoNOS records being completed. At points of transfer the admitting staff have final responsibility. Are there different systems for different service-user groups? There are several versions of HoNOS. The glossary has been modified for each group to facilitate rating. For this reason, the scales are not comparable between groups. HoNOS for working age adults HoNOS65+ for older people HoNOSCA for children and adolescents HoNOS-Secure for use in health and social care settings secure psychiatric, prison health care and related forensic services, including those based in the community) HoNOS-LD for learning disabilities HoNOS-ABI for acquired brain injury How long does it take to complete HoNOS ratings? The ratings are made when all the information (e.g. from an assessment, informant view, GP, notes, investigations) is available. Once staff are trained in the use of the scales, the actual 12 ratings take, on average, an extra 4 minutes or so. If a multidisciplinary group of staff make a collective rating it can take longer and appropriate time should be set aside. Best practice is to discuss a rating that is brought to the MDT meeting by the client s named care coordinator or lead nurse. How easy is it to train in HoNOS use? The Royal College of Psychiatrists recommends that clinical staff have one day training initially, and a half-day re-training every 2 years to maximise inter-rater reliability. Southern Health Foundation Trust provides a shorter introductory session that will be supported with e-based learning materials. Multi-team, multidisciplinary training is of great value in stimulating discussion, and is recommended. To maintain inter rater reliability we recommend that teams discuss a rating at least once a month. Who can make HoNOS ratings? Any qualified mental health care professional working with people with severe mental illness who has undergone official HoNOS training. Unqualified staff can be provided with training that gives them an understanding of the scales that will enable them to contribute to multidisciplinary team discussions about HoNOS ratings.

3 What is done with the scores? They are stored in patient s notes, and should be used to support care planning. For instance, if, after assessment, the non-accidental self injury scale (Scale 2) is scored at more than 1, it may be necessary to justify omission of any plan to reduce suicidal risk. As the Trust transfers patient records to an electronic format on RiO, there will be an opportunity to view client s HoNOS total scores over time. Reviewing this information should lead to further assessment and intervention- for instance, if a scale score remains obdurately high. In addition to helping review individual patient data, aggregated data can be accessed for any team or service. This can help staff look at changes in their whole caseload. Feedback sessions give teams more contextualised information about HoNOS with respect to patient demographics, diagnosis and interventions. What do the scores mean clinically? Comparing the total score made by adding up all 12 scales may not be particularly informative, as they are so wide in their coverage. Marked improvements in one scale may be cancelled out by deterioration in another, such that it looks as if nothing has changed. Looking at changes in individual scales is more helpful in showing areas of service impact. SHFT hopes to use clinical outcomes measures to support service improvement and provide evidence of service impact for health care commissioners. The input of clinical staff is essential to this process and interested staff and trainers are invited to attend the HoNOS clinical development group which meets quarterly. Sound interpretation of clinical outcomes requires that good quality HoNOS data is collected and analysed in the context of service intervention, patient demographics, diagnosis and any other information that will impact on change in HoNOS score. What part do the service-users' views play in this process? Is it user-centred? What about carers and other stakeholders? HoNOS ratings are made by staff, and reflect the staff's view of the situation, although in many ratings, service-users' views are taken into account. Service users, carers, referrers, commissioners and others may have quite different reasons for being interested in outcomes, quite different desired outcomes, and quite different approaches to how to measure outcomes. The HoNOS system is not designed to cover all aspects of outcomes; merely those that relate to staff views. SHFT is developing the use of PROMs (patient recorded outcomes measures). Other outcomes measures more appropriate to specific services can also be adopted, for example CORE (clinical outcomes routine evaluation) is used in psychological services. Are there any obvious gaps in the scales? Yes. For instance, in HoNOS and HoNOS65+ elation must be rated under the "other" scale (8). There is no place to rate spiritual or existential difficulties. But the HoNOS system was designed with severe mental illness in mind and to be brief. It cannot be all things to all situations. What's to stop staff deliberately rating higher initially, and then lower, to show a spurious improvement?

4 Nothing but their honesty. However, most services implementing HoNOS ratings will also implement quality control systems including, for instance, independent assessments and ratings of a sample of service users to check the degree with which this tendency is occurring. The results of these "validation" checks can then be incorporated into the aggregate analysis. Comparisons between similar activities at different times and between different teams can also indicate such gaming practices. Surely staff will disagree so often that it will all depend on who does the rating rather than the service-user's real level of problems? HoNOS was designed to maximise inter-rater reliability and there are published data about this. However, like all such ratings, HoNOS ratings are subjective and prone to some disagreement. Like the validation quality checks mentioned above, services using HoNOS will be asked periodically to get all their staff to rate the same video or paper vignette of a service user. This will be used to evaluate the inter rater reliability in a team and highlight where further training is needed. To improve inter rater reliability, teams are recommended to discuss an example of HoNOS rating once a month. What is the HoNOS system not designed for? it does not predict risk; it is a measure of the preceding period only it is not a standard interview or assessment it does not produce a medical diagnostic label it is not designed for use in primary care it is not designed specifically for use in clinical trials; it is to be used by clinicians who know the service-user well. On their own, HoNOS ratings- even repeated - say little about whether an outcome is related to the care provided. True assessment of clinical outcomes requires data to be contextualised such that the intervention used, and the context of the situation- for instance, the diagnosis, or other events which might have a bearing on change are considered. HoNOS is thus necessary, but not sufficient, for routine clinical outcomes assessment. What is the difference between HoNOS and HoNOS65+? I have trained in one can I use the other? The scales cover identical areas, and are scored in the same way, but the glossaries are different. The HoNOS65+ glossary is more detailed than that for HoNOS, and is particularly aimed at common situations in old age psychiatry. The two scales cannot be directly compared. Scale 12 in particular is defined differently. Staff are recommended to attend training for the tool that they will use in their directorate. Where staff change directorate the Trust recommends that staff retrain in using the appropriate HoNOS tool as there are significant differences in glossaries between HoNOS tools. It is hoped that an on-line e-learning tool will be available next year to facilitate this process. Can scores be used against staff? Every tool for building can be used for destruction. But the HoNOS system, including careful analysis of context and intervention, can strengthen the case for better resources for people with severe mental illness and the staff who deal with them.

5 Isn't HoNOS just another piece of paper? Nearly all bureaucracy is introduced with the aim of improving patient care, and the HoNOS system is no exception. The difference with HoNOS is that clinicians will have the results fed back to them. Seeing results relevant to their service-users and their interventions is aimed at facilitating reflective clinical practice and service impact. With this in mind, the Trust will provide feedback to individual teams at regular intervals (6 monthly) about their HoNOS data. It is hoped that lead clinicians and managers will use this information for reviewing and improving clinical care. What will my service gain from using the HoNOS system? Clinicians can build up a picture over time of their service-users' patterns of response to interventions and events that might not be easy to achieve without measurement. If ratings are incorporated into care plans then objectives can be quantified. Managers can examine differences between outcomes between different teams and interventions on similar service-user groups. Commissioners can move from a purely activity/structure approach to a more rational purchasing model involving health gain. Routine outcomes measurement involves more than HoNOS or other repeated measures, and development of systems for coding interventions and context will move services into a reflective and evidence-based culture that has many other tangible and less tangible benefits. This process "tests" crucial clinical governance systems (e.g. training, information and supervision systems). It is important that staff are aware of how HoNOS data can be used for service improvement and strive to produce high quality data to facilitate this process.