Mental Health Outcomes Information Collection Protocol

Appendix 2: HoNOS65+ rating guidelines and glossary

General rating guidelines

Perform a full clinical assessment of the patient's clinical history and current problems
Rate items in order from 1 to 12.
Do not include information already rated in an earlier item.
Rate the most severe problem that occurred in the period rated.
The rating period is generally the preceding two weeks for inpatients at admission, for hospital outpatients, and for all clients of community-based services. The exception is at discharge from acute inpatient care, in which case the rating period should generally be the preceding 72 hours.
Each item is rated on a 5-point scale of severity (0 to 4) as follows:
0. No problem
1. Minor problem requiring no formal action
2. Mild problem. Should be recorded in a care plan or other case record
3. Problem of moderate severity
4. Severe to very severe problem
7. Not known / Unable to rate.
Specific help for rating each point on each item is provided in the Glossary.
As far as possible, the use of rating point 7 should be avoided, because missing data make scores less comparable over time or between settings.

HoNOS65+ scores: Clinical significance and recommended actions

Not clinically significant	0	No problem	Problem not present.
Not clinically significant	1	Minor problem	Requires no formal action. May or may not be recorded in clinical file.
Clinically significant	2	Mild problem	Warrants recording in clinical file. May or may not be incorporated in care plan.
	3	Moderate problem	Warrants recording in clinical file. Should be incorporated in care plan.
	4	Severe to very severe problem	Most severe category for patients with this problem. Warrants recording in clinical file. Should be incorporated in care plan. Note: Patient can get worse.

HoNOS65+ glossary

1. Behavioural disturbance (eg. overactive, aggressive, disruptive or agitated behaviour, uncooperative or resistive behaviour)

Include such behaviour due to any cause, eg. dementia, drugs, alcohol, psychosis, depression, etc.

Do not include bizarre behaviour, rated at Scale 6.

0.	No problems of this kind during the period rated.
1.	Occasional irritability, quarrels, restlessness etc., but generally calm and co-operative and not requiring any specific action.
2.	Includes aggressive gestures, pushing or pestering others; threats or verbal aggression; lesser damage to property (e.g. broken cup, window); significant overactivity or agitation; intermittent restlessness or wandering (day or night); uncooperative at times, requiring encouragement and persuasion.
3.	Physically aggressive to others or animals (short of rating 4); more serious damage to, or destruction of, property; frequently threatening manner, more serious or persistent overactivity or agitation; frequent restlessness or wandering; significant problems with co-operation, largely resistant to help or assistance.
4.	At least one serious physical attack on others (over and above rating of 3); major or persistent destructive activity (e.g. fire-setting); persistent and threatening behaviour; severe overactivity or agitation; sexually disinhibited or other inappropriate behaviour (e.g. deliberate inappropriate urination or defecation); virtually constant restlessness or wandering; severe problems related to non-compliant or resistive behaviour.

2. Non-accidental self-injury

Do not include accidental self-injury (due eg. to dementia or severe learning disability); any cognitive problem is rated at Scale 4 and the injury at Scale 5.

Do not include illness or injury as a direct consequence of drug or alcohol use rated at Scale 3, (eg. cirrhosis of the liver or injury resulting from drunk-driving are rated at Scale 5).

0.	No problem of this kind during the period rated.
1.	Fleeting thoughts of self-harm or suicide; but little or no risk during the period rated.
2.	Mild risk during period; includes more frequent thoughts or talking about self-harm or suicide (including 'passive' ideas of self-harm such as not taking avoiding action in a potentially life-threatening situation, eg. while crossing a road).
3.	Moderate to serious risk of deliberate self-harm during the period rated; includes frequent or persistent thoughts or talking about self-harm; includes preparatory behaviours, eg. collecting tablets.
4.	Suicidal attempt or deliberate self-injury during period.

3. Problem drinking or drug-taking

Do not include aggressive or destructive behaviour due to alcohol or drug use, rated at Scale 1.

Do not include physical illness or disability due to alcohol or drug use, rated at Scale 5.

0.	No problem of this kind during the period rated.
1.	Some over-indulgence but within social norm.
2.	Occasional loss of control of drinking or drug-taking; but not a serious problem.
3.	Marked craving or dependence on alcohol or drug use with frequent loss of control, drunkenness, etc.
4.	Major adverse consequences or incapacitated due to alcohol or drug problems.

4. Cognitive problems

Include problems of orientation, memory, and language associated with any disorder: dementia, learning disability, schizophrenia, etc.

Do not include temporary problems (eg. hangovers) which are clearly associated with alcohol, drug or medication use, rated at Scale 3.

0.	No problem of this kind during the period rated.
1.	Minor problems with orientation (eg. some difficulty with orientation to time) or memory (eg. a degree of forgetfulness but still able to learn new information), no apparent difficulties with the use of language.
2.	Mild problems with orientation (eg. frequently disorientated to time) or memory (eg. definite problems learning new information such as names, recollection of recent events; deficit interferes with everyday activities); difficulty finding way in new or unfamiliar surroundings; able to deal with simple verbal information but some difficulties with understanding or expression of more complex language.
3.	Moderate problems with orientation (eg. usually disorientated to time, often place) or memory (eg. new material rapidly lost, only highly learned material retained, occasional failure to recognise familiar individuals); has lost the way in a familiar place; major difficulties with language (expressive or receptive).
4.	Severe disorientation (eg. consistently disorientated to time and place, and sometimes to person) or memory impairment (eg. only fragments remain, loss of distant as well as recent information, unable to effectively learn any new information, consistently unable to recognise or to name close friends or relatives); no effective communication possible through language or inaccessible to speech.

5. Physical illness or disability problems

Include illness or disability from any cause that limits mobility, impairs sight or hearing, or otherwise interferes with personal functioning (eg. pain).

Include side-effects from medication; effects of drug/alcohol use; physical disabilities resulting from accidents or self-harm associated with cognitive problems, drunk driving etc.

Do not include mental or behavioural problems rated at Scale 4.

0.	No physical health, disability or mobility problems during the period rated.
1.	Minor health problem during the period (e.g. cold); some impairment of sight or hearing (but still able to function effectively with the aid of glasses or hearing aid).
2.	Physical health problem associated with mild restriction of activities or mobility (e.g. restricted walking distance, some degree of loss of independence); moderate impairment of sight or hearing (with functional impairment despite the appropriate use of glasses or hearing aid); some degree of risk of falling, but low and no episodes to date; problems associated with mild degree of pain.
3.	Physical health problem associated with moderate restriction of activities or mobility (e.g. mobile only with an aid - stick or Zimmer frame - or with help); more severe impairment of sight or hearing (short of rating 4); significant risk of falling (one or more falls); problems associated with a moderate degree of pain.
4.	Major physical health problem associated with severe restriction of activities or mobility (e.g. chair or bed bound); severe impairment of sight or hearing (e.g. registered blind or deaf); high risk of falling (one or more falls) because of physical illness or disability; problems associated with severe pain; presence of impaired level of consciousness.

6. Problems associated with hallucinations and delusions

Include hallucinations and delusions (or false beliefs) irrespective of diagnosis.

Include odd and bizarre behaviour associated with hallucinations or delusions (or false beliefs).

Do not include aggressive, destructive or overactive behaviours attributed to hallucinations, delusions or false beliefs, rated at Scale 1.

0.	No evidence of delusions or hallucinations during the period rated.
1.	Somewhat odd or eccentric beliefs not in keeping with cultural norms.
2.	Delusions or hallucinations (eg. voices, visions) are present, but there is little distress to consumer or manifestation in bizarre behaviour, that is, a present, but mild clinical problem.
3.	Marked preoccupation with delusions or hallucinations, causing significant distress or manifested in obviously bizarre behaviour, that is, moderately severe clinical problem.
4.	Mental state and behaviour is seriously and adversely affected by delusions or hallucinations, with a major impact on consumer or others.

7. Problems with depressive symptoms

Do not include overactivity or agitation, rated at Scale 1.

Do not include suicidal ideation or attempts, rated at Scale 2.

Do not include delusions or hallucinations, rated at Scale 6.

Rate associated problems (eg. changes in sleep, appetite or weight; anxiety symptoms) at Scale 8.

0.	No problems associated with depression during the period rated.
1.	Gloomy; or minor changes in mood only.
2.	Mild but definite depression on subjective or objective measures (eg. loss of interest or pleasure, lack of energy, loss of self-esteem, feelings of guilt).
3.	Moderate depression on subjective or objective measures (depressive symptoms more marked).
4.	Severe depression on subjective or objective grounds (eg. profound loss of interest or pleasure, preoccupation with ideas of guilt or worthlessness).

8. Other mental and behavioural problems

Rate only the most severe clinical problem not considered at Scales 6 and 7 as follows: specify the type of problem by entering the appropriate letter: A phobic: B anxiety; C obsessive-compulsive; D stress; E dissociative; F somatoform; G eating; H sleep; I sexual; J other, specify.

0.	No evidence of any of these problems during period rated.
1.	Minor non-clinical problems.
2.	A problem is clinically present, but at a mild level, for example the problem is intermittent, the consumer maintains a degree of control or is not unduly distressed.
3.	Moderately severe clinical problem, for example, more frequent, more distressing or more marked symptoms.
4.	Severe persistent problems that dominates or seriously affects most activities.

9. Problems with relationships

Problems associated with social relationships, identified by the consumer or apparent to carers or others. Rate the consumer's most severe problem associated with active or passive withdrawal from, or tendency to dominate, social relationships or non-supportive, destructive or self-damaging relationships.

0.	No significant problems during the period.
1.	Minor non-clinical problems.
2.	Definite problems in making, sustaining or adapting to supportive relationships (eg. because of controlling manner, or arising out of difficult, exploitative or abusive relationships), definite but mild difficulties reported by consumer or evident to carers or others.
3.	Persisting significant problems with relationships; moderately severe conflicts or problems identified within the relationship by the consumer or evident to carers or others.
4.	Severe difficulties associated with social relationships (eg. isolation, withdrawal, conflict, abuse); major tensions and stresses (eg. threatening breaking down of relationship).

10. Problems with activities of daily living

Rate the overall level of functioning in activities of daily living (ADL): eg. problems with basic activities of self-care such as eating, washing, dressing, toilet; also complex skills such as budgeting, recreation and use of transport, etc.

Include any lack of motivation for using self-help opportunities, since this contributes to a lower overall level of functioning.

Do not include lack of opportunities for exercising intact abilities and skills, rated at Scales 11 and Scale 12.

0.	No problems during period rated; good ability to function effectively in all basic activities (eg. continent - or able to manage incontinence appropriately, able to feed self and dress) and complex skills (eg. driving or able to make use of transport facilities, able to handle financial affairs appropriately).
1.	Minor problems only without significantly adverse consequences, for example, untidy, mildly disorganised, some evidence to suggest minor difficulty with complex skills but still able to cope effectively.
2.	Self-care and basic activities adequate (though some prompting may be required), but difficulty with more complex skills (eg. problem organising and making a drink or meal, deterioration in personal interest especially outside the home situation, problems with driving, transport or financial judgements).
3.	Problems evident in one or more areas of self-care activities (eg. needs some supervision with dressing and eating, occasional urinary incontinence or continent only if toileted) as well as inability to perform several complex skills.
4.	Severe disability or incapacity in all or nearly all areas of basic and complex skills (eg. full supervision required with dressing and eating, frequent urinary or faecal incontinence).

11. Problems with living conditions

Rate the overall severity of problems with the quality of living conditions, accommodation and daily domestic routine, taking into account the consumer's preferences and degree of satisfaction with circumstances.

Are the basic necessities met (heat, light, hygiene)? If so, does the physical environment contribute to maximising independence and minimising risk, and provide a choice of opportunities to facilitate the use of existing skills and develop new ones?

Do not rate the level of functional disability itself, rated at Scale 10.

NB: Rate consumer's usual accommodation. If in acute ward, rate the home accommodation. If information not obtainable, rate 7.

0.	Accommodation and living conditions are acceptable; helpful in keeping any disability rated at Scale 10 to the lowest level possible and minimising any risk, and supportive of self-help; the consumer is satisfied with their accommodation.
1.	Accommodation is reasonably acceptable with only minor or transient problems related primarily to the consumer's preferences rather than any significant problems or risks associated with their environment (eg. not ideal location, not preferred option, doesn't like food).
2.	Basics are met but significant problems with one or more aspects of the accommodation or regime (eg. lack of proper adaptation to optimise function relating for instance to stairs, lifts or other problems of access); may be associated with risk to consumer (eg. injury) which would otherwise be reduced.
3.	Distressing multiple problems with accommodation; eg. some basic necessities are absent (unsatisfactory or unreliable heating, lack of proper cooking facilities, inadequate sanitation); clear elements of risk to the consumer resulting from aspects of the physical environment.
4.	Accommodation is unacceptable: eg. lack of basic necessities, insecure, or living conditions are otherwise intolerable, contributing adversely to the consumer's condition or placing them at high risk of injury or other adverse consequences.

12. Problems with occupation and activities

Rate the overall level of problems with quality of day-time environment. Is there help to cope with disabilities, and opportunities for maintaining or improving occupational and recreational skills and activities? Consider factors such as stigma, lack of qualified staff, lack of access to supportive facilities, eg. staffing and equipment of day centres, social clubs, etc.