Clarifications and Special Considerations in Rating the NOCC Measures

Authored by Dr Tim Coombs of AMHOCN and Mr Allen Morris-Yates of the Private Psychiatric Hospitals Association Data Reporting and Analysis Service (PPHADRAS), this paper has been developed as a comprehensive guide and reference for clinicians on rating the HoNOS.

The purpose has been to document the authors' considered understanding of the HoNOS rating process, drawing on over fifty years of combined experience in training clinical staff. The aim has been to provide clarification grounded in that training experience. Rather than simply collating frequently asked questions with brief responses, the authors have sought to articulate the core concepts and rating principles that underpin accurate and clinically meaningful use of the HoNOS.

Read or download: Comprehensive guidelines for the reliable and valid rating of the Health of the Nation Outcome Scales (HoNOS) in Australian mental health services

The HoNOS Glossary for Scale 10 Problems with activities of daily living, states:

Rate the overall level of functioning in activities of daily living (ADL): e.g., problems with basic activities of self–care such as eating, washing, dressing, toilet; also, complex skills such as budgeting, organising where to live, occupation and recreation, mobility and use of transport, shopping, self–development, 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 Item 11 and Item 12.

The Royal College of Psychiatrists (RCP) provide additional detailed guidance, adding:

Item 10, problems with activities of daily living, summarises the severity of personal and social handicap associated with problems rated at Items 1 to 9 and with the patient's motivation.

Consider the overall level of functioning achieved by the patient during the period rated. Rate the level of actual performance, not potential competence. The rating is based on the assessment of three kinds of problem:

• First, a summary of the effects on personal and social functioning of the problems rated at Items 1 to 9
• Second, a lack of opportunities in the environment to use and develop intact skills
• Third, a lack of motivation or encouragement to use opportunities that are available.

The overall level of performance rated may therefore be due to lack of competence, to lack of opportunities in the environment, to lack of motivation, or to a combination of all these.

Two levels of functioning are considered when deciding the severity of problems:

• The basic level includes self-care activities such as eating, washing, dressing, toileting and simple occupations. If performance is moderately or seriously low, rate 3 or 4.
• The complex level includes the use of higher-level skills and abilities in occupational and recreational activities, money management, household shopping, child care, etc., as appropriate to the patient's circumstances.  If these are normal or as adequate as they can be, rate 0 or 1.  Ratings of 2 and 3 are intermediate.

The AMHOCN online training module advises that you “Do not rate lack of opportunities for exercising intact abilities or skills,” which is taken straight from the HoNOS glossary.

Should lack of opportunities be rated at Scale 10?

There has been some confusion that the additional advice provided by the Royal College of Psychiatrists is confusing and contradictory.

Scale 10 is rating actual performance, not potential competence, within existing environmental constraints. Scales 11 and 12 are rating the person’s environment and the limits that the environment may have on supporting skills development or preventing skills deterioration.  At Scale 10 you are rating what the person is actually doing, while at 11 and 12 you are rating the environment and its provision of access and opportunity to improve or maintain skills.

For example, the patient may currently reside in long-term residential accommodation for people with severe and chronic mental illness. This environment affords them little opportunity to demonstrate complex skills such as undertaking housework or washing and ironing their own clothes. At Scale 10 you are rating the patient’s actual performance. The constraints of the environment mean that the patient’s potential competence cannot be demonstrated. This means that actual performance attracts a higher rating given the patient’s inability to demonstrate complex activities of daily living. However, if environmental modifications could lead to improvements in actual performance (such as providing training in household duties) then the extent of the need for environmental modifications are rated at Scales 11 and 12 with the increasing need for environmental modification attracting higher ratings.

Scale 11 Problems with living conditions

This scale requires a knowledge of the patient’s usual domestic environment during the period rated, whether at home or in some other residential setting. If this information is not available (usually because someone is in an acute setting who has not previously been in contact with services), rate 9 (not known). Where a patient is in a longer term placement such as a long stay rehabilitation setting, if the plan of care is for that person to remain in that setting for at least 6 months then it is that environment that should be rated. Consider the overall level of performance this patient could reasonably be expected to achieve given appropriate help in an appropriate domestic environment. Take into account the balance of skills and disabilities. How far does the environment restrict, or support, the patient’s optimal performance and quality of life? Do staff know (as they should) what the patient’s capacities are? The rating must be realistic, taking into account the overall problem level during the period, ratings on scales 1-10, and information on the following points:

• are the basics provided for – heat, light, food, money, clothes, security and dignity? If the basic level conditions are not met, rate 4;
• consider the quality and training of staff, relationships with staff or with relatives or friends at home;
• the degree of opportunity and encouragement to improve motivation and maximise skills, including: interpersonal problems; provision for privacy and indoor recreation; problems with other residents; helpfulness of neighbours. Is the atmosphere welcoming? Are there opportunities to demonstrate and use skills: e.g. to cook, manage money, exercise talents and choice, and maintain individuality? If full autonomy has been achieved, i.e. the residential environment does not restrict optimum performance overall, rate 0.  A less full but adequate regime is rated 1. An overall judgement is required as to how far the environment restricts achievable autonomy during the period. 2 indicates moderate restriction, 3 substantial, 4 very substantial.

Scale 12 Problems with occupation and activities

The principles considered at scale 11 also apply to the outside environment. This scale requires a knowledge of the patient’s usual day time environment during the period rated, whether at home or in some other residential setting. If this information is not available (usually because someone is in an acute setting who has not previously been in contact with services), rate 9 (not known). Where a patient is in a longer term placement, such as a long stay rehabilitation setting, if the plan of care is for that person to remain in that setting for at least 6 months then it is the environment around that placement that should be rated.

Consider arrangements for encouraging activities such as: shopping; using local transport; amenities such as libraries; understanding local geography; possible physical risks in some areas; use of recreational facilities. Take into account accessibility, hours of availability, and suitability of the occupational environment provided for this patient at day hospital, drop-in or day centre, sheltered workshop, etc. Are specific (e.g. educational) courses available to correct deficits or provide new skills and interests? Is a sheltered outside space available if the patient is vulnerable in public (e.g. because of odd mannerisms, talking to self, etc.)? For how long is the patient unoccupied during the day? Do staff know what the patient’s capacities are? The rating is based on an overall assessment of the extent to which the daytime environment brings out the best abilities of the patient during the period rated, whatever the level of disability rated at scale 10. This requires a judgement as to how far changing the environment is likely to improve performance and quality of life and whether any lack of motivation can be overcome.

If the level of autonomy in daytime activities is not restricted, rate 0. A less full but adequate regime is rated 1. If minimal conditions for daytime activities are not met (with the person severely neglected and/or with virtually nothing constructive to do), rate 4. Between these ratings, a judgement is required as to how far the environment restricts achievable autonomy – 2 indicates moderate restriction and 3 substantial.

The Health of the Nation Outcome Scales (HoNOS) Glossary contains few examples of the problems associated with eating disorders. This guidance can be used alongside the HoNOS Glossary to ensure better accuracy in rating the HoNOS with consumers who have eating disorders. View Rating Eating Disorders Using the HoNOS - Guidance and Vignette

This guidance on using the HoNOS in perinatal services has been prepared by the Royal College of Psychiatrists in collaboration with the National Health Service (NHS) Wales Perinatal Mental Health Network. Go to:  Additional Guidance in the Use of the HoNOS in Perinatal Services

This resource - Frequently Asked Questions: The Clinician's FAQ to HoNOSCA in Australia - aims to provide clinicians with guidance on several common in the HoNOSCA glossary that may require further clarification.