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Recent Initiatives in Health Status Measurement

• Commonwealth Outcome Measurement Trials
• The Victorian 1996 HoNOS Trial
• Routine Use of HoNOS in Clinical Practice

A number of recent developments have informed the outcome measurement project.

Commonwealth Outcome Measurement Trials

One of the key objectives of the first National Mental Health Strategy was to undertake regular reviews of outcomes of mental health services. To assist with this process, the National Mental Health Plan implemented a two-stage research program. Stage 1 identified six potentially useful outcome measures (Andrews, Peters & Teeson, 1994). These included three measures of self-reporting (BASIS, MHI and SF36) and three clinician rating measures (HoNOS, RFS and LSP). The authors argue that measurement of outcome should cover symptoms and disability. Andrews et al reviewed uni-dimensional measures (symptoms, quality of life, functioning, burden) as well as multi-dimensional measures and concluded that a measure which can be used across all groups of consumers (that is, a generic measure) for comparison may be the most appropriate for routine measurement on a large scale (nationwide or statewide) rather than a measure which addresses only the particular facets of a single condition.

Stage 2 was centred around the field trialing of the recommended measures. The Commonwealth trials have shown that the issue of outcome measurement is broader than the choice of a rating tool, and that the issues of utility and acceptability to both consumers and clinicians need to be explored further. In the interim, the Mental Health Inventory has been recommended by the Commonwealth for consideration as a self-rating measure 'in appropriate situations' and the HoNOS as a measure for rating by clinicians.

Under the Second National Mental Health Plan, the Commonwealth is undertaking to support:

• Further refinement and introduction of population-based outcome measures to assess the mental health and well-being of the Australian community.
• Further refinement and introduction of outcome measures to monitor service performance.
• Further development of individual clinical outcome measures including quality of life and measures to assess consumer and carer satisfaction with services.

The Victorian 1996 HoNOS Trial

Background
In 1996 the Victorian Department of Human Services conducted a clinical outcome measurement trial in a number of mental health services. The objective of the trial was to examine the utility of consumer outcome measures in the Victorian context.

Choice of Instrument
The instrument selected for the trial was HoNOS (Health of the Nation Outcome Scales), which was developed by the Royal College of Psychiatrists in London. HoNOS comprises a set of 12 items. These include both clinical problems such as depressed mood, hallucinations and delusions, as well as social aspects of clients' functioning such as living conditions and relationships. By comparing HoNOS ratings over time, outcomes can be measured, informing the consumer, clinical practice and statewide planning. HoNOS was chosen because of its perceived brevity, clarity, comprehensiveness, sensitivity to change and because it does not rely on a diagnosis.

Scope and Timelines
The sample population for the trial consisted of persons who were being treated by public mental health services. The trial commenced in April 1996 and involved five area mental health services (three metropolitan and two rural). These agencies were:

• The Royal Melbourne Hospital
• The Alfred Health Care Group
• Central East/PANCH
• Geelong Mental Health Service
• Lakeside Hospital.

The agencies assessed clients from the range of service elements (from crisis to continuing care) and included both community-based and inpatient services. More than 3,500 ratings were collected during the three-month trial. The data collection process was followed by statistical analysis and an exploration of the utility of HoNOS as a clinical outcome measurement tool.

Training
HoNOS training for the Victorian trial was based on the guidelines and other resource materials supplied by the UK HoNOS Project. A working party developed a Victorian 'Train the Trainer' course, which was delivered to clinical staff from the participating agencies. The trainees from each participating agency in turn provided training to all prospective raters within their agency. Approximately 300 raters were trained in the use of HoNOS prior to the start of the trial. Training working party members continued to provide local support for rating queries during the trial.

Inter-Rater Reliability
HoNOS ratings were made by staff from a variety of professional backgrounds. Just over half of all the ratings were performed by nurses, with others completed by psychiatrists, medical officers, clinical psychologists, social workers and occupational therapists. Some ratings were completed by a multi-disciplinary team. 152 ratings of 46 clients were made specifically for the examination of inter-rater agreement. The analysis of the trial data established that the total HoNOS score has very good inter-rater reliability.

Findings

• The HoNOS has very good inter-rater reliability.
• The instrument is sensitive to change in consumers' mental health.
• The HoNOS rating reflects clinical assessment.
• The HoNOS can be used as an indicator of severity of mental illness.
• There was a strong correlation between the total HoNOS score and the service setting with higher scores (greater severity) found in inpatient, homeless, CAT, secure/extended care and MST services, and much lower scores in non-acute service settings. The mean total HoNOS score ranged from 9.9 in continuing care services (n=926) to 17.3 in acute inpatient services (n=176).
• The HoNOS is convenient and easy to use. By the end of the trials it took 39 per cent of raters less than five minutes and a further 44 per cent of raters five to ten minutes to complete a HoNOS rating.
• Adequate training needs to be provided to all potential raters.
• It is essential that consumers and service providers have access to data in a timely and confidential manner.

Routine Use of HoNOS in Clinical Practice

The Health of the Nation Outcome Scales (HoNOS) are receiving increased acceptance in mental health services across Australia. In Victoria a recent audit found that, of more than 60 mental health services canvassed, more than half were routinely using outcome measures. Two of the measures proposed for use in the outcome measurement suite, namely the HoNOS and the Life Skills Profile (LSP), were among the instruments most commonly used.

For example, following the Victorian HoNOS trial, Geelong Hospital continued their use of HoNOS through participation in the Mental Health Classification and Service Costs (MH-CASC) study, and outcome measurement has now become a routine component of clinical practice. It was noted that 'there was considerable clinical value in ensuring that each clinician thought about the full range of issues canvassed by HoNOS each time a client was assessed, reviewed or discharged from the service'.

Traditionally, all State-managed mental health services have been required to use the Psychiatric Records Information System Manager (PRISM). The Redevelopment of Acute and Psychiatric Information Directions (RAPID) will provide a more integrated approach to information management needs and support the introduction of routine outcome measurement. Health status ratings made by consumers or clinicians and other outcome data will be entered at agency level, enabling local aggregation and analysis.

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