Completion rates for HoNOS have risen dramatically at MidCentral DHB in the past three years, from 9 per cent in 2008 to 84 per cent in 2012.

One reason for this change is clinical staff moving from resistance to enthusiasm. This attitude change is due to the way HoNOS helps them with their work and benefits clients.

If you actually get your head around it…[HoNOS] can…help you quite a lot to get clients invested,” Deane Davies, Psychiatric Social Worker, MidCentral DHB

Now (staff) just seem to get on and do it. And they’re utilising it more - they’re using it for multi-disciplinary team meetings and what it was intended to be used for,” Esther McLean, Consumer Adviser, MidCentral DHB

The views of a reluctant HoNOS user

Clinician Deane Davies admits freely that if HoNOS was not compulsory at MidCentral he wouldn’t use it. While finding it useful, he thinks other tools could do the same job, and he’d rather do less paper work and spend more time with clients.

But despite this Deane’s attitude towards HoNOS has softened. When he first encountered it in 2006 he thought it was a "boring, big fat waste of time". Now he says: "it’s not that hard. It doesn’t really take that much time…and it can be a useful tool that helps you with your work”.

Deane says that one reason he changed his mind is that “us guys don’t like wasting our time doing things we don’t have to do. So seeing how it can be used in your work is useful.”

He remembers the days when clinicians were “told we had to do it but the fine details of why…weren’t explained”. Since attending training he says: “I have a more in-depth understanding of why they have to be done. They’re actually used now to inform the treatment plan so that’s the useful part.”

Deane first finds HoNOS useful at the assessment interview. He says that lots of high scores for symptoms – 3’s and 4’s – can flag that this person may meet the moderate to severe benchmark. On the other hand, lots of low scores of 1’s and 2’s may indicate that this is not the right service for that person.

You sit down with the client and their whanau…show them the scores and graph and create a discussion point,” Deane Davies, Psychiatric Social Worker, Oranga Hinengaro Maori (Maori Mental Health Service), MidCentral DHB

Deane also uses HoNOS to engage with new clients. He says: “it’s a non-threatening way, if you frame it right, to engage with people who are relative strangers and introduce yourself…and get them invested from the start.”

If the person is accepted into the service, their HoNOS scores inform their treatment plan. The clinician can point out the 3 and 4 scores and say “these are the areas to work on, where do you want to start?”

Deane also tells his client and their whanau “you want to get the scores down to 2 – when you do that we can discharge.

A lot of people realise they have problems and issues…when they see it on a graph it can help promote insight,” Deane Davies, Psychiatric Social Worker, Oranga Hinengaro Māori (Māori Mental Health Service), MidCentral DHB

Once the scores are in, he can sit down and discuss them with the tamariki or adolescents and their whanau. This provides a chance for everyone to say what they think of the scores, if they disagree with them and why. Deane also shows clients graphs illustrating changes in their scores over time.

“Far and away the majority of time you get buy in,” he says.

“People, especially kids, like to see the graphs come down, even whanau.”

By using it in the MDT, it becomes more useful because it flags issues that need to be addressed in treatment plans and it could also generate referrals to other teams, other services, other interventions,” Kerrie Theunissen, PRIMHD Site Coordinator, MidCentral DHB

HoNOS is also used at multi-disciplinary team meetings (MDTs), where it is a standing agenda item. Each clinician has a copy of the client list, showing their current HoNOS score and admission score. They discuss every case during the one to two hour meeting, focusing on scores of 2, 3 or 4.

“Back in the day when I first started,” Deane says, HoNOS “was done and shipped off to the Ministry and that was it. Now it’s used at the MDT, used with clients…which is probably why it’s more useful and we’re getting more buy in, because clinicians can see that it’s not just a big waste of their time.”

When asked how well Māori clients respond to HoNOS Deane responds: “all of the people I’ve shown it to have been Māori and none of them have had a problem.”

He finds he can overlay cultural issues on what HoNOS covers. Deane’s last comment – somewhat tongue in cheek – is: “And of course if you do it the bosses are happy with you and they’re not on your case!”

Now when you present at the MDT regarding clients…what you’re talking about is HoNOS scores, specially 3’s and 4’s,” Deane Davies, Psychiatric Social Worker, Oranga Hinengaro Māori (Māori Mental Health Service), MidCentral DHB

Why one clinician is enthusiastic about HoNOS

Community psychiatric nurse Carroll Grobler radiates enthusiasm for HoNOS.

“If you do it every three months then you can actually start to see changes happening,” she says, which makes her feel wonderful. It tells her that she’s on the right track. Carroll says: “I think to myself - yes, I’m doing a good job.”

I get positive responses from my clients. They get excited when I say ‘don’t you think we ought to be looking at discharge?’” Carroll Grobler, Community Psychiatric Nurse, MidCentral DHB

She’s not the only one who gets a boost from seeing HoNOS scores going down. Most of her clients are delighted to see symptoms such as sleeping problems or anxiety decreasing. When Carroll tells a client "you were at a 3 for hearing voices when you first came in – now you’re at a 2," they can see that they’re making progress.

“They may not see it until it’s written down in black and white,” she says.

I tell (clients) ‘this is the way we’re going to track (progress) and get better service,” Carroll Grobler, Community Psychiatric Nurse, MidCentral DHB

To clinicians who feel that HoNOS is a time-consuming piece of paper shuffling that takes them away from their real work with clients Carroll would say “this is a way of helping clients because clients get better services.”

Firstly, HoNOS shows whether the integrated treatment plan is actually moving the person in the desired direction. Carroll also thinks that “it’s good for the client because it’s giving them a chance to say how they feel.” Lastly, HoNOS helps clients by highlighting areas of the service that might benefit from greater support or funding.

It’s feedback without asking for feedback – that data can tell us that the service isn’t working,” Esther McLean, Consumer Adviser, MidCentral DHB

As for being time-consuming, it takes Carroll 20 to 30 seconds to tick appropriate scores after completing a clinical assessment. She finds that by the third or fourth administration clients automatically tell her their current scores.

“They’ve got so used to it they know what I’m going to ask,” Carroll says.

However, she acknowledges that it did take a few weeks for her to come to grips with doing HoNOS. It does take longer at the first assessment – about 10 to 15 minutes.

It’s the time factor. Once you’ve done this for a while…it doesn’t take you too long. but when you’re first starting off it does take a long time,” Deane Davies, Psychiatric Social Worker, MidCentral DHB

Another benefit of using HoNOS is that it helps develop the therapeutic alliance between Carroll and her clients. She thinks that this is because she is asking them about themselves. This is one of the reasons Carroll insists that the client must be involved in filling out HoNOS.

“It’s their HoNOS,” she says emphatically. “It belongs to them.”

It’s not just a bit of paper,” Carroll Grobler, Community Psychiatric Nurse, MidCentral DHB

Making HoNOS relevant to clinicians – why and how

One of the barriers to HoNOS compliance identified at DHBs nationally is that clinicians are unwilling to complete the forms. MidCentral had a big focus on making HoNOS more relevant to the clinical process so that clinicians are more willing to use it and don’t see it as a waste of their time.

If it was simply based on compliance alone I don’t know how sustainable that would be. If you use it as a clinical tool then you have a reason to use it,” Jerry Varghese, Clinical Director, Mental Health Services, MidCentral DHB

How have they done this?

  • Making reporting on HoNOS scores and changes a standing item on multi-disciplinary team (MDT) meeting agendas
  • A policy that any symptoms scoring 2, 3 and 4 on HoNOS must be addressed in treatment plans
  • Dr Jerry Varghese, the clinical director of mental health, leads by example, entering HoNOS data for the clients he sees
  • HoNOS allows people to focus on the client’s clinical picture, where active interventions can make a big difference, which can then be used monitor progress, within MDTs, reviewing severity of ones case loads, as well as informing clients of their progress with treatment.   
  • Using HoNOS as another way to assess risk.

By the time they get to discharge, the whole MDT has been aware of changes in the person’s process,” Aroha Whakamoe Nomea, Manager Māori Mental Health Services and Quality, MidCentral DHB

All this has resulted in clinician’s changing from seeing HoNOS as a waste of time to seeing it as useful.

“The trick is to use HoNOS as a tool that can guide your clinical decision making,” says Aroha Whakamoe Nomea.

How including a consumer perspective made a difference

Getting consumers involved drives HoNOS use to a different level according to Kerrie Theunissen. Consumer adviser, Esther McLean works tirelessly to promote HoNOS to consumers and staff.

Basically, Esther said ‘You need to ask questions about why this data is being collected, and make sure you…know what it is saying,’” Aroha Whakamoe Nomea, Service Manager, Māori Mental Health Services and Quality, MidCentral DHB

Esther is so enthusiastic about HoNOS she uses it herself, and even went to the Train the Trainers mental health outcomes training to learn more.

“As soon as you look at HoNOS you can’t help but be interested in it from a consumer perspective,” Esther says.

“It’s real info, it’s about you, and…you can see how well you’ve done.”

I became aware of it because everyone was talking about HoNOS and how much they hated it,” Esther McLean, Consumer Adviser, MidCentral DHB

On the KPI (Key Performance Indicator) national benchmarking team Esther is a vocal advocate of HoNOS. To increase HoNOS use she also:

  • talks with consumers about HoNOS in recovery courses and consumer group meetings, highlighting its value to consumers, and encourages them to ask for their results and ask why they got that score;
  • attends all HoNOS training to tell trainees how HoNOS aids consumer recovery; and
  • distributes information pamphlets for adults, teens and parents to help them understand HoNOS. These are used on the ward, left in waiting areas and sent out with information for triage appointments. Kerrie says these are so easy to understand some other DHBs have started using them.

To send information on HoNOS straight out with appointment information is too much – it needs to be done at the triage appointment,” Esther McLean, Consumer Adviser, MidCentral DHB