Training Manual 2003 by VII9jovw

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									Contents
PART 4: THE SUITE OF MEASURES FOR AGED PERSONS MENTAL HEALTH
SERVICES .......................................................................................................... 1

  THE PROTOCOL .......................................................................................................... 1
     Overview of data collection occasions ............................................................... 1
  THE MEASURES .......................................................................................................... 2
     The Health of the Nation Outcome Scales for Older Persons (HoNOS 65+) ........ 2
        Overview ................................................................................................................. 2
        General guidelines for administration ...................................................................... 3
        Glossary................................................................................................................... 4
        Scoring .................................................................................................................. 10
        Missing data........................................................................................................... 10
        Frequently asked questions ................................................................................... 11
        Sample HoNOS 65+ rating sheet .......................................................................... 14
     The Abbreviated Life Skills Profile (LSP-16) ..................................................... 15
        Overview ............................................................................................................... 15
        Background............................................................................................................ 16
        General guidelines for administration .................................................................... 17
        Glossary................................................................................................................. 17
        Scoring .................................................................................................................. 19
        Missing data........................................................................................................... 20
        Frequently asked questions ................................................................................... 20
        Sample LSP-16 rating sheet .................................................................................. 22
     The Focus of Care (FOC) .................................................................................. 23
        Overview ............................................................................................................... 23
        General guidelines for administration .................................................................... 24
        Glossary................................................................................................................. 25
        Frequently asked questions ................................................................................... 26
        Sample Focus of Care rating sheet ........................................................................ 27
     The Behaviour and Symptom Identification Scale (BASIS-32) ........................... 28
        Overview ............................................................................................................... 28
        Background............................................................................................................ 30
        General guidelines for administration .................................................................... 30
        Capacity to participate in self-rating...................................................................... 31
        Glossary................................................................................................................. 32
        Scoring .................................................................................................................. 34
        Missing data........................................................................................................... 34
        Frequently asked questions ................................................................................... 35
        Sample BASIS-32 rating sheet .............................................................................. 37
     Activities of Daily Living (RUG-ADL) ................................................................ 40
        Overview ............................................................................................................... 40
        General guidelines for administration .................................................................... 40
        Glossary................................................................................................................. 40



                           Victorian Outcome Measurement Training Manual—2nd edition —2003 103
      Scoring .................................................................................................................. 42
      References ............................................................................................................. 42




104                      Victorian Outcome Measurement Training Manual—2nd edition —2003
Part 4: The suite of measures for
aged persons mental health
services
The protocol

Overview of data collection occasions


The data collection occasions for Aged Persons Mental Health Services (APMHS) are
given in Table 4.1. Please note that self-rating is always voluntary and that a
number of exclusions are specified in the National Outcomes and Casemix
Collection (NOCC) protocol.

Table 4.1 Data collection occasions for APMHS
                                                       Community
    Service setting:             Inpatient             Residential            Ambulatory

  Collection occasion:       A      R        D     A       R         D    A       R        D

Measure       Purpose

HoNOS 65+     Symptoms       √      √        √                            √       √        √

LSP-16        Functioning                                                         √        √

BASIS-32      Self-report                                                 √       √        √

RUG-ADL       Dependency     √      √
Focus of Care Interpreting
              the results           √        √                                    √        √
A Admission; R Review; D Discharge
Notes
   1. The LSP-16 is not included as a measure for use in inpatient settings as, in
      its current form, it requires ratings to be based on the consumer’s
      functioning over the previous three months. This is difficult for the majority
      of inpatient episodes which are relatively brief.
   2. The classification of BASIS-32 as mandatory is intended only to indicate the
      expectation that consumers will be invited to complete the BASIS-32 at the
      specified collection occasions, not that it will always be appropriate. Special
      considerations applying to the collection of BASIS-32 are discussed in this
      manual.
   3. Introduction of BASIS-32 in inpatient episodes is not included as a national
      requirement at this stage but will be reviewed in the future following
      experience in use of BASIS-32 in other settings. Individual jurisdictions or
      service agencies may, however, choose to trial and encourage BASIS-32
      completion in inpatient settings.
   4. See Chapter 2 of this Manual for detailed guidelines as to the resolution of
      protocol issues.




                     Victorian Outcome Measurement Training Manual—2nd edition —2003   1
The measures

The Health of the Nation Outcome Scales for Older Persons
(HoNOS 65+)

Overview

The Health of the Nation Outcome Scales for Older Persons (HoNOS 65+) was
developed in the UK as a tool to be used by clinicians in their routine clinical work
to measure consumer outcomes. It was designed specifically for use with older
people with a mental illness and is best considered as a general measure of
severity of mental health disorder.

The HoNOS 65+ focuses on health status and severity of symptoms. It consists of
12 items that cover the sorts of problems that may be experienced by people with
a significant mental illness. The items include aggressive or disruptive behaviour,
suicidal thoughts or self-injury, health and social problems associated with alcohol
and drug abuse, problems involving memory, orientation and understanding,
problems associated with physical disorders, depressed mood, problems with
unusual experiences such as hallucinations, and problems with living conditions
and relationships.

    The clinician rates the consumer on each of the scales in terms of their
     assessment of the older person’s situation over the recent period, usually
     defined as the previous two weeks.

    The clinician is expected to draw on all relevant and useful information to make
     their ratings, the same as you gather in your normal clinical duties, for
     example case notes, interviews with the older person and their carer, team
     meetings and so forth.

    HoNOS 65+ is designed to easily fit in to day-to-day work; it does not need
     any special interviews or procedures.

Each scale follows the same format and clinicians are asked to rate the older
person as having:

    no problem
    a minor problem that requires no action
    a mild problem
    a moderately severe problem
or
    a severe to very severe problem.

Although the HoNOS was developed in the UK, Australia has acquired more
experience in using this measure than any other country. Both inpatient and
community-based mental health services have found that the measure performs
well and that clinicians generally have no problems learning or using it. It has been
shown to be helpful in contributing to the development of treatment and care plans
for individual consumers and in monitoring progress. It is capable of being
condensed to give an overall picture of the caseload complexity of consumers
treated by an agency and in comparing agencies.




2                    Victorian Outcome Measurement Training Manual—2nd edition —2003
The HoNOS 65+ was chosen because it is brief and does not rely on a diagnosis.
On average, it takes about five minutes to complete once the clinician becomes
familiar with the scales.

For these reasons, the HoNOS 65+ is one of the central OM tools agreed to by all
states and territories for routine use.

Many Victorian services now have some practice in the use of the HoNOS 65+. It is
also being used widely in Australia’s private psychiatric hospitals.

The HoNOS 65+ has been shown to be both reliable and valid and the instrument
is supported by the Victorian RAPID/CMI system and the Wellbeing Reporting Tool.

General guidelines for administration

In APMHS, the HoNOS 65+ is rated by the clinician on each mandatory data
collection occasion, that is at:

      admission to inpatient services
      review in inpatient services (where applicable)
      discharge from inpatient services
      intake in ambulatory services
      case review in ambulatory services
      case closure in ambulatory services.


The general guidelines used for completing the HoNOS 65+are summarised below:

      Rate items in order from 1 to 12.
      Use all available information in making your rating.
      Do not include information already rated in an earlier item.
      Consider both the degree of distress the problem causes and the effect it
       has on behaviour
      Rate the most severe problem that occurred in the period rated.
      The rating period is generally the preceding two weeks, except at discharge
       from inpatient care, when it is the previous three days.


Each item is rated on a five-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
       9   Not known or not applicable

As far as possible, the use of rating point 9 should be avoided, because missing
data make scores less comparable over time and between settings. Refer to
Scoring (page 10) for information regarding the scoring of missing data.

Specific information on how to rate each point on each item is provided in the
following section.




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Glossary

[LAYOUT AS PER HoNOS GLOSSARY IN PART 2]


Note: an updated, tabulated version of the HoNOS 65+ Glossary was produced by the
British Royal College of Psychiatry in April 2002. This is the version currently posted on their
website. However, in keeping with the NOCC protocol, Victorian health services should use
the older version of the glossary, reproduced below for the sake of national uniformity and
comparability of data. Services will be advised formally of any refinements or revisions to
the protocol, if and when these occur.

1     Behavioural disturbance (for example, overactive, aggressive, disruptive or
      agitated behaviour, uncooperative or resistive behaviour)
               Include such behaviour due to any cause, for example, dementia,
                drugs, alcohol, psychosis, depression.

               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
            cooperative and not requiring any specific action.
      2     Includes aggressive gestures, pushing or pestering others; threats or verbal
            aggression; lesser damage to property (such as 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 cooperation, 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 (for example, fire–setting); persistent
            and threatening behaviour; severe overactivity or agitation; sexually
            disinhibited or other inappropriate behaviour (for example, 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 (for example, due 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 (for example, cirrhosis of the liver or injury resulting
                from drunk–driving is 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, for example, while
            crossing a road).




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     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, such as 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.
     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, such as dementia, learning disability, schizophrenia.
             Do not include temporary problems (such as 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 (for example, some difficulty with orientation to
           time) or memory (for example a degree of forgetfulness but still able to learn
           new information), no apparent difficulties with the use of language.
     2     Mild problems with orientation (such as frequently disorientated to time) or
           memory (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 (for example, usually disorientated to time,
           often place) or memory (for example, 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 (for example, consistently disorientated to time and place,
           and sometimes to person) or memory impairment (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.




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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 (for example,
               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 (such as a 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
           (for example, 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 (for example, 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 (chair or bed bound); severe impairment of sight or hearing (for
           example, 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 (for example, voices, visions) are present, but there
           is little distress to patient 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 patient or others.




6                    Victorian Outcome Measurement Training Manual—2nd edition —2003
7   Problems with depressive symptoms
             Do not include over-activity 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 (such as 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 (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 (for example, 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 patient 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 which dominates or seriously affects most activities.


9   Problems with relationships
     Problems associated with social relationships, identified by the patient or apparent to
     carers or others. Rate the patient’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
           (for example, because of controlling manner, or arising out of difficult,
           exploitative or abusive relationships), definite but mild difficulties reported by
           patient or evident to carers or others.
     3     Persisting significant problems with relationships; moderately severe conflicts or
           problems identified within the relationship by the patient or evident to carers or
           others.
     4     Severe difficulties associated with social relationships (for example, isolation,
           withdrawal, conflict, abuse); major tensions and stresses (such as threatening
           breaking down of relationship).




                     Victorian Outcome Measurement Training Manual—2nd edition —2003          7
10 Problems with activities of daily living

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

             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 (for example, continent or able to manage incontinence appropriately,
           able to feed self and dress) and complex skills (such as 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 (such as 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 (for example,
           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 (for example, 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 patient’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.
     Note: Rate patient’s usual accommodation. If the older person is in an acute ward,
     rate the home accommodation. If information not obtainable, rate 9.
     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 patient is satisfied with their accommodation.
     1     Accommodation is reasonably acceptable with only minor or transient problems,
           related primarily to the patient’s preferences rather than any significant
           problems or risks associated with their environment (for example, 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 (for example, lack of proper adaptation to optimise
           function relating for instance to stairs, lifts or other problems of access); may




8                    Victorian Outcome Measurement Training Manual—2nd edition —2003
           be associated with risk to patient (for example, injury) which would otherwise
           be reduced.
     3     Distressing multiple problems with accommodation; some basic necessities are
           absent (unsatisfactory or unreliable heating, lack of proper cooking facilities,
           inadequate sanitation); clear elements of risk to the patient resulting from
           aspects of the physical environment.
     4     Accommodation is unacceptable; lack of basic necessities, insecure or living
           conditions are otherwise intolerable, contributing adversely to the patient’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 the quality of the daytime
              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, staffing and equipment of day centres, social
              clubs, etc.
             Do not rate the level of functional disability itself, rated at Scale 10.
     Note: Rate the patient’s usual situation. If the older person is in an acute ward, rate
     activities during period before admission. If information not available, rate 9.
     0     Patient’s daytime environment is acceptable; helpful in keeping any disability
           rated at Scale 10 to the lowest level possible, and maximising autonomy.
     1     Minor or temporary problems, good facilities available but not always at
           appropriate times for the patient.
     2     Limited choice of activities; for example, insufficient carer or professional
           support, useful day setting available, but for very limited hours.
     3     Marked deficiency in skilled services and support available to help optimise
           activity level and autonomy, little opportunity to use skills or to develop new
           ones; unskilled care difficult to access.
     4     Lack of any effective opportunity for daytime activities makes the patient’s
           problems worse or patient refuses services offered which might improve their
           situation.




                     Victorian Outcome Measurement Training Manual—2nd edition —2003      9
Scoring

All HoNOS 65+ items are answered on an item-specific anchored 4-point scale with
higher scores indicating more problems.

The 12 HoNOS 65+ items can be aggregated into four subscales as shown in table
4.2.

Table 4.2 The four HoNOS 65+ subscales and their component items

 Subscale and brief item name                          Item scores     Subscale scores

 A. Behavioural Problems                                               0–12

     1. Aggression                                     0–4

     2. Self-harm                                      0–4

     3. Substance use                                  0–4

 B. Impairment                                                         0–8

     4. Cognitive dysfunction                          0–4

     5. Physical disability                            0–4

 C. Symptomatic Problems                                               0–12

     6. Hallucinations and delusions                   0–4

     7. Depression                                     0–4

     8. Other symptoms                                 0–4

 D. Social Problems                                                    0–16

     9. Personal relationships                         0–4

     10. Overall functioning                           0–4

     11. Residential problems                          0–4

     12. Quality of daytime environment                0–4

 E. Total score (1-12)                                 0 – 48




The total score, E, range 0–48, represents overall severity. For some purposes,
items 11 and 12 may be excluded from this total because they measure features of
the consumer’s environment rather than of the consumer.

Missing data

As a general rule, there should be no missing data from the clinician-completed
suite of measures. As part of routine clinical practice, observing the older person’s
presentation and gathering information from them or their significant others should
allow the clinician to make a rating. In calculating total and subscale scores,
missing items (and items scored as a 9) are assigned a value of 0 because no




10                        Victorian Outcome Measurement Training Manual—2nd edition —2003
problem has been recorded. Subscales are calculated automatically as part of the
Wellbeing Reporting Tool.

Frequently asked questions

  Q            Who completes the HoNOS 65+?

  A            Any qualified mental health professional can complete the HoNOS 65+.
               In general, the HoNOS 65+ will be completed by the older person’s
               case manager in preference to the treating doctor, unless the treating
               doctor has also gleaned sufficient information to estimate how the older
               person has been functioning over the period being rated or is the
               nominated case manager.

  Q            Do I need to be trained to rate a client on the HoNOS 65+?

  A            Yes, the HoNOS 65+ requires training. Training is an essential
               component of the OM implementation strategy.

  Q            What questions do I ask the older person?

  A            The HoNOS 65+ is not a structured interview. Make the assessment in
               your usual way. You will need to take into account all sources of
               information (discussion with the older person, carers, other staff as
               well as observation and review of the clinical record).

  Q            How is the HoNOS 65+ filled in?

  A            Always start at Scale 1 and work down through the 12 scales. Choose a
               severity rating for each scale and enter it in the corresponding space
               on the form.

  Q            How do I know where on the form to rate a particular problem?

  A            HoNOS scales are arranged to avoid rating any of their content twice.
               When you have rated one problem, you do not rate it again further
               down the list. For example, if you have an older person who is
               hallucinating and aggressive, you rate the severity of the aggressive
               behaviour only in Scale 1. When you come to Scale 6, you rate the
               severity of the hallucination only. Similarly, suicidal behaviour is rated
               at Scale 2 and the severity of depressed mood, if present, is rated at
               Scale 7. Further guidance is provided in the HoNOS 65+ glossary.

  Q            What if two problems are present on the same scale but of
               different severity?

  A            This happens quite often because each scale represents a wide range of
               problems. Always rate the most severe problem that has occurred
               during the period being rated.

  Q            What information should be used to make the ratings?

  A            Use all available information, including clinical records and reports from
               other informants.


  Q            What if there is insufficient information available to make a
               rating?

  A            If you find it impossible to make an informed estimate of the severity
               of an item, enter a rating of 9. Be aware, however, that ratings of 9 are




                   Victorian Outcome Measurement Training Manual—2nd edition —2003 11
         treated as if they were zeroes (that is, no problems) when total scores
         are computed.

     Q   What rating is given if a problem like serious violence or a
         serious suicidal attempt has occurred only once during the
         period rated?

     A   Such events are always rated 4, even if they only occur once in the
         period. The glossary is very clear about this.

     Q   What if the HoNOS 65+ items do not reflect what the older
         person says is important to their health status?

     A   The HoNOS 65+ is only one of the outcome measures in the suite. Rate
         based on your own professional opinion. The other measures (the LSP,
         the BASIS-32 and the RUG-ADL) may more accurately reflect important
         issues for an older person.

     Q   When two clinicians rate an older person at the same time, how
         similar should their ratings be?

     A   Generally, ratings within one point of each other are considered
         acceptable on all HoNOS 65+ items. Where ratings differ by two points
         or more this usually indicates that the raters are not considering the
         same evidence or there is disagreement about a fundamental aspect of
         the scale.

     Q   Should cigarettes be taken into account when rating Scale 3
         (problem drinking or drug use)?

     A   This is a difficult issue in the mental health field because of the high
         prevalence of smoking within the consumer population. A person
         should not be given a rating above 0 simply because they smoke. For
         the purposes of this item, you are rating only health risks that are
         likely during the period being rated (for example, risks of fire if the
         older person smokes in bed) rather than risks that may occur later
         (such as longer term risks of lung cancer). If the older person is
         currently experiencing physical problems associated with smoking
         these should be rated on Scale 5. In making your rating, consider the
         extent to which the person’s smoking causes problems such as loss of
         control, inability to engage in activities where smoking is banned (for
         example, cinemas), spending all disposable income on cigarettes,
         socially undesirable behaviour such as begging for cigarettes and
         dangerous behaviour such as smoking in bed. Thus, some older
         persons who smoke might be scored 0 while others are rated higher.

     Q   How do I rate Scale 11 (living conditions) and Scale 12
         (occupation and activities) for a person in long term residential
         care?

     A   Both of these scales are concerned with rating the quality of the
         person’s usual living environment and whether it suits their needs. For
         older persons in longer-term residential care, the residence should be
         considered to be their usual environment, so you rate the extent to
         which the residential service meets their current needs.

     Q   How do I rate the elated mood when it is present in a person
         with a bipolar disorder?

     A   Where elated mood is present, it is rated on Scale 8 ‘Other mental and
         behavioural problems’ and coded J. Note that where over-activity or
         irritability is also present, these should be rated at Item 1 (Behavioural




12           Victorian Outcome Measurement Training Manual—2nd edition —2003
    disturbance).

Q   I work in an aged persons mental health service and I see many
    of our consumers get worse rather than better. Will our service
    get into trouble?

A   Not at all. You need to measure outcomes in accordance with the
    national protocol. This will document the realities of clinical practice in
    your area. In the mental health area generally, gains can be small or
    temporary. In APMHS even the most effective service will not be able
    to halt the deterioration that can be associated with some conditions
    and with old age. You are asked simply to document your practice, not
    to manufacture false positives. Even in areas where there is no
    improvement, you will still be able to compare your current and past
    practice. You will also have a benchmark for trying out new models of
    care that is based on careful observation over time rather than on
    anecdotal evidence.




        Victorian Outcome Measurement Training Manual—2nd edition —2003 13
Sample HoNOS 65+ rating sheet

Enter the severity rating for each item in the corresponding item box to
the right of the item. Rate 9 if not known or not applicable

1    Behavioural disturbance                              0   1   2   3     4

2    Non-accidental self-injury                           0   1   2   3     4

3    Problem drinking or drug-use                         0   1   2   3     4

4    Cognitive problems                                   0   1   2   3     4

5    Physical illness or disability problems              0   1   2   3     4

6    Problems with hallucinations and delusions           0   1   2   3     4

7    Problems with depressive symptoms                    0   1   2   3     4

8    Other mental and behavioural problems                0   1   2   3     4

     (specify disorder A, B, C, D, E, F, G, H, I or J)

9    Problems with relationships                          0   1   2   3     4

10 Problems with activities of daily living               0   1   2   3     4

11 Problems with living conditions                        0   1   2   3     4

12 Problems with work and leisure activities              0   1   2   3     4


Key for Item 8

A    Phobias – including fear of leaving home, crowds, public places, travelling, social
     phobias and specific phobias
B    Anxiety and panics
C    Obsessional and compulsive problems
D    Reactions to severely stressful events and traumas
E    Dissociative ('conversion') problems
F    Somatisation – persisting physical complaints in spite of full investigation and
     reassurance that no disease is present
G    Problems with appetite, over- or under-eating
H    Sleep problems
I    Sexual problems
J    Problems not specified elsewhere including expansive or elated mood.




14                     Victorian Outcome Measurement Training Manual—2nd edition —2003
The Abbreviated Life Skills Profile (LSP-16)

Overview

The second measure in the OM suite for older persons is the short version of the
Life Skills Profile, also known as the LSP. This was developed by a team of clinical
researchers in Sydney (Rosen et al. 1989, Parker et al. 1991) and is in fairly wide
use in Australia and in several other countries. The LSP focuses on the
consumer’s general functioning and disability rather than their clinical symptoms.
That is, how the consumer functions in terms of their social relationships, their
ability to do day-to-day tasks and so forth. When combined with the HoNOS 65+
measure, with its focus on the most serious problem encountered, the LSP
contributes towards gaining a more comprehensive understanding of the older
person.

In its original form, the LSP consisted of 39 items but it has been simplified to a
16-item scale. These include items that focus on the extent to which the
consumer is having problems in social relationships or looking after themselves,
and a range of areas and items that examine therapy and medication usage.

The clinician is required to rate the older person’s overall situation over the past
three months. This differs from the HoNOS 65+ because it is necessary to take a
longer-range view to make a proper assessment in these areas, rather than be
swayed by the temporary ups and downs that may occur in a person’s day-to-day
functioning.

Consumers are rated on each item. The items differ slightly in their format but
each one offers a choice of four responses. The clinician can rate their client by
simply circling the appropriate response1 that includes:

         0   having no problem

         1   having a slight problem

         2   having a moderate problem

         3   having an extreme problem.

         For variations on specific anchor points, refer to the section on Scoring.

Like the HoNOS 65+, the LSP takes about five minutes to complete once the
clinician gets used to its format and content. It is also one of the central OM tools
agreed by all states and territories for routine use in mental health services for
adults and aged persons.




1    Note that the order of the scores shown here is the reverse of the order of the original scale. The
original scale was ordered to emphasise strengths in its highest scores. The MH-CASC team reversed the
order of the abbreviated version so that both the HoNOS and the LSP ran in the same direction. The
original LSP-39 remains as a 1-4 scale emphasising strengths in the highest scores.




                        Victorian Outcome Measurement Training Manual—2nd edition —2003 15
Background

The LSP was originally developed as a brief, specific and jargon-free scale
designed to assess distinct behaviours and capable of being completed by family
members and community housing members as well as professional staff.

The initial focus of the LSP was on the function and disability of individuals with
schizophrenia being transferred from institutions to area-based and largely
community-focused services. The authors of the LSP developed the measure to
meet a number of specific requirements, including:

    the LSP measure should focus on those aspects of functioning that affect
     survival and adaptation in the community

    it should not focus on excessively fine detail but broad issues relevant to the
     measuring of disability

    it should be able to be completed by both professional and non-professional
     raters

    because of the bias that can be inherent in rating scales, the measure should
     aim to assess observable behaviours

    it should be brief and aimed at ready administration

    it should meet appropriate standards of administration

    each item should focus on a single distinct behaviour with broad dimensions
     derived from subscales

    the scores should be relevant to mental health workers and service users.

Five factors were identified in the original 39-item measure. These factors were
self-care, non-turbulence, social contact, communication and responsibility.
However, further study by Trauer et al. (1995) recommended fine-tuning of the
factor structure and suggested an alternative five-factor model. Further work
undertaken as part of the MH-CASC project saw the original 39 items reduced to
16 by the original designers in consultation with the MH-CASC research team.
This reduction in item numbers reduces the rating burden on clinicians when the
measure is used in conjunction with the HoNOS 65+.

Selection of these 16 items was based on two primary criteria. First, the items do
not duplicate client attributes captured by the HoNOS 65+. Second, the
psychometric strengths of the overall scale and its component subscales were
retained, except for the communication subscale. Therefore, for each scale the
top four items of each subscale were demonstrated to have between 85 and 90
per cent concordance with the full subscale. The final 16 items selected cover four
broad domains: withdrawal, antisocial behaviour, self-care and compliance.

The focus of the LSP-16 on general functioning at the exclusion of crisis situations
complements the HoNOS 65+, where clinicians are asked to rate the most serious
problem encountered in the rating period, including crisis situations. The
measures also complement each other because of the LSP-16’s utility in
demonstrating change over time and level of disability in longer-term acute and
non-acute settings in comparison to the ability of HoNOS 65+ to demonstrate
clinical status change in acute settings.




16                  Victorian Outcome Measurement Training Manual—2nd edition —2003
General guidelines for administration

The measure is completed by the clinician and requires an assessment of the
older person’s general functioning (that is how well the older person functioned
for the three months before they became ill or experienced a crisis).

In APMHS, the LSP is rated by the clinician on the following data collection
occasions:

        case review in ambulatory services

        case closure in ambulatory services.

Glossary

 1        Does the person generally have difficulty with initiating and responding to
          conversation? Measures the ability to begin and maintain social interaction, ensuring the flow of
          conversation; taking turns in conversation, silence as appropriate.

 2        Does the person generally withdraw from social contact? Does the person isolate
          themselves when part of a group? Does the person participate in leisure activities with others
          or spend long hours alone watching TV or videos? When part of an aged care facility and
          appropriate group activity, is participation voluntary and sustained?

 3        Does the person generally show warmth to others? Does the individual demonstrate
          affection, concern or understanding of situation of others?

 4        Is the person generally well groomed (neatly dressed, hair combed)? Does the person use
          soap when washing, shave as appropriate/ use make-up appropriately, use shampoo?

 5        Does the person wear clean clothes generally, or ensure that they are cleaned if dirty?
          Does the person recognise the need to change clothes on a regular basis? Are clothes grimy, are
          collars and cuffs marked, are there food stains?

 6        Does the person generally neglect their physical health? Does the person have a medical
          condition for which they are not receiving appropriate treatment? Does the person lead a
          generally healthy lifestyle? Does the person neglect their dental health?

 7        Is the person violent to others? Does the person display verbal and/or physical aggression to
          others?

 8        Does the person generally make or keep friendships? Does the person identify individuals as
          friends? Do others identify the person as a friend? Does the person express a desire to continue
          to interact with others?

 9        Does this person generally maintain an adequate diet? Does the person eat a variety of
          nutritious foods regularly? Do they watch their fat and fibre intake?

 10       Does this person generally look after and take their own prescribed medication (or
          attend for prescribed injections on time) without reminding? Does the person adhere to
          their medication regimen as prescribed? The right amount at the right time on a regular basis?
          Does the person need prompting or reinforcement to adhere to their medication regimen?

 11       Is the person willing to take medication when prescribed by a doctor? Does the person
          express an unwillingness to take medication as prescribed, bargain or inappropriately question the
          need for continuing medication?

 12       Does this person cooperate with health services (doctors and/or other health
          workers)? Is the person deliberately obstructive in relation to treatment plans? Do they attend
          appointments, undertake therapeutic homework activities?

 13       Does this person generally have problems (for example, friction, avoidance) living with
          others in the household? Is the person identified as ‘difficult to live with’? Do they have
          difficulty establishing or keeping to house rules or are they always having arguments about




                       Victorian Outcome Measurement Training Manual—2nd edition —2003 17
      domestic duties?

 14   Does the person behave offensively (includes sexual behaviour)? Does the person behave
      in a socially inept or unacceptable way demonstrating inappropriate social or sexual behaviours or
      communication?

 15   Does this person behave irresponsibly? Does the person deliberately act in ways that are
      likely to inconvenience, irritate or hurt others? Does the person neglect basic social obligations?

 16   What sort of work is this person generally capable of (even if unemployed, retired or
      doing unpaid domestic duties or volunteer work)? What level of assistance/guidance does
      the individual require to undertake occupational activities?




18                 Victorian Outcome Measurement Training Manual—2nd edition —2003
Scoring

All items are answered on an anchored four-point scale, with higher scores
indicating a greater degree of disability. In the 16-item version, a score of 3
represents greater dysfunction and a score of 0 represents good functioning 2.
Specific anchor points are provided for each item. For example, in relation to the
medication compliance item, the specific anchor points are (0) reliable with
medication, (1) slightly unreliable, (2) moderately unreliable and (3) extremely
unreliable. A total LSP scale score is calculated by adding individual scores for the
whole scale together. Therefore, for the LSP–16, the total score can range from 0
to 48.

Four subscale scores can be also be calculated by adding together the scores for
the items that form each subscale as shown in the table below:

Table 4.3 The four LSP-16 subscales and their component items

    Subscale and brief item name                              Item scores         Subscale scores

    A. Withdrawal                                                                 0–12

    1. Difficulty in conversation                             0–3

    2. Withdraws from social contact                          0–3

    3. Shows warmth                                           0–3

    8. Maintains friendships                                  0–3

    B. Self-care                                                                  0–15

    4. Well groomed                                           0–3

    5. Clean clothes                                          0–3

    6. Neglects health                                        0–3

    9. Adequate diet                                          0–3

    16. Work/activities capability                            0–3

    C. Compliance                                                                 0–9

    10. Looks after own prescribed medication                 0–3

    11. Willing to take prescribed medication                 0–3

    12. Cooperates with health services                       0–3

    D. Anti-social                                                                0–12

    7. Violent                                                0–3

    13. Problems with others                                  0–3




2       Readers familiar with the full 39-item version of the LSP should note that this differs from the
original scoring approach where higher scores represent better functioning rather than greater
dysfunction. The change in scoring for the LSP-16 is designed to be consistent with the HoNOS 65+ so
that for both instruments, higher scores indicate a greater degree of problems.




                           Victorian Outcome Measurement Training Manual—2nd edition —2003 19
 14. Offensive behaviour                               0–3

 15. Irresponsible behaviour                           0–3

 E. Total score (1–16)                                 0–48




Missing data

As a general rule, there should be no missing data from the clinician-rated
outcome measure suite. As part of routine clinical practice, observing the older
person’s presentation and gathering information from the older person or their
significant others should allow the clinician to make a rating. In calculating total
and subscale scores, missing items (and items scored as a 9) are assigned a
value of 0 because no problem has been recorded. The scores are calculated
automatically by the Wellbeing Reporting Tool.

Frequently asked questions


     Q           Who completes the LSP–16?

     A           Anyone can complete the LSP-16. The LSP has been used successfully
                 by carers and family members. In general, the LSP-16 will be
                 completed by the older person’s case manager in preference to the
                 treating doctor, unless the treating doctor has also gleaned sufficient
                 information to assess how the older person has been functioning over
                 the period being rated or is the nominated case manager.

     Q           Is the LSP-16 a structured interview?

     A           No, the LSP-16 is not a structured interview. You rate the older person
                 from your knowledge of their level of functioning. Gaps in your
                 understanding of the older person’s level of functioning present
                 opportunities for you to talk with the older person and learn more
                 about how they are functioning through routine clinical assessment.

     Q           What information should be used to make the ratings?

     A           Use all available information, including clinical records and reports from
                 other informants.

     Q           What do you mean ’rate the consumer’s general functioning
                 over the last three months’?

     A           The principle is to use the LSP to describe the person’s most typical
                 level of functioning over the previous three months. Don’t refer to how
                 they are functioning now.

                 As part of your routine clinical assessment, including psychosocial,
                 social and functional history, you will be able to gauge how this person
                 has typically functioned for the three months leading up to becoming
                 unwell.

                 This differs from the HoNOS 65+, which rates the person at their most
                 severe within the rating period.

                 Note: if the older person has been functioning poorly because of their
                 acute illness over the whole three-month period, then this should be




20                    Victorian Outcome Measurement Training Manual—2nd edition —2003
    considered as their ‘typical’ functioning over that time.

Q   How do I rate a person who is in residential care and is well
    groomed and wears clean clothes only because of the
    assistance they receive from the staff?

A   You are rating the older person’s functioning, not the quality of care
    provided—so consider how the person would function if the care was
    not available.

Q   How do I rate a person who cooperates with health services
    (item 12) and takes prescribed medication (item 11) only
    because he/she is on a Community Treatment Order (CTO)?

A   You are rating the older person’s functioning. In some cases the person
    is on a CTO primarily because they are unable or unwilling to cooperate
    in treatment. In these cases, consider how the person would function if
    they were not on the CTO.

Q   How do I rate the maintenance of an adequate diet – does this refer to
    food preparation and cooking or to eating behaviour?

A   Item 9 requires consideration of the person’s eating behaviour and
    willingness to eat rather than food preparation as such. For example, if
    the person receives meals on wheels and only eats the dessert, leaving
    the rest, you would assess this item as a being a moderate problem.




        Victorian Outcome Measurement Training Manual—2nd edition —2003 21
 Sample LSP-16 rating sheet

 Assess the older person’s general functioning over the past three months. Do not assess
 functioning during crises when the older person was ill or becoming ill. Answer all 16 items
 by circling the appropriate response.

                                                   0                1             2                3
1. Does this person generally have any
                                                             Slight         Moderate       Extreme
difficulty with initiating and responding to No difficulty
                                                             difficulty     difficulty     difficulty
conversation?
                                             Does not                                      Withdraws
2. Does this person generally withdraw from                  Withdraws      Withdraws
                                             withdraw at                                   totally or
social contact?                                              slightly       moderately
                                             all                                           nearly totally
3. Does this person generally show warmth Considerable       Moderate       Slight         No warmth at
to others?                                   warmth          warmth         warmth         all
                                             Well            Moderately     Poorly         Extremely
4. Is this person generally well groomed
                                             groomed         well groomed   groomed        poorly
(neatly dressed, hair combed)?
                                                                                           groomed

5. Does this person wear clean clothes Maintains             Moderate       Poor           Very poor
generally, or ensure that they are cleaned if cleanliness of cleanliness of cleanliness of cleanliness of
dirty?                                        clothes        clothes        clothes        clothes

                                               No neglect    Slight neglect Moderate       Extreme
6. Does this person generally neglect her or                 of physical    neglect of     neglect of
his physical health?                                         health         physical       physical
                                                                            health         health

7. Is this person violent to others?           Not at all    Rarely         Occasionally   Often

                                          Friendships  Friendships          Friendships    No
                                          made or kept made or kept         made or kept   friendships
8. Does this person generally make and/or
                                          up well      up with slight       up with        made or
keep up friendships?
                                                       difficulty           considerable   none kept up
                                                                            difficulty

                                               No problem    Slight         Moderate       Extreme
9. Does this person generally maintain an                    problem        problem
adequate diet?
                                                                                           problem

10. Does this person generally look after Reliable with      Slightly       Moderately     Extremely
and take her or his own prescribed medication                unreliable     unreliable
medication (or attend for prescribed                                                       unreliable
injections on time) without reminding?

11. Is this person willing to take psychiatric Always        Usually        Rarely         Never
medication when prescribed by a doctor?

12. Does this person cooperate with health Always            Usually        Rarely         Never
services (doctors and/or other health
workers)?
13. Does this person generally have No obvious               Slight         Moderate       Extreme
problems (friction, avoidance) living with problem           problems       problems       problems
others in the household?

14. Does this person behave offensively Not at all           Rarely         Occasionally   Often
(includes sexual behaviour)?

15. Does this person behave irresponsibly?     Not at all    Rarely         Occasionally   Often

16. What sort of work is this person Capable of              Capable of     Capable only   Totally
generally capable of (even if unemployed, full-time          part-time      of sheltered   incapable
retired or doing unpaid domestic duties)? work               work           work           of work

  Rosen A, Parker G & Hadzi-Pavlovic D 1999. In use in Victoria with permission of the authors.




 22                      Victorian Outcome Measurement Training Manual—2nd edition —2003
The Focus of Care (FOC)



Overview

The third measure in the APMHS OM suite to be routinely completed by clinicians is
a rating called Focus of Care. This is not so much a measure of outcome but an
important aid to understanding the other two measures.

Focus of Care is used to identify ‘markers’ or time points within episodes at which
significant changes may have occurred in the older person’s clinical status and
treatment goals. Focus of Care is rated by the clinician and requires:

   judgement about the older person’s primary need for care

   the treatment objective

   identification of which one of four types of care foci best describes the care
    provided to the older person over the immediately preceding period.

Focus of Care requires the clinician to make a retrospective judgement about the
primary goal of care by identifying which focus of care best describes the care
provided to the older person over the recent period:

   Acute, where the primary emphasis is the short term reduction in severity of
    symptoms and/or personal distress associated with recent onset or
    exacerbation of a psychiatric disorder.

   Functional gain, where the main goal is to foster improvements in the
    person’s personal, social or occupational functioning.

   Intensive extended, where the main goal is prevention or minimisation of
    further deterioration, and reduction of harm for people who have a stable
    pattern of severe symptoms, frequent relapses; or severe inability to function
    independently

   Maintenance, where the goal is to maintain the current status of an older
    person who has become stable and is functioning relatively independently.

All of these aspects may be found in the mental health care of any consumer.
However, the concept here is to identify the most important current goal, given
that these often change over time. Many older persons require different phases in
their care program and the focus of care may change. Understanding care goals is
necessary to understand outcomes because different outcomes can be expected
under different goals. For example, the outcome that might be expected for a
consumer with a long-standing but stable mental illness could differ from that
expected in a young person who has a recent onset of an acute illness. In the first
example, the desired outcome might be for the consumer to be maintained in the
community, build up their social networks and develop a satisfying life. In the
other example, the outcome might be rapid relief from the acute symptoms of
mental illness and helping the consumer restore the level of functioning that they
had prior to the onset of their illness.




                    Victorian Outcome Measurement Training Manual—2nd edition —2003 23
This emphasises an important point in understanding and interpreting outcome
information—there is no standard outcome for everybody because it depends on
each person’s unique situation and needs.

The measure puts into operation the concept of ‘phase’ which has strong clinical
meaning in the mental health field, with consumers moving between stable and
more acute episodes of care with corresponding changes in demand for service
intervention and treatment. The four focus categories (acute, functional gain,
intensive extended and maintenance) were developed in consultation with
clinicians and are distinguished on the basis of the key clinical attributes of the
consumer and the primary goal of care. By rating these at various points
throughout inpatient and community episodes, there is scope to recognise
clinician-defined episodes of care occurring within a single setting and to identify
the key clinical changes and resource use patterns associated with changes in
clinical focus.

The Focus of Care is a four-item measure of the intersection between the related
concepts of ‘consumer need’ and ‘goal of care’.

In APMHS, the Focus of Care is rated by the clinician at the following data
collection occasions:

        case review in inpatient services (likely to be an uncommon scenario)

        discharge from inpatient services

        case review in ambulatory services

        case closure in ambulatory services.

General guidelines for administration

Clinicians are asked to identify the main focus of care for the period over which
outcomes are being measured. There are four options.

Because the focus of care can change within a rating period, it is necessary to
define the ‘main’ focus of care when there has been more than one within the
period (for example, a flare up of symptoms in a consumer receiving maintenance
care such that the focus is now treating the acute symptoms). In such
circumstances, clinicians should choose the main focus of care as the focus of care
that has consumed the most treatment effort during the period being rated. For
example, if the focus of care was ‘maintenance’ for most of the period, and ‘acute’
for just a few days, the clinician would rate the main focus of care as maintenance.

There is no provision for missing data from the Focus of Care scale as there is
only one item to rate.




24                    Victorian Outcome Measurement Training Manual—2nd edition —2003
        Glossary



                       Consumer characteristics                             Service requirements

              Sympto   Function-    Primary      Indicative     Indicative             Examples of typical
                ms        ing         goal         time to      treatment          documentation in care plan to
                                                  achieve        intensity              support the rating
                                                  primary
                                                     goal
Acute         High and Low-High    Reduce        Days to    Daily contact over     Interventions designed to reduce
              of recent            symptoms      weeks      a short period         the intensity of positive
              onset                                                                symptoms, (such as reduce
                                                                                   hallucinations and delusions,
                                                                                   ameliorate thought disorder,
                                                                                   reduce severity of depressive
                                                                                   symptoms or the level of anxiety,
                                                                                   manage hostile or aggressive
                                                                                   behaviour related to mental
                                                                                   illness).

Functional    Low      Low-        Improve       Weeks to    Weekly contact, or    Interventions designed to result in
Gain                   medium      functioning   months      multiple              a significant improvement in the
                                                             attendances per       consumer’s personal, social and/or
                                                             week in a             occupational functioning in the
                                                             structured            short term (weeks to months).
                                                             rehabilitation        This may include the development
                                                             program               of basic ‘community survival’ skills
                                                                                   (for example, shopping, cooking);,
                                                                                   social skills (for example,
                                                                                   conversation) or vocational skills
                                                                                   (for example, job seeking or job
                                                                                   maintenance).

Intensive     High and Low         Reduce risk Months to     Minimum of            Inpatient- or outreach-based
Extended      unremitt-            that arises years         multiple weekly       interventions (the latter typically
              ing                  from                      contacts, more        in the consumer’s own
                                   symptoms                  frequent as           environment) aimed to:
                                   and/or low                required; delivered
                                   functioning               over an indefinite    (1) minimise the risks and
                                                             period.               handicaps associated with the
                                                                                   ongoing symptoms and
                                                                                   psychosocial dysfunctions arising
                                                                                   from a psychiatric disorder

                                                                                   (2) strengthen the consumer’s
                                                                                   capacity to use supportive
                                                                                   professional and non-professional
                                                                                   networks.

Maintenance   Low      Low-high    Maintain      Months to   Scheduled weekly Interventions designed to
                                   functioning   years       to monthly contact consolidate the consumer’s
                                                                                current functioning (at least in the
                                                                                short-term) while working toward
                                                                                improvement in the long-term or
                                                                                planning for the consumer’s exit
                                                                                from the service.




                             Victorian Outcome Measurement Training Manual—2nd edition —2003 25
Frequently asked questions

 Q      Who completes the Focus of Care?

 A      Any qualified mental health professional can complete the Focus of Care. In
        general, the consumer’s case manager or treating doctor will complete the
        Focus of Care.

 Q      Is ‘acute’ the highest rating and ‘maintenance’ the lowest?

 A      No, they are simply different ratings, indicating different goals of care. There is
        no implied order or precedence among the Focus of Care categories

 Q      Shouldn’t all older persons treated in an acute inpatient unit be rated
        as acute Focus of Care?

 A      No. Focus of Care is concerned with the goal for the individual older person,
        not the treatment setting. While most older persons treated in an acute
        inpatient unit have an acute Focus of Care, this need not be the case,
        especially with longer lengths of stay or assessment unit stays often used by
        APMHS.

 Q      Is Focus of Care meant to be about the primary goals for the person’s
        future care?

 A      No, the clinician outcome measures always rate the preceding period. You
        should always rate your primary goal of care over the previous episode.

 Q      Over what period should I rate the FOC?

 A      Rate the entire period of care since the preceding data collection occasion.

 Q      Can I rate more than one FOC rating when there is more than one
        goal?

 A      No, you only make one rating. Rate the primary goal of care over the
        period.

 Q      If I rate the Focus of Care as maintenance, am I implying that there
        will be no further improvement?

 A      No, most people rated as maintenance will continue to improve in the longer
        term. As clinicians, we must remain committed to all of our consumers
        improving and convey this in all our clinical interactions. By rating the Focus of
        Care as maintenance, you are indicating that the main purpose of continuing
        contact with the person during the period rated was to assist them to
        consolidate the gains they have made while working towards further
        improvements in the longer term.




26                 Victorian Outcome Measurement Training Manual—2nd edition —2003
Sample Focus of Care rating sheet




FOCUS OF CARE

                               Acute - Short-term reduction in severity of symptoms and/or personal distress
                                        associated with recent onset or exacerbation of psychiatric disorder.
                               Functional gain - Improve personal, social or occupational functioning or promote
                                        psychosocial adaptation in a patient with impairment arising from a
                                        psychiatric disorder.
        Indicate main          Intensive extended - Prevent or minimise further deterioration and reduce risk of
         focus of care                  harm in a consumer who has a stable pattern of severe symptoms/frequent
        since last data                 relapses/severe inability to function independently, and is judged to require
                                        care over an indefinite period.
           collection          Maintenance - Maintain level of functioning, minimise deterioration or prevent
           occasion
           Occasion                     relapse where the consumer has stabilised and functions relatively
                                        independently.




                     Victorian Outcome Measurement Training Manual—2nd edition —2003 27
The Behaviour and Symptom Identification Scale (BASIS-32)

Overview

Choosing an appropriate measure for consumers to make assessments of their own
health and functioning has been a difficult aspect of OM implementation. While
considerable research and trials have been conducted for rating measures used by
clinicians, the use of consumer self-ratings as a routine part of clinical care is
relatively unexplored. Three instruments were trialled in a 1996 national project,
with each having strengths and limitations.

Consumer views on outcome assessment typically emphasise the need for a
different approach from that taken by clinicians and suggest that a symptom-
centred assessment of outcome is not compatible with the recovery process. For
example:

     Health professionals often disrupt the normalisation process (that emphasises
     abilities and recovery) by continually introducing a problem saturated
     perspective which services the illness rather than providing the help one needs
     for getting on with your life...The participants focussed on their strengths and
     used them to help themselves recover. A major problem with health
     professionals was their focus on deficits, on symptoms, on what the person
     could not do, resulting in the stripping of hope. 3

Consumers have advocated for the need to develop a new approach that has
significant consumer input and is customised to reflect both the Australian mental
health service delivery environment and a consumer perspective. The Victorian
Department of Human Services has conducted in recent years two major projects
to consult with consumers about future approaches to self-rating.

The Department of Human Services believes that it is essential that some form of
self-assessment ratings be introduced in parallel with clinician ratings. This will
allow valuable experience to be gained while new measures are explored and give
consumers with an opportunity to participate from the outset in this phase of
development.

The consumer self-rating measure that will be used as an interim tool in mental
health services for adults and aged persons in Victoria is the Behaviour and
Symptom Identification Scale, or BASIS-32. The BASIS-32 was developed by a
team in the United States for use in outcome assessment. It is derived from
consumer perspectives and covers the major symptoms and functioning difficulties
experienced by people as a result of a mental illness.

The BASIS-32 was designed for self-completion but can also be used in an
interview situation. It asks the consumer to respond to 32 questions that assess
the extent to which they have been experiencing difficulties over the past two
weeks4 on a range of dimensions such as managing day-to-day life; relating to
other people; self-esteem; motivation; clinical symptoms such as depression,



3Tooth BA, Kalyanansundaram, V, Glover H Recovery from schizophrenia: a consumer perspective: Final
Report to Health and Human Services Research Development Grants Program. Department of Health and
Aged Care, Canberra, 1997
4    The original instructions for the BASIS-32 request the consumer to rate their experiences over the
past week. This has been amended for implementation in Victoria to ensure consistency between the
HoNOS, BASIS-32 and Focus of Care in the period rated.




28                       Victorian Outcome Measurement Training Manual—2nd edition —2003
anxiety and mood swings; physical symptoms such as headaches and sleep
disturbance; drug and alcohol use; and level of satisfaction with life.

The items differ slightly in their format but each one offers a choice of five
responses. The consumer can respond by simply ticking the box to indicate
whether they are having:

                no difficulty
                a little difficulty
                moderate difficulty
                quite a bit of difficulty; or
                extreme difficulty.


For example:

To what extent are you experiencing difficulty in the area of:

                                                      No       A little   Moderate   Quite a bit Extreme
                                                  difficulty
1.   Managing day-to-day life (for example,
     getting to places on time, handling money,
                                                                                               
     making everyday decisions)



The 32 items are grouped into five domains, representing:

                Relation to self and others;

                Daily living and role functioning;

                Depression and anxiety;

                Impulsive and addictive behaviour; and

                Psychosis.

Scores can be derived for each of these groups, and for the whole scale and the
Wellbeing Reporting Tool provides this feedback.

Completion of the BASIS-32 is voluntary.

Consumers can complete the BASIS-32 by themselves, with assistance, or as an
interview with the clinician or case manager. Older people should be encouraged to
seek the assistance of their carer or a staff member if they need help to complete
the BASIS-32. Under most conditions, the instrument takes only 10 minutes to
complete.

It is acknowledged that each Aged Persons Mental Health Service has its own
culture that includes the extent to which older persons and their clinicians
collaborate. A critical factor in the concept of performance monitoring is the
accuracy of the information that is collected. Research suggests that in terms of
OM, clinician ratings and consumer self-ratings are often quite different. However,
comparison and discussion of ratings can contribute to a more comprehensive
clinical picture that will enable realistic outcome measures to be achieved. These
ratings then provide both a stronger information base for the development of
individual service plans and a commitment to these plans.




                        Victorian Outcome Measurement Training Manual—2nd edition —2003 29
Background

The BASIS-32 was developed by mental health workers in the USA as a brief
consumer report measure for use by consumers of mental health services. It was
developed with the intention of gaining the consumer’s perspective on several
major areas of functioning and psychiatric problems. It was also designed to
combine individualised and standardised approaches to the assessment of
consumers’ problems.

Initial work showed that the five groups of questions were stable and meaningful,
and repeat self-ratings made by consumers after a few days were quite similar to
the first self-rating, indicating that the ratings could be relied upon. Consumers
who were judged to be more ill, rated themselves as having more problems and
more severe problems than other consumers. On the basis of results like these, the
BASIS-32 was considered to have good instrument properties for the purpose for
which it was designed.

Different workers have studied different ways of gaining responses, including using
structured interviews, consumer self-administration, telephone interviews and
mailed questionnaires. Structured interviews have been found to take about 15 to
20 minutes to complete, while most consumers can complete it unassisted in about
five to 10 minutes. Studies comparing different modes of administration have
found little to choose between the self-report and the structured interview.

General guidelines for administration

Consumers of Aged Persons Mental Health Services should be invited to complete
the BASIS-32 on the following occasions:

        intake in ambulatory services

        case review in ambulatory services

        case closure in ambulatory services.

An opportunity to complete on discharge from an acute inpatient unit is
encouraged, especially if there has been an extended length of stay.

Consistent with good practice, the invitation to the consumer to complete the
BASIS-32 should include:

        an explanation of the purpose or the reason you are asking them to
         complete the BASIS-32

        an assurance that this is not a test, that there are no right or wrong
         answers and that, while it is desirable that all questions are answered, the
         older person should feel free to ignore items that they feel uncomfortable
         about

        an opportunity for the older person to discuss the responses they record
         with their clinician.

After the older person has completed filling out the BASIS-32, use the opportunity
to invite them to discuss their answers, elaborate on how they feel and discuss
how it might impact on their individual service plan. Alternately, make a time for a
later date to discuss the older person’s answers.




30                    Victorian Outcome Measurement Training Manual—2nd edition —2003
Capacity to participate in self-rating

The OM protocol has been designed in close collaboration with clinicians and aims
to support good practice. The rating points are based on common sense. For
example, the protocol does not require the BASIS-32 to be offered to older people
when they are being admitted to, or treated in, an acute inpatient service, as this
is likely to be a time of great distress.

Clinicians should use their clinical judgement in determining whether BASIS-32
ratings are likely to be helpful or counterproductive.

Irrespective of the service setting, the national protocol suggests a number of
situations where consumers should not be offered a BASIS-32.

General contra-indications

           The older person’s cognitive functioning is insufficient to enable
            understanding of the task as a result of an organic mental disorder or an
            intellectual disability.

           Cultural or language5 issues make the BASIS-32 measure inappropriate.

Temporary contra-indications

           Where the older person’s current clinical state is of sufficient severity to
            make it unlikely that their responses to a BASIS-32 questionnaire could be
            obtained or, if their responses were obtained, it would be unlikely that they
            were a reasonable indication of the person’s feeling and thoughts about
            their current emotional and behavioural problems and wellbeing.

           Where an invitation to complete the BASIS-32 is likely to be experienced as
            distressing or requires a level of concentration and effort the person feels
            unable to give.

Older people who meet any of the above exclusion criteria should be offered an
opportunity to complete a BASIS-32 at a future time when they do meet the
criteria.

At all other times, they should be given an opportunity to participate in OM by
completing a BASIS-32.

Conversely, older people who request a copy of the BASIS-32 should generally be
given the opportunity to complete one, even if the data collection occasion or the
service setting does not require the BASIS-32 to be offered routinely. Bear in mind
that the NOCC protocol specifies minimum requirements and that it is acceptable
for either the older person or the clinician to make and enter additional ratings.




5   It is anticipated that BASIS-32 will be made available in a variety of translations.




                              Victorian Outcome Measurement Training Manual—2nd edition —2003 31
Glossary



 1    Managing day-to-day life: deciding what to wear, what to eat, using public
      transport, self-care including dressing, bathing etc.

 2    Household responsibilities: home management, care of children or old persons (if
      not done as paid employment), laundry, making bed, organising clothing and personal
      possessions.

 3    Work: paid employment, if unemployed, efforts to find or keep a job, preparing
      resumes, handling interviews, managing rehabilitation services, career groups or job
      training programs. Not applicable to those not needing or wanting to work.

 4    School: high school, vocational or technical training, college or university. Recreational
      classes (for example, piano lessons, self-improvement) should be included under item
      5, Leisure time.

 5    Leisure time: difficulty structuring free time or finding things to do, boredom. Leisure
      time activities include hobbies, social clubs, reading, jogging, sports, fitness, etc. Also
      includes recreational classes, such as piano lessons, self-improvement, arts.

 6    Adjusting to major life stresses: medical illness, job loss, financial or housing
      difficulty, victim of abuse, violence or other crime, etc. Does not include the current
      hospitalisation. If the person has experienced no major stresses, item is not applicable
      and should be rated 0. Adjustment to stressors should be considered during the past
      week. The stressors do not have to have occurred in the past week.

 7    Relationships with family members: relatives or long-term significant others. If
      relationships vary with different family members, older persons should give their best
      estimate of family relationships overall.

 8    Getting along with people outside the family: roommates, friends, neighbours,
      supervisors and co-workers.

 9    Isolation, loneliness: subjective feelings of isolation          or   loneliness   may   be
      independent of actual degree of contact with others.

 10   Being able to feel close to others: feeling close (trusting, in harmony with,
      affectionate) to people you especially care about.

 11   Being realistic about yourself or others: having realistic expectations, not too high
      or too low regarding your own behaviour or that of others.

 12   Recognising or expressing emotions appropriately: showing appropriate affect,
      recognising, acknowledging affects such as sadness, anger, affection, etc.

 13   Developing independence, autonomy: feeling that you can take care of most things
      (financial, emotional, social) without being uncomfortably dependent on other people;
      feeling that you are in control of decisions about your life. Age, occupation and other
      factors may affect autonomy. This question asks about the degree to which lack of
      independence is problematic for the respondent.

 14   Goals or direction in life: knowing what you want to be doing in your life; working
      towards a goal.

 15   Lack of self-confidence, feeling bad about yourself: feeling that you are not a
      good, likeable or worthwhile person; feeling stupid or incapable of accomplishing




32                 Victorian Outcome Measurement Training Manual—2nd edition —2003
     anything.

16   Apathy, lack of interest in things: not caring about anything; not feeling like you
     want to do things that you usually enjoy.

17   Depression, hopelessness: feeling depressed, sad, hopeless about the future, lack of
     pleasure in life.

18   Suicidal feeling or behaviour: thinking about, planning, gesturing or attempting
     suicide by any means.

19   Physical symptoms: difficulty should be rated regardless of aetiology (medication
     side effects).

20   Fear, anxiety, panic: nervousness, tension, jitters, agitation, fear of open spaces,
     heights, darkness, etc.

21   Confusion, concentration, memory: difficulty understanding things, thinking clearly,
     remembering, maintaining focus on a task.

22   Disturbing or unreal thoughts or beliefs: paranoid ideation (feeling as if you are
     being watched, poisoned, or that others can read your mind); delusions, for example,
     that your body is rotting, that you can fly, that a TV personality is speaking to you
     personally, etc.

23   Hearing voices, seeing things: auditory or visual hallucinations; hearing messages
     or commands from a voice in one’s head; seeing things that no one else can see.

24   Manic, bizarre behaviour: racing thoughts, decreased need for sleep, increased
     talking, spending money, exaggerated sense of wellbeing; inappropriate behaviour
     including undressing in public, speaking incoherently to strangers, behaviour that
     others would generally consider very unusual or inappropriate.

25   Mood swings, unstable moods: feeling happy one minute, sad the next; frequent
     emotional ups and down, often unrelated to what is going on in your life at the time.

26   Uncontrollable, compulsive behaviour: any behaviour that you feel compelled to
     frequently repeat, including eating disordered behaviour, checking, washing, gambling.

27   Sexual activity or preoccupation: any sexual issue experienced as problematic (for
     example, impotence, sexual addiction, fetishes, sexual identity confusion).

28   Drinking alcoholic beverages: including difficulty dealing with urges, efforts to find
     alcohol.

29   Taking illegal drugs, misusing drugs: any illegal substance of abuse (cocaine,
     heroin, crack, marijuana, etc.); misuse or overuse of prescription drugs (sedatives,
     stimulants, diet pills, anti-anxiety agents, etc.).

30   Controlling temper, outbursts of anger, violence: screaming, throwing things,
     kicking, hitting, etc.

31   Impulsive, illegal, or reckless behaviour: includes dangerous or illegal behaviour,
     such as reckless driving, vandalism, assault, fraud, selling drugs, forging cheques, etc.

32   Feeling satisfaction with your life: happy with what you are doing, general sense of
     wellbeing.




                  Victorian Outcome Measurement Training Manual—2nd edition —2003 33
Scoring

BASIS-32 is scored into five subscales and an overall average. Just as each item is
rated on a five-point scale (from 0 for least difficulty to 4 for greatest difficulty),
subscale and overall mean scores also range from 0 to 4. The lowest possible score
is 0 (if every item is rated ‘no difficulty’). The highest possible score is 4 (if every
item is rated ‘extreme difficulty’). The items comprising each subscale are as
follows:

     Relation to self/others          Items 7, 8, 10, 11, 12, 14 and 15.
     Depression/anxiety               Items 6, 9, 17, 18, 19 and 20.
     Daily living/role functioning    Items 1, (2, 3, 4), 5, 13, 16, 21 and 32.
     Impulsive/addictive behaviour    Items 25, 26, 28, 29, 30 and 31.
     Psychosis                        Items 22, 23, 24 and 27.
     BASIS-32                         Items 1 to 32.


Four of the five subscale scores and the BASIS-32 average are computed by
adding the total for all items and averaging the ratings using the number of non-
missing items as the denominator. The four subscale scores computed this way
are: relation to self/others, depression/anxiety, impulsive/addictive behaviour and
psychosis.

For example, if the older person answers all items in the relation to self/others
subscale, the subscale score is the sum of the ratings for items 7, 8, 10, 11, 12, 14
and 15 divided by 7. If one item is omitted, the subscale score is the sum of the
ratings for the items answered, divided by 6.

The same process is followed for the three other subscales noted above, using the
items comprising each subscale. The only exception to this scoring process is for
the daily living/role functioning scale. In this case, items 2, 3 and 4 are used to
create one ‘role functioning’ rating by taking the highest of the three ratings
(indicating greatest difficulty). The role functioning item can be created if a rating
is available for at least one of the three items (2, 3 or 4).

The total and subscale scores are calculated automatically by the Wellbeing
Reporting Tool.

Missing data

Missing data are not included in the calculation of the BASIS-32 subscale or overall
mean scores. If more than five items have been omitted, the entire instrument will
be considered ‘missing data’ and will not be counted as a valid record in the
Wellbeing Reporting Tool.




34                    Victorian Outcome Measurement Training Manual—2nd edition —2003
Frequently asked questions

Q.   I felt worse at the beginning of the week, but better now. How should I respond?

A.   Try to average how you have felt during the past 14 days, including today.

Q.   I can’t decide between a 3 and 4 rating.

A.   Suggest that the older person think about what rating comes a little closer to how they
     feel. If they still can’t decide, suggest that they skip the item for now and come back to it
     at the end.

Q.   I have no difficulty with some of the examples given for the item (for example,
     getting to places on time), but I have difficulties managing money.

A.   Suggest the older person think of how much difficulty they are having in the category as a
     whole. The examples are not meant to include everything within each item. They are
     meant only to illustrate the idea.

Q.   I can’t do this. Will you do it for me?

A.   I can’t do this for you because I can’t say how much difficulty you are experiencing. Only
     you can tell me that. I am very interested in what you think and feel.

Q.   This is a really good idea for me to think about how I feel but these questions
     are not about the main issues I have in my life.

A.   No single questionnaire can hope to include all of the issues that are important to every
     older person. We would like to see a better measure developed in the future. Until then,
     we are using the BASIS-32 but it is not meant to replace your usual clinical
     communications. What are the main things that you’d like to discuss?

Q.   Some older persons in our service clearly lack the capacity to complete the
     BASIS-32. What should I do?

A.   Clinicians should use their clinical judgement in determining whether the BASIS-32 is
     likely to be helpful or counterproductive—and whether it is even feasible to use with an
     individual older person. For example, older people who are suffering from an organic brain
     disorder may lack the insight and cognitive capability to interpret the questions and to
     complete the questionnaire in any meaningful way. Raters should acquaint themselves
     with the temporary and general exclusion criteria explained earlier in this section of the
     manual.

Q.   The older person wasn’t feeling very well and I decided against offering her the
     BASIS-32 on this occasion. When should I offer it again?

A.   You can offer the BASIS-32 when you next see the older person, provided she is better, or
     at the next data collection occasion, such as the next formal review.

     Older persons who meet any of the temporary exclusion criteria need not be invited to
     complete a BASIS-32 at the time when they meet the criteria. At all other times, they
     should be given an opportunity to participate in outcome measurement by completing a
     BASIS-32.

Q.   My eyesight is not very good—do you have a large print version of this form?

A.   It is anticipated that a large-print version of the BASIS-32 will be produced by the
     Department of Human Services. Until this is available, this situation can be resolved by
     encouraging the older person to ask for assistance or to complete the BASIS-32 in an
     interview situation.




                      Victorian Outcome Measurement Training Manual—2nd edition —2003 35
Q.   My English is not very good—do you have this form in my language?

A.   Translated versions of the BASIS-32 in a number of languages are being planned and
     should be available later in 2003-2004.




36                  Victorian Outcome Measurement Training Manual—2nd edition —2003
Sample BASIS-32 rating sheet

The behaviour and symptom identification scale (BASIS-32)

Put a tick in the box which best describes the degree of difficulty you have been experiencing
in each area during the PAST TWO WEEKS.

                                                No       A Little Moderate      Quite   Extreme
                                             Difficulty Difficulty Difficulty   a Bit   Difficulty
To what extent are you experiencing difficulty in the area of:

1     Managing day-to-day life                                                          
      (for example, getting to places on
      time, handling money, making
      everyday decisions)

2     Household responsibilities                                                        
      (for example, shopping, cooking,
      laundry, keeping room clean, other
      chores

3     Work                                                                              
      (for example, completing tasks,
      performance level, finding / keeping
      a job)

4     School                                                                            
      (for example, academic
      performance, completing
      assignments, attendance)

To what extent are you experiencing difficulty in the area of:

5     Leisure time or recreational                                                      
      activities

6     Adjusting to major life stresses                                                  
      (for example, separation, divorce,
      moving, new job, new school, a
      death)

7     Relationships with family members                                                 
8     Getting along with people outside of                                              
      the family

9     Isolation or feelings of loneliness                                               
To what extent are you experiencing difficulty in the area of:

10    Being able to feel close to others                                                




                       Victorian Outcome Measurement Training Manual—2nd edition —2003 37
The behaviour and symptom identification scale (BASIS-32)

11   Being realistic about yourself or                                          
     others

12   Recognising and expressing                                                 
     emotions appropriately

13   Developing independence,                                                   
     autonomy

14   Goals or direction in life                                                 
15   Lack of self-confidence, feeling bad                                       
     about yourself




To what extent are you experiencing difficulty in the area of:

16   Apathy, lack of interest in things                                         
17   Depression, hopelessness                                                   
18   Suicidal feeling or behaviour                                              
19   Physical symptoms                                                          
     (for example, headaches, aches and
     pains, sleep disturbance, stomach
     aches, dizziness)

20   Fear, anxiety or panic                                                     
To what extent are you experiencing difficulty in the area of:

21   Confusion, concentration, memory                                           
22   Disturbing or unreal thoughts of                                           
     beliefs

23   Hearing voices, seeing things                                              
24   Manic, bizarre behaviour                                                   
25   Mood swings, unstable moods                                                
26   Uncontrollable, compulsive                                                 
     behaviour

     (for example, eating disorder, hand-
     washing, hurting yourself)

     Please specify: if you want, you can write down
     more information about this here.




38                    Victorian Outcome Measurement Training Manual—2nd edition —2003
The behaviour and symptom identification scale (BASIS-32)




To what extent are you experiencing difficulty in the area of:

27   Sexual activity or preoccupation                                          
28   Drinking alcoholic beverages                                              
29   Taking illegal drugs, misusing drugs                                      
30   Controlling temper,     outbursts     of                                  
     anger, violence

31   Impulsive,    illegal   or     reckless                                   
     behaviour

32   Feeling satisfaction with your life                                       




                      Victorian Outcome Measurement Training Manual—2nd edition —2003 39
Activities of Daily Living (RUG-ADL)

Overview

The RUG-ADL was developed by Fries et al. in the USA to measure nursing
dependency. It measures ability with regard to ‘late loss’ activities, that is, those
activities that are likely to be lost late in life, such as independent eating, bed
mobility and toileting. ‘Early loss’ activities (such as dressing and grooming) are
included in the LSP-16. The RUG-ADL is widely used in Australian nursing homes
and aged care residential settings.

The RUG-ADL comprises four items only and is usually completed by nursing staff.

General guidelines for administration

The RUG-ADL is only used in APMH inpatient services. The data collection occasions
required by the NOCC protocol are admission and review. The fact that no rating is
required at discharge shows that the RUG-ADL is required for the purposes of
classification rather than OM.

General guidelines for completing the RUG-ADL are:

        Record what the person actually does, not what they are capable of doing.
         That is, record their poorest performance during the period rated.

        Do not omit any ratings.

        It is essential that the rater knows what behaviours and tasks are contained
         within each scale and has a ‘working knowledge’ of the scale.

Glossary


Item 1 Bed mobility

Ability to move in bed after the transfer into bed has been completed.

1 Independent/supervision: Is able to readjust position in bed and perform own
pressure area relief through spontaneous movement around bed or with prompting
from carer. No hands-on assistance is required. May be independent with the use
of a device.

3 Limited assistance: Is able to readjust position in bed, and perform own
pressure area relief, with the assistance of one person.

4 Other than two-person: Requires use of a hoist or other assisting device to
readjust position in bed and physical assist pressure relief. Still requires the
assistance of only one person for task.

5 Two-person physical assist: Requires two assistants to readjust position, and
perform own pressure area relief.

(Note: a rating of 2 is not included in the domain of valid ratings.)




40                    Victorian Outcome Measurement Training Manual—2nd edition —2003
Item 2 Toileting

Includes mobilising to the toilet, adjusting clothing before and after toileting and
maintaining perineal hygiene without the incidence of incontinence or soiling of
clothes.

If the person cares for the catheter or other device independently and is
independent on all other tasks, rate 1.

1 Independent/supervision: Is able to mobilise to the toilet, adjust clothing,
cleans self, has no incontinence or soiling of clothing. All tasks performed
independently or with prompting from carer. No hands-on assistance required. May
be independent with the use of device.

3 Limited assistance: Requires hands-on assistance of one person for one or
more of the tasks.

4 Other than two-person: Requires the use of a catheter, uridome or urinal, or a
colostomy, bedpan or commode chair, or insertion of enema or suppository.
Requires the assistance of one person for the management of the device.

5 Two-person physical assist: Requires two assistants to perform any step of the
task.

(Note: a rating of 2 is not included in the domain of valid ratings.)


Item 3 Transfer

Includes transfer in and out of bed, bed to chair, in and out of shower or tub.

1 Independent/supervision: Is able to perform all transfers independently or with
prompting from carer. No hands-on assistance required. May be independent with
the use of a device.

3 Limited assistance: Requires hands-on assistance of one person to perform any
transfer of the day or night.

4 Other than two-person: Requires the use of a device for any of the transfers
performed in the day or night.

5 Two-person physical assist: Requires two people to perform any transfer during
the day or night.

(Note: a rating of 2 is not included in the domain of valid ratings.)


Item 4 Eating

Includes the tasks of cutting food, bringing food to the mouth and chewing and
swallowing of food. Does not include preparing the meal.

1 Independent/supervision: Is able to cut, chew and swallow food independently
or with supervision, once meal has been presented in the customary fashion. No
hands-on assistance required. If individual relies on parenteral or gastrostomy
feeding which they administer themself, then rate 1.




                     Victorian Outcome Measurement Training Manual—2nd edition —2003 41
2 Limited assistance: Requires hands-on assistance of one person to set–up or
assist in bringing food to mouth, or requires food to be modified (soft or staged
diet).

3 Extensive assistance/total dependence/tube fed: Person needs to be fed meal
by assistant or, if the individual does not eat or drink full meals by mouth but relies
on parenteral or gastrostomy feeding and does not administer feeds by themself.

Scoring

The total score is calculated as the sum of the four item scores, as per Table 4.4. If
any item is not completed, it must be treated as a zero score in the total.

Please note that, for items 1, 2 and 3, a score of 2 is not permitted.

Table 4.4 Calculating the summary score

 Item               Item description                     Possible       Summary score
                                                         item scores
 RUG-ADL item 1     Bed mobility                         1, 3–5

 RUG-ADL item 2     Toileting                            1, 3–5

 RUG-ADL item 3     Transfer                             1, 3–5

 RUG-ADL item 4     Eating                               1–3

 RUG-ADL total score                                                    4–18




The total score for the RUG-ADL will be calculated automatically by the Wellbeing
Reporting Tool.

References

Further information on the RUG-ADL can be found in:

Fries BE, Schneider DP, et al (1994): Refining a casemix measure for nursing
homes. Resource Utilisation Groups (RUG-III). Medical Care, 32, 668-685.

Williams BC (1994) Activities of daily living and costs in nursing homes. Health
Care Financing Review, 15, 117-135.

Buckingham W, Burgess P, Solomon S, Pirkis J & Eagar K (1998) Developing a
casemix classification for mental health services. Volume 1: Main report. Canberra:
Commonwealth Department of Health and Family Services




42                     Victorian Outcome Measurement Training Manual—2nd edition —2003
Victorian Outcome Measurement Training Manual—2nd edition —2003 43

								
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