Making the Health of the Nation Outcome Scale Work For Us

Published 30 April 2018. Last updated 8 April 2021.

This project added an additional multidisciplinary team meeting to the Older Persons Mental Health Team (OPMHT) schedule each week and adjusted the meeting agenda, to allow more time for mental health care reviews.


To increase the number of completed care plans developed in partnership with the client and carer, to 100 per cent within six months.


  • Prioritises what is important to the client and their carer, including psychological, functional, physical and social aspects of their recovery.
  • Provides a comprehensive assessment, multidisciplinary care planning and regular reviews in partnership with the client and their carer.
  • Upholds National Standards for Mental Health Services and the NSW Specialist Mental Health Services for Older People (SMHSOP) Community Model of Care Guideline.1-2


The OPMHT at South Eastern Sydney Local Health District (SESLHD) is a community service that provides specialised care for people aged over 65 with mental health concerns. The team includes psychiatrists, mental health nurses, allied health staff and other specialists, providing clients with a multidisciplinary approach to mental health care. The Health of the Nation Outcome Scale 65+ (HoNOS 65+) is a nationally mandated assessment tool for older people, using 12 scales that measure behaviour, impairment, symptoms and social functioning. It is used by the OPMHT during the initial assessment and during the development of interventions for the client’s care plan. The HoNOS 65+ is repeated every 13 weeks as part of the mental health care review, to measure and evaluate changes in the client’s presentation that can be attributed to the interventions in their care plan. The plan can then be amended according to the outcome of the review.

An audit of electronic medical records (eMR) conducted in October 2017 showed that care plans and mental health care reviews were often not completed for Sutherland OPMHT clients. At the time, only 12 per cent of Sutherland OPMHT clients had an updated care review, while only 31 per cent had a completed care plan. Discussions with staff found that care plans were not completed or updated because they were rarely used to guide client care. Staff also suggested there was not enough time in team meetings to carry out mental health care reviews every 13 weeks.

HoNOS 65+ assessments were completed by the team for all clients, as this information is required for activity based management and activity based funding purposes. When a HoNOS 65+ is due, a red warning clock is displayed against the client’s name in their eMR. However, prior to the project, results of the HoNOS 65+ assessments were not shared with the rest of the clinical team, or used as part of the assessment and care planning process or mental health care reviews.


From November 2017, an additional weekly multidisciplinary team meeting was introduced, increasing the number of reviews from one to two. Each meeting lasts for one hour and is attended by the whole multidisciplinary team. Previously, the meeting began by discussing new referrals and issues with existing clients during the week. This often left little or no time for mental health care reviews. As well as introducing an additional meeting, the agenda of the meeting was changed to exclude discussion of inpatients, as these patients were already discussed during videoconference meetings with the Older Persons Mental Health Inpatient Unit.

When discussing clients at a mental health care review, clinicians are encouraged to complete eMR documentation before the meeting and present the information using the ISBAR (Identify, Situation, Background, Assessment and Recommendation) format. This ensures all relevant information is presented in the most concise manner, allowing more reviews to be completed. HoNOS 65+ assessments are discussed by the team at the same time as the mental health care review is completed, improving the accuracy of the ratings.

At the start of the project, in-service training sessions on HoNOS 65+ were organised for the whole team, to improve the accuracy and consistency of assessments. Where possible, the team accompany colleagues on visits so clinicians can meet clients managed by other team members. In addition to improving leave cover, it means clinicians can make informed contributions to HoNOS 65+ assessments and mental health care reviews. Care plans are discussed and evaluated during each mental health care review and amendments made as required.


Implementation – The project is ready for implementation or is currently being implemented, piloted or tested.


October 2017 – April 2018

Implementation sites

Sutherland Older Persons Community Mental Health Team, SESLHD


Clinical Excellence Commission, Clinical Leadership Program


A full evaluation will be undertaken in 2018, measuring the following outcomes:

  • percentage of clients with care plans completed (target 100 per cent)
  • percentage of clients with quarterly care reviews completed (target 100).
  • number of HoNOS reviews completed (target 100 per cent)
  • attendance at multidisciplinary team meetings
  • staff feedback on new processes.

Lessons learnt

Even though the Sutherland OPMHT is a small team, it took a surprisingly long time to get everyone together to discuss the project and agree on the project aim and primary and secondary drivers. It is recommended that these discussions with relevant stakeholders start much earlier in the process.


  1. Commonwealth of Australia. National Standards for Mental Health Services 2010. Canberra, ACT: The Department of Health; 2010.
  2. NSW Ministry of Health. Specialist Mental Health Services for Older People (SMHSOP) Community Model of Care Guideline. Guideline GL2017_003. North Sydney, NSW: NSW Health; 2017.

Further reading


Brian Tomney
Clinical Nurse Consultant, Older Persons Mental Health Team
The Sutherland Hospital and Community Health Service
South East Sydney Local Health District
Phone: 02 9540 7800

Sally Peters
Nurse Manager and Leadership Development Facilitator
South East Sydney Local Health District
Phone: 02 9540 8270


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Mental healthIntegrated careAged healthSouth Eastern SydneyMetropolitanClinical Leadership Program
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