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| Measure Information | 2023 Reporting Period | 2024 Reporting Period |
|---|---|---|
| Title | Global Malnutrition Composite Score | Global Malnutrition Composite Score |
| CMS eCQM ID | CMS986v1 | CMS986v2 |
| Short Name |
GMCS |
GMCS |
| NQF Number | 3592e | 3592e |
| Description |
This measure assesses the percentage of hospitalizations for adults aged 65 years and older prior to the start of the measurement period with a length of stay equal to or greater than 24 hours who received optimal malnutrition care during the current inpatient hospitalizations where care performed was appropriate to the patient's level of malnutrition risk and severity. Malnutrition care best practices recommend that for each hospitalization, adult inpatients are screened for malnutrition risk, assessed to confirm findings of malnutrition risk, and if identified with a "moderate" or "severe" malnutrition status in the current performed malnutrition assessment, receive a current "moderate" or "severe" malnutrition diagnosis and have a current nutrition care plan performed. |
This measure assesses the percentage of hospitalizations for adults aged 65 years and older at the start of the inpatient encounter during the measurement period with a length of stay equal to or greater than 24 hours who received optimal malnutrition care during the current inpatient hospitalization where care performed was appropriate to the patient's level of malnutrition risk and severity. Malnutrition care best practices recommend that for each hospitalization, adult inpatients are screened for malnutrition risk, assessed to confirm findings of malnutrition risk or for a hospital dietitian referral order, and if identified with a "moderate" or "severe" malnutrition status in the current performed malnutrition assessment, receive a current "moderate" or "severe" malnutrition diagnosis and have a current nutrition care plan performed. |
| Initial Population |
Valid Encounter: Inpatient hospitalizations during the measurement period with length of stay of 24 hours or more among individuals 65 years of age and older at the start of the measurement period. |
Valid Encounter: Inpatient hospitalizations during the measurement period with length of stay of 24 hours or more among individuals 65 years of age and older at the start of the inpatient encounter |
| Measure Steward | Academy of Nutrition and Dietetics | Academy of Nutrition and Dietetics |
| Measure Scoring | Continuous Variable measure | Continuous Variable measure |
| Measure Type | Intermediate Clinical Outcome measure | Intermediate Clinical Outcome measure |
| Improvement Notation |
Higher score indicates better quality of care. |
Higher score indicates better quality of care |
| Guidance |
The measure is constructed as an arithmetic average of four equally weighted component measures expressed as a percentage. The four measure populations used to calculate the Total Components Measure Score may differ. Component Measure 1: Inpatient hospitalizations for patients with a current screening for malnutrition risk performed at the time of admission. Component Measure 2: Inpatient hospitalizations for patients with a current assessment for malnutrition performed from an "at risk" finding in a current malnutrition screening. Component Measure 3: Inpatient hospitalizations for patients with a current malnutrition diagnosed as a result of a "moderate" or "severe" malnutrition status from a current malnutrition assessment. Component Measure 4: Inpatient hospitalizations for patients with a current nutrition care plan performed as a result of a "moderate" or "severe" malnutrition status from a current malnutrition assessment. The activities of the four component numerators do not need to be performed sequentially. This eCQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter with a length of stay of greater than or equal to 24 hours during the measurement period. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. |
This measure is constructed of four clinically eligible components that are aggregated as an arithmetic average of eligible hospitalizations and expressed as a percentage. The four populations used to calculate the four components may differ and the measure observations for the four components do not need to be performed sequentially. The initial population are hospitalizations during the measurement period for patients aged 65 years and greater with a length of stay of 24 hours and greater. Component Measure 1: Inpatient hospitalizations for patients with a current "Malnutrition Risk Screening" performed. Component Measure 2: Inpatient hospitalizations for patients with a current "Nutrition Assessment" performed from a "Malnutrition Screening At Risk Result" during the current hospitalization or a "Hospital Dietitian Referral" order from a physician or eligible clinician during the current hospitalization. For Component Measure 1 and Component Measure 2, only report LOINC code '84291-4 Nutrition and dietetics Risk assessment and screening note' when the RD or RDN performs both the "Malnutrition Risk Screening" and "Nutrition Assessment". Component Measure 3: Inpatient hospitalizations for patients with a current documented "Malnutrition Diagnosis" as a result of a current "Nutrition Assessment Status Moderately Malnourished" OR current "Nutrition Assessment Status Severely Malnourished". Component Measure 4: Inpatient hospitalizations for patients with a current "Nutrition Care Plan" performed as a result of a current "Nutrition Assessment Status Moderately Malnourished" OR current “Nutrition Assessment Status Severely Malnourished”. "Population 5 Measure Observation TotalMalnutritionComponentsScore" Calculations -For each hospitalization, Population Criteria 5 represents the subtotal of Measure Observations performed for Population Criteria 1, 2, 3, and 4. -For the reporting facility, the Population Criteria 5 Aggregate Operator 'Count' counts the number of eligible hospitalizations during the measurement period.
"Population 6 Measure Observation TotalMalnutritionCompositeScore as Percentage" Calculations: -For each hospitalization, Population Criteria 6 represents the sum of performed Measure Observations 1, 2, 3, and 4 divided by the number of clinically eligible denominators. -For the reporting facility, the Population Criteria 6 Aggregate Operator 'Average' averages the performance of each "TotalMalnutritionCompositeScore as Percentage" across all eligible hospitalizations during the measurement period. "TotalMalnutritionCompositeScore Eligible Denominators" is always 4 except in the following two instances: -If a "Malnutrition Risk Screening" was performed and a "Malnutrition Screening Not At Risk Result" was identified AND "Hospital Dietitian Referral" was not ordered, then the "TotalMalnutritionCompositeScore Eligible Denominators" is 1. -If a "Nutrition Assessment" was performed and a "Nutrition Status Not or Mildly Malnourished" was identified, then the "TotalMalnutritionCompositeScore Eligible Denominators" are 2. The "TotalMalnutritionCompositeScore Eligible Denominators" equals 4: -If a "Malnutrition Risk Screening" was performed AND a "Malnutrition Screening At Risk Result" was identified AND a "Nutrition Assessment" was not performed. -If a "Malnutrition Risk Screening" was not performed AND a "Nutrition Assessment" was not performed. -If a "Hospital Dietitian Referral" was ordered AND a "Nutrition Assessment" was not performed. -If a "Nutrition Assessment Status Moderately Malnourished" OR "Nutrition Assessment Status Severely Malnourished" was identified. This eCQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter with a length of stay of greater than or equal to 24 hours during the measurement period. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. |
| Next Version | CMS986v2 | No Version Available |
| Previous Version | No Version Available |
| Measure Information | |
|---|---|
| CMS eCQM ID | CMS986v1 |
| Short Name |
GMCS |
| NQF Number | 3592e |
| Description |
This measure assesses the percentage of hospitalizations for adults aged 65 years and older prior to the start of the measurement period with a length of stay equal to or greater than 24 hours who received optimal malnutrition care during the current inpatient hospitalizations where care performed was appropriate to the patient's level of malnutrition risk and severity. Malnutrition care best practices recommend that for each hospitalization, adult inpatients are screened for malnutrition risk, assessed to confirm findings of malnutrition risk, and if identified with a "moderate" or "severe" malnutrition status in the current performed malnutrition assessment, receive a current "moderate" or "severe" malnutrition diagnosis and have a current nutrition care plan performed. |
| Initial Population |
Valid Encounter: Inpatient hospitalizations during the measurement period with length of stay of 24 hours or more among individuals 65 years of age and older at the start of the measurement period. |
| Steward | Academy of Nutrition and Dietetics |
| Measure Scoring | Continuous Variable measure |
| Measure Type | Intermediate Clinical Outcome measure |
| Improvement Notation |
Higher score indicates better quality of care. |
| Guidance |
The measure is constructed as an arithmetic average of four equally weighted component measures expressed as a percentage. The four measure populations used to calculate the Total Components Measure Score may differ. Component Measure 1: Inpatient hospitalizations for patients with a current screening for malnutrition risk performed at the time of admission. Component Measure 2: Inpatient hospitalizations for patients with a current assessment for malnutrition performed from an "at risk" finding in a current malnutrition screening. Component Measure 3: Inpatient hospitalizations for patients with a current malnutrition diagnosed as a result of a "moderate" or "severe" malnutrition status from a current malnutrition assessment. Component Measure 4: Inpatient hospitalizations for patients with a current nutrition care plan performed as a result of a "moderate" or "severe" malnutrition status from a current malnutrition assessment. The activities of the four component numerators do not need to be performed sequentially. This eCQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter with a length of stay of greater than or equal to 24 hours during the measurement period. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. |
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