Malnutrition Care Score

This measure assesses the percentage of eligible encounters of adults aged 18 years and older at the start of the eligible encounter during the measurement period, with a length of stay equal to or greater than 24 hours, who received optimal malnutrition care where care performed was appropriate to the patient's level of malnutrition risk and severity. Malnutrition care best practices recommend that for each eligible encounter, adult inpatients are (1) screened for malnutrition risk or for a dietitian referral order to be placed, (2) assessed by a registered dietitian (RD) or registered dietitian nutritionist (RDN) to confirm findings of malnutrition risk, and if identified with a "moderate" or "severe" malnutrition status in the current performed nutrition assessment, (3) receive a "moderate" or "severe" malnutrition diagnosis by a physician or eligible clinician as defined by the Centers for Medicare & Medicaid Services (CMS), and (4) have a current nutrition care plan performed by an RD/RDN.

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For the reporting facility, the Aggregate Operator 'Count' includes the number of eligible encounters during the measurement period. For the reporting facility, the Aggregate Operator 'Average' averages the performance of each "Total Malnutrition Care Score as Percentage" across all eligible encounters during the measurement period.

Malnutrition has been documented in approximately one-third of patients in developed countries upon admission to the hospital, and, if left untreated, can significantly impact important clinical outcomes (Mogensen et al., 2019). Adult patients with malnutrition have a significantly longer hospital length of stay (LOS) (Hudson, Chittams, Griffith, & Compher, 2018 and Mosquera et al., 2016) and significantly more patients with malnutrition have a LOS of greater than 7 days when compared to their well-nourished counterparts. Additionally, both higher rates of 30-day readmission and a significantly higher likelihood of 30-day readmission are observed in these patients (Mogensen et al., 2019; Hiller, Shaw, & Fabri, 2016; Mosquera et al., 2016). Lastly, hospitalized adults with malnutrition have an increased likelihood of death within 90 days of discharge (Hiller, Shaw, & Fabri, 2016). These consequences demonstrate the importance of addressing malnutrition in hospitalized patients to improve outcomes. 

The components of this measure are supported by clinical guidance that recommends (1) malnutrition screening for patients admitted into the acute inpatient care setting; (2) nutrition assessment for patients identified at risk for malnutrition or with a dietitian referral order to form the basis for appropriate nutrition interventions; (3) appropriate recognition, diagnosis, and documentation of the nutrition status of a patient in order to (4) address their condition with an appropriate plan of care and communicate patient needs to other care providers (Academy of Nutrition and Dietetics, 2017).

The process for risk identification, assessment, diagnosis, and treatment of malnutrition necessitates a multi-disciplinary care team that begins with the identification of an initial risk population for a more thorough assessment by the RD/RDN. The RD/RDN, in turn, provides the necessary treatment recommendations to address nutrition problems utilizing a nutrition diagnosis and care plan, along with the clinical indicators that inform a medical diagnosis of malnutrition completed by a physician or eligible clinician as defined by CMS. The four measure observations individually provide a portion of the necessary information on the quality of care for patients at risk for or with malnutrition. Therefore, the four components are summed and averaged according to a patient’s degree of malnutrition and/or malnutrition risk to determine an encounter-level Malnutrition Care Score. 

High performance on this measure requires malnutrition risk screening and/or referral to RDNs for appropriate nutrition assessment for identified patients during the current hospitalization. For patients identified with moderate or severe malnutrition by the nutrition assessment, best practice also recommends a medical diagnosis by a physician or other eligible clinician and the execution of the nutrition care plan by an RD/RDN. Evidence demonstrates that implementing a standardized protocol for screening, assessment, diagnosis, and care planning results in better identification of patients with malnutrition and subsequent improvements in rates of associated nutrition interventions. Outcomes modeling demonstrates benefits to patient outcomes, including reduced risk of 30-day readmissions, length of hospital stays, and complications, as well as improved quality of life after hospitalization (Sriram et al., 2016).

American Society for Parenteral and Enteral Nutrition (ASPEN) clinical guidelines on nutrition screening, assessment, and intervention in adults indicate that screening for nutrition risk is suggested for hospitalized patients (Mueller, Compher, Druyan, & ASPEN Board of Directors, 2011). 

This guideline places nutrition assessment and screening in the context of intervention as part of nutrition care. Screening those individuals at risk for malnutrition is the first step in nutrition care as risk for malnutrition, identified by nutrition screening, is associated with longer length of hospital stay, complications, and mortality. Malnutrition screening is also a predictor of mortality risk. 

Malnourished patients, identified by nutrition assessment tools, have more complications and longer hospitalizations than do patients with optimal nutrition status. Such patients, identified by nutrition assessment tools, have more infectious and noninfectious complications, longer hospital length of stay, and greater mortality. 

Nutrition intervention is recommended for patients identified by assessment as at risk for malnutrition or malnourished. Nutrition intervention with associated monitoring and evaluation plans in patients identified as at risk for malnutrition or malnourished improves clinical outcomes. Nutrition interventions and their associated monitoring and evaluation plans in malnourished patients are associated with improved nutrition status, nutrient intake, physical function, and quality of life. Hospital readmissions, inpatient length of stay, and complications were reduced with increased nutrition support interventions.

Increased score indicates improvement

Reference Type: Citation

Reference Text: 'Academy of Nutrition and Dietetics. The Nutrition Care Process Model. Published 2017. Accessed June 12, 2023. https://www.ncpro.org/pubs/2020-encpt-en/ncp-model'

Reference Type: Citation

Reference Text: 'Hiller, L.D., Shaw R.F., & Fabri P.J. (2017) Difference in composite end point of readmission and death between malnourished and nonmalnourished veterans assessed using Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition clinical characteristics. Journal of  Parenteral and Enteral Nutrition, 41(8), 1316-1324. https://doi.org/10.1177/0148607116668523'

Reference Type: Citation

Reference Text: 'Hudson, L., Chittams, J., Griffith, C., & Compher, C. (2018) Malnutrition identified by Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition is associated with more 30-day readmissions, greater hospital mortality, and longer hospital stays: a retrospective analysis of nutrition assessment data in a major medical center. Journal of Parenteral and Enteral Nutrition, 42(5), 892-897. https://doi.org/10.1002/jpen.1021'

Reference Type: Citation

Reference Text: 'Mogensen, K.M., Malone, A., Becker, P., Cutrell, S., Frank, L., Gonzales, K., ... Guenter, P.  (2019) Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition Consensus Malnutrition Characteristics: Usability and Association With Outcomes. Nutrition in Clinical Practice, 34 (5),  657–665. https://doi.org/10.1002/ncp.10310'

Reference Type: Citation

Reference Text: 'Mosquera, C., Koutlas, N.J., Edwards, K.C., Strickland, A., Vohra, N. A., Zervos, E.E., & Fitzgerald, T.L. (2016). Impact of malnutrition on gastrointestinal surgical patients. Journal of Surgical Research. 205(1), 95-101. https://doi.org/10.1016/j.jss.2016.05.030'

Reference Type: Citation

Reference Text: 'Mueller C, Compher C, Druyan M.E., & the ASPEN Board of Directors. (2011). ASPEN clinical guidelines on nutrition screening, assessment, and intervention in adults: Journal of Parenteral and Enteral Nutrition, 35(1), 16-24. https://doi.org/10.1177/0148607110389335'

Reference Type: Citation

Reference Text: 'Sriram K, Sulo S, VanDerBosch G, Partridge J, Feldstein J, Hegazi RA, Summerfelt WT. (2016) A comprehensive nutrition-focused quality improvement program reduces 30-day readmissions and length of stay in hospitalized patients. Journal of Parenteral and Enteral Nutrition, 41(3), 384-391. https://doi.org/10.1177/0148607116681468'

Malnutrition Risk Screening - the process of identifying and referring those individuals and populations who are at risk for nutrition-related problems, are appropriate for nutrition care services, and would benefit from nutrition interventions. For the inpatient or acute care setting, the Malnutrition Risk Screening can be completed by any eligible healthcare clinician as defined by local, state and federal guidelines. 

Nutrition Assessment - a systematic approach for collecting, classifying, and synthesizing important and relevant data to describe nutritional status related nutritional problems, and their causes. This assessment includes review of the "whole" patient and evaluates the anthropometrics (i.e., body measurements and proportions), biochemical data (i.e., laboratory findings), clinical observations, and diet history (also known as 'ABCD'). For the inpatient or acute care setting, the Nutrition Assessment is performed by a RD or RDN. 

Malnutrition Diagnosis - a documented diagnosis that identifies and describes a specific nutrition problem(s) that can be resolved or improved through nutrition intervention(s), monitoring, and evaluation. For the inpatient or acute care setting, the Malnutrition Diagnosis is identified by the physician or other eligible clinician as defined by CMS based on the scope of practice regulations within the respective state, commonwealth, or territory of care delivery. 

Nutrition Care Plan - a documented plan based on information collected during the Nutrition Assessment of individualized nutrition recommendations, interventions, and monitoring and evaluation plans that are directed toward resolving the Malnutrition Diagnosis by altering or eliminating the nutrition etiology. The Nutrition Care Plan may encompass the interventions of Food and Nutrient Delivery, Nutrition Education, Nutrition Counseling, Coordination of Nutrition Care, and Population Based Nutrition Action, along with a plan for monitoring and evaluation, and is documented by the RD or RDN.

This measure is constructed of four clinically eligible components that are aggregated as an arithmetic average of eligible encounters 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. 

This eCQM is an episode-based measure. An episode is defined as each eligible encounter with a length of stay of greater than or equal to 24 hours among individuals 18 years of age and older at the start of the inpatient encounter. 

This version of the eCQM uses QDM version 5.6. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

TBD

Eligible encounters during the measurement period with length of stay of 24 hours or more among individuals 18 years of age and older at the start of the inpatient encounter

Equals Initial Population

Encounters with a discharge disposition for hospice care or with a hospice care order during the inpatient qualifying encounter

Component Measure 1: Eligible encounters for patients with a current "Malnutrition Risk Screening" performed by an eligible healthcare clinician or a Dietitian Referral. 

"Measure Observation 1" is "Encounters with Malnutrition Risk Screening and Identified Result or a Dietitian Referral" 

"Measure Observation 1" identifies eligible encounters where a "Malnutrition Risk Screening" was performed or authored during the encounter (including preceding observation or emergency department encounters) with an identified "Malnutrition Screening Finding of Not At Risk Result" or "Malnutrition Screening Finding of At Risk Result". It also identifies an eligible encounter where there is a Dietitian Referral, whether there is a "Malnutrition Risk Screening" performed or not.

Component Measure 2: Eligible encounters for patients with a documented "Nutrition Assessment" performed by an RD/RDN, after a "Malnutrition Screening Finding of At Risk Result" or a "Dietitian Referral" order from a physician or eligible clinician during the current encounter. 

"Measure Observation 2" is "Encounter With Most Recent Nutrition Assessment And Identified Status" 

"Measure Observation 2" identifies eligible encounters where a "Nutrition Assessment" was performed or authored during the encounter (including preceding observation or emergency department encounters) with an identified "Nutrition Assessment Status Finding of Well Nourished or Not Malnourished or Mildly Malnourished", "Nutrition Assessment Status Finding of Moderately Malnourished", or "Nutrition Assessment Status Finding of Severely Malnourished".

Component Measure 3: Eligible encounters for patients with a documented "Malnutrition Diagnosis" based on the most recent finding of "Nutrition Assessment Status Finding of Moderately Malnourished" or "Nutrition Assessment Status Finding of Severely Malnourished". 

"Measure Observation 3" is "Encounters with Malnutrition Diagnosis"

"Measure Observation 3" identifies eligible encounters where a "Malnutrition Diagnosis" was active during the encounter (including preceding observation or emergency department encounters).

Component Measure 4: Eligible encounters for patients with a documented "Nutrition Care Plan" based on the most recent finding of "Nutrition Assessment Status Finding of Moderately Malnourished" or “Nutrition Assessment Status Finding of Severely Malnourished”. 

“Measure Observation 4” is “Encounters with Nutrition Care Plan”

"Measure Observation 4" identifies eligible encounters where a "Nutrition Care Plan" was performed or authored during the encounter (including preceding observation or emergency department encounters). 

Population 5 "Measure Observation Total Malnutrition Components Score" Calculations
-For each eligible encounter, Population Criteria 5 represents the subtotal of Measure Observations performed for Population Criteria 1, 2, 3, and 4. Possible values may be 0, 1, 2, 3, or 4.
 
Population 5 "Measure Observation Total Malnutrition Components Score" is ("Measure Observation 1" plus "Measure Observation 2" plus "Measure Observation 3" plus "Measure Observation 4")

Population 6 "Measure Observation Total Malnutrition Care Score as Percentage" Calculations:
-For each eligible encounter, Population Criteria 6 represents the sum of performed Measure Observations 1, 2, 3, and 4 divided by the number of clinically eligible occurrences. 

Population 6 "Measure Observation Total Malnutrition Care Score as Percentage" is 100 multiplied by ("Measure Observation Total Malnutrition Components Score" divided by "Total Malnutrition Care Score Eligible Occurrences"). Possible values may be 0, 50, 75, or 100 percent. 

"Total Malnutrition Care Score Eligible Occurrences" is always 4 except in the following instances:
-The "Total Malnutrition Care Score Eligible Occurrences" is 1 if
---A "Malnutrition Risk Screening" was performed and a "Malnutrition Screening Finding of Not At Risk Result" was identified and "Dietitian Referral" was not ordered.
- The "Total Malnutrition Care Score Eligible Occurrences" is 2
---If the most recent "Nutrition Assessment" performed has a result of "Nutrition Status Finding of Well Nourished or Not Malnourished or Mildly Malnourished".
--- A "Malnutrition Risk Screening" was performed and a "Malnutrition Screening Finding of Not At Risk Result" was identified and "Dietitian Referral" was ordered or a "Malnutrition Risk Screening" was performed and a "Malnutrition Screening Finding of At Risk Result" was identified but the “Nutrition Assessment” was not performed.

For every patient evaluated by this measure also identify payer, race, ethnicity and sex

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