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How to Implement the Global Malnutrition Composite Score eCQM

The Global Malnutrition Composite Score (GMCS) eCQM is the first nutrition-related quality measure to be introduced into CMS’s Inpatient Quality Reporting (IQR) program. It is available now as one of the optional measures you can choose in order to meet your self-selected eCQM requirements.

But this measure is not like all the others. It’s a continuous variable measure, NOT a proportion measure. In mathematical terms, that means your score is an aggregate of individual values, and each of those individual values can fall anywhere along a continuous scale. In layman’s terms, it means that GMCS does not have the traditional one numerator, one denominator framework you’ve come to know and love.

But don’t stress: this is your complete guide to getting started with the Global Malnutrition Composite Score eCQM. We’re here to break down what the measure is, why it matters, and how it works—plus some handy tips to help your entire team (and it will take a team!) get this measure off to a healthy start.

What Does the Global Malnutrition Composite Score eCQM Measure?

The Global Malnutrition Composite Score eCQM measures the percentage of adults aged 65 years and older who receive “optimal nutrition care” during their inpatient stay at your hospital.

“Optimal nutrition care” is defined under this measure as a 4-component framework. The first component is a malnutrition risk screening. At minimum, all patients ages 65 and older and hospitalized for 24 hours or more, should receive this component of care. If a patient is determined to be at risk, he or she should advance to the second component, a nutrition assessment. If the patient is then deemed moderately to severely malnourished, he or she should then advance to the third and fourth components, a malnutrition diagnosis and a documented care plan.

GMCS-blog-arrows

The GMCS eCQM then aggregates and calculates your rate of performance across these 4 distinct components of care to arrive at a final score. A high percentage is the goal—the higher your rate, the more patients are getting “optimal nutrition care.”

Why Do We Need the GMCS Measure Now?

Malnutrition is one of the costliest conditions for patients today, both in financial terms, and in terms of quality of life. Patients with malnutrition are 5 times more likely to die in the hospital as compared to the general patient population. They have a 56% higher likelihood of 30-day readmissions, and their hospital stay typically costs 34% more than a non-malnourished patient’s stay.

But malnutrition is also one of the most overlooked conditions. Currently, only 9% of hospitalized patients are officially diagnosed with malnutrition. However, studies show that as many as 20-50% of hospitalized patients are at risk for or have malnutrition.

Closing this gap could be a key victory in the fight to improve patient outcomes, reduce readmissions, and lower costs. In fact, the data shows that malnourished patients who have a proper nutrition care plan have a 24% relative reduction in readmission risk than patients who don’t. One 2017 study, cited by the Malnutrition Quality Improvement Initiative, showed how a 4-hospital system was able to generate $4.8 million in cost savings by implementing a nutrition-focused quality improvement program.

Now CMS wants to replicate that success nationwide by incentivizing hospitals to screen, diagnose, and treat malnutrition more efficiently and effectively through the aforementioned “optimal nutrition care” framework.

How the GMCS eCQM Works

!

Specification Update

Before we get started, please note that CMS has recently recognized a flaw in the measure observation logic and has published an updated logic pathway to amend this. Make sure you refer to it as you’re building out your measure.

 

Measure Population

Layman’s Description:

To be included in the Measure Population (aka the Initial Patient Population), the patient must be 65 years of age or older and have a length of stay equal to or greater than 24 hours.

Simplified Logic:

  • Inpatient encounter during reporting period
  • Age ≥ 65 years
  • Length of stay ≥ 24 hours

Workflow:

IPP/Measure Population

Data Element

Data Capture Workflow

Code Type

Inpatient Encounter

Admission/Registration

SNOMED

 

Measure Population Exclusions

There are no exclusions for this measure. Any encounter that falls within your measure population should immediately be funneled into your first Measure Observation.

Measure Observations 1-4: Optimal Nutrition Care Components

Layman’s Description:

There are 6 measure observations (MOs) total. The first 4 ask you to track if the “optimal nutrition care” framework was completed during a patient encounter.

  • If the standard of care was completed, you will give it a score of 1.
  • If the standard of care was not completed, you will give it a score of 0.
  • If the standard of care was not completed because the patient did not qualify for it, you will still score it as a 0. However, that component will not be counted against you into the encounter’s eligible denominator (see next section).

Component

What’s Required

Who Qualifies

Measure Observation 1 (MO1)

Malnutrition Risk Screening and Identified Result

All patients in the Measure Population

Measure Observation 2 (MO2)

Nutrition Assessment and Identified Status

All patients who have either:

·      Hospital dietitian referral

OR

·      At-Risk Result from MO1

Measure Observation 3 (MO3)

Malnutrition Diagnosis

All patients who have Moderately or Severely Malnourished Result from MO2

Measure Observation 4 (MO4)

Nutrition Care Plan

 

Simplified Logic:

  • Completed = 1
  • Not Completed = 0
  • Not Completed Because Patient Did Not Qualify = 0

Workflow: 

Measure Observation

Data Elements

Data Capture Workflow

Code Type

1

Malnutrition Risk Screening (At risk or Not at risk) 

Clinical Documentation

LOINC
SNOMED

Hospital Dietitian Referral

Orders
Clinical Documentation

SNOMED

2

Malnutrition Risk Screening (At risk)

Clinical Documentation

SNOMED

Nutrition Assessment (Not, Mildly, Moderately, Severely Malnourished)

Clinical Documentation

LOINC

SNOMED

3

Nutrition Assessment Status (Moderately or  Severely Malnourished)

Clinical Documentation

SNOMED

Malnutrition Diagnosis

Coding
Problem List

ICD

SNOMED

4

Nutrition Assessment (Moderately or Severely Malnourished) 

Clinical Documentation

ICD

SNOMED

Nutrition Care Plan 

Clinical Documentation

SNOMED

  

Eligible Denominator

Layman’s Description:

The eligible denominator tallies up how many of the 4 Measure Observations should be performed based on the patient’s clinical needs. This ensures that patients who are cleared during the malnutrition risk screening and/or assessment are not counted against you in your composite score.

Simplified Logic:

Each patient encounter should total up to 1 of 4 possible denominators:

  • Eligible denominator = 1
    • The patient is not identified as at risk after the Malnutrition Risk Screening AND a Hospital Dietitian Referral was not ordered (i.e., only MO 1 was required)
  • Eligible denominator = 2
    • The patient is not identified with moderate or severe malnutrition after the Nutrition Assessment (i.e., only MO 1 and MO 2 were required)
  • Eligible denominator = 3 & 4
    • The patient was identified with moderate or severe malnutrition after the Nutrition Assessment (i.e., all 4 MOs were required)
    • MO1 and MO2 was not performed (i.e., the patient was not moved through the optimal care framework at all)
    • A Hospital Dietitian Referral exists but a Nutrition Assessment was not performed (i.e., the patient was not moved through the optimal care framework correctly)

Measure Observations 5-6: Scoring

Layman’s Description:

Now it’s time to tally your results. MO5 is the sum of your scores for MOs 1-4 during the patient encounter.

MO6 is your rate of compliance based on your MO5 sum divided by the patient’s eligible denominator. The ultimate goal for MO6 is to score 100% - that means you did everything you were supposed to do in that particular patient encounter.

Simplified Logic:

Component

Name

Equation

Measure Observation 5 (MO5)

Total Malnutrition Components Score

MO1 + MO2 + MO3 + MO4

Measure Observation 6 (MO6)

Total Malnutrition Components Score as Percentage

100 * (MO5 / Eligible Denominator)

 

Example 1:

In MO1, the patient screens as “not at risk” and no hospital dietitian referral (HDR) is present, so they only qualify for MO1 in their eligible denominator.

Measure Observation

Result

Score

Eligible Denominator

MO1 – Screening

Not At Risk
No HDR

1

1

MO2- Assessment

n/a

0

0

MO3 - Diagnosis

n/a

0

0

MO4 - Care Plan

n/a

0

0

MO5 - Total Score

1+0+0+0 = 1

MO6 - Total Score as Percentage

100 * (1/1) = 100%

 

Example 2:

The patient is diagnosed as severely malnourished, but a care plan is never put into place. So, they qualified for all 4 MOs in their denominator, but the care team failed to deliver on all 4.

Measure Observation

Result

Score

Eligible Denominator

MO1 – Screening

At Risk

1

1

MO2- Assessment

Severely Malnourished

1

1

MO3 - Diagnosis

Severe Malnutrition

1

1

MO4 - Care Plan

None

0

1

MO5 - Total Score

1+1+1+0 = 3

MO6 - Total Score as Percentage

100 * (3/4) = 75%

 

Example 3:

The patient is deemed not at risk during the screening, however an HDR is present. The HDR leads to an assessment by a dietitian, during which it’s determined the patient is only mildly malnourished. Thus, the patient qualifies for both MO1 and MO2 in their denominator.

Measure Observation

Result

Score

Eligible Denominator

MO1 – Screening

Not At Risk
HDR Present

1

1

MO2- Assessment

Mildly Malnourished

1

1

MO3 - Diagnosis

n/a

0

0

MO4 - Care Plan

n/a

0

0

MO5 - Total Score

1+1+0+0 = 2

MO6 - Total Score as Percentage

100 * (2/2) = 100%

 

Example 4:

The patient was not screened at all. They qualified for all 4 MOs in their denominator, but the care team failed to deliver on all 4.

Measure Observation

Result

Score

Eligible Denominator

MO1 – Screening

At Risk

0

1

MO2- Assessment

Severely Malnourished

0

1

MO3 - Diagnosis

Severe Malnutrition

0

1

MO4 - Care Plan

None

0

1

MO5 - Total Score

0+0+0+0 = 0

MO6 - Total Score as Percentage

100 * (0/4) = 0%

 

Aggregate Performance Score

Layman’s Description:

So far, we have discussed how to score an individual patient encounter. To arrive at your hospital’s aggregate performance score, add together all your individual MO6 scores, then divide it by the number of encounters being measured. The closer you are to 100%, the better.

Example:

Now let's just use the top 3 examples (not the one with 0%). Our aggregate performance score would be as follows:

Encounter

MO6 Score

Encounter 1

100%

Encounter 2

75%

Encounter 3

100%

Sum of MO6 Scores

100 + 75 + 100 = 275

Aggregate Performance

275/3 encounters = 92%

 

Tips for Getting Started with the Global Malnutrition Composite Score eCQM

  • Not all EHRs are set up to fully support this measure. Start by reviewing your EHR to see if the GMCS measure’s data mapping points and standardized terminology are in place. If they’re not, schedule a meeting with your vendor to find out when they can have it set up for you.
  • Your dietitians are crucial to the success of this measure, but because this is the first nutrition-focused eCQM, they may not have a lot of experience with the requirements that come with quality reporting – such as adhering to specific workflows and EHR inputs. Invest the time to thoroughly train and educate them on why these requirements matter, their role in the measure’s success, and the day-to-day processes they will be expected to implement.
  • It's not just your dietitians who will be impacted by this measure. In order to have high scores, a number of different disciplines will likely be touching the patient at different stages of the encounter. It’s a good idea to build a GMCS task force that comprises staff champions from every touchpoint to make sure your workflow requirements are being disseminated across the patient experience.
  • The Commission on Dietetic Registration has created an easy-to-use GMCS scoring calculator. It’s a great tool that can help you practice and learn how to score patient encounters as you get the hang of this measure.
  • Schedule a time to talk to Medisolv. The GMCS eCQM is available now in our ENCOR for Electronic Hospital Measures software, so you can get the measure up and running. Click here to send us a message.

More “How To” Guides from Medisolv

Need help getting started with CMS’s other new measures? Check out these latest “how to implement” guides from Medisolv:



 

Medisolv Can Help

This is a big year for Quality. Medisolv can help you along the way. Along with award-winning software, you receive a Clinical Quality Advisor that helps you with all of your technical and clinical needs.

We consistently hear from our clients that the biggest differentiator between Medisolv and other vendors is the level of one-on-one support. Especially if you use an EHR vendor right now, you’ll notice a huge difference.

  • We help troubleshoot technical and clinical issues to improve your measures.
  • We keep you on track for your submission deadlines and ensure you don’t miss critical dates.
  • We help you select and set up measures that make sense based on your hospital’s situation.
  • You receive one Clinical Quality Advisor that you can call anytime with questions or concerns. 

Contact us today.

 

 

Erin Heilman

Erin Heilman is the Vice President of Marketing for Medisolv, Inc.

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