Brief description of measure ​CMS986: Global Malnutrition Composite Score: 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. Description of issue The measure developer received a question on the measure logic related to the Aggregate Functions, specifically "Count" for Population 5 and "Average" for Population 6. This complex Continuous Variable eCQM incorporates four components to assess care delivery for an Episode-of-Care (i.e., hospitalization). For each hospitalization, Population Criteria 5 (i.e., “TotalMalnutritionComponentsScore”) 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 hospitalizations during the measurement period. For each hospitalization, Population Criteria 6 (i.e., “Measure Observation TotalMalnutritionComponentsScore as Percentage” represents the final score for a single hospitalization using “TotalMalnutritionComponentsScore” (Population Criteria 5) and the Function “TotalMalnutritionComponentsScore Eligible Denominators”, which defines the number of clinically eligible denominators for each hospitalization as either 1, 2, or 4. For the reporting facility, the Population Criteria 6 Aggregate Operator “Average” represents the aggregated score across all hospitalizations during the measurement period. The measure developer recommends additional language to the Rate Aggregation and Guidance header sections to clarify the intent of Aggregate Functions in the "Measure Observation TotalMalnutritionComponentsScore" and "Measure Observation TotalMalnutritionComponentsScore as Percentage" and ease implementation. Goal of review Obtain technical feedback

Proposed solution Update the Rate Aggregation and Guidance narrative in the header to clarify the intent of aggregate operators in the "Measure Observation TotalMalnutritionComponentsScore" and "Measure Observation TotalMalnutritionComponentsScore as Percentage". CURRENT RATE AGGREGATE HEADER NARRATIVE: This measure is constructed as an arithmetic average of the four equally weighted measure populations. A single measure population is used to calculate the Total Components Measure Score and the Total Components Measure Score as Percentage. […] Measure Observation 2 = Encounters with Malnutrition Assessment / Encounters with Malnutrition Screening At Risk Result […] Measure Observation Total Components Measure Score = ("Measure Observation 1" + "Measure Observation 2" + "Measure Observation 3" + "Measure Observation 4") Measure Observation Total Components Measure Score as Percentage = 100 * ("Measure Observation 1" + "Measure Observation 2" + "Measure Observation 3" + "Measure Observation 4") / "Total Components Measure Score Eligible Denominators" Total Malnutrition Components Score Eligible Denominators equals: 1, if Malnutrition Risk Screening was performed and a Malnutrition Screening At Risk Result was not identified OR 2, if Malnutrition Assessment was performed and a Nutrition Assessment Result of Moderate or Severe Malnourishment was not identified OR 4, if Malnutrition Screening was not performed    OR Malnutrition Screening At Risk Result was identified AND a Nutrition Assessment was not performed    OR a Nutrition Assessment Result of Moderate or Severe Malnourishment was identified PROPOSED RATE AGGREGATE HEADER NARRATIVE: This measure is constructed of four equally weighted and clinically eligible components that are aggregated as an arithmetic average of hospitalizations. A single measure population is used to calculate the “TotalMalnutritionComponentsScore” and “TotalMalnutritionComponentsScore as Percentage”. […] Measure Observation 2 = Encounters with Nutrition Assessment / Encounters with Malnutrition Screening At Risk Result […] Population 5 Measure Observation TotalMalnutritionComponentsScore = ("Measure Observation 1" + "Measure Observation 2" + "Measure Observation 3" + "Measure Observation 4")  Population 6 Measure Observation TotalMalnutritionComponentsScore as Percentage = 100 * ("Measure Observation Total Components Measure Score ") / "Measure Observation TotalMalnutritionComponentsScore Eligible Denominators" “TotalMalnutritionComponentsScore Eligible Denominators” equals: 1, if Malnutrition Risk Screening was performed and a Malnutrition Screening Not At Risk Result was identified OR 2, if Nutrition Assessment was performed and a Nutrition Assessment Result of Nutrition Assessment Result Status Well Nourished was identified OR 4, if Malnutrition Risk Screening was not performed AND a Nutrition Assessment was not performed    OR Malnutrition Screening At Risk Result was identified AND a Nutrition Assessment was not performed AND a Malnutrition Diagnosis was not documented OR a Nutrition Assessment Result of Moderate or Severe Malnourishment was identified CURRENT GUIDANCE HEADER NARRATIVE: 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 2: Inpatient hospitalizations for patients with a current assessment for malnutrition performed from an "at risk" finding in a current malnutrition screening. […] PROPOSED GUIDANCE HEADER NARRATIVE: The measure is constructed as an arithmetic average of four equally weighted and clinically eligible components measures expressed as a percentage. The four measure populations used to calculate the Total Components Measure Score may differ. The activities of the four components do not need to be performed sequentially. […] Component Measure 2: Inpatient hospitalizations for patients with a current assessment for malnutrition performed from an "at risk" finding in a current malnutrition screening or from a physician or eligible clinical referral to a registered nutritionist. […] Population 5: “TotalComponentsMeasureScore” -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 hospitalizations during the measurement period. Population 6: “TotalMalnutritionComponentsScore as Percentage” -For each hospitalization, Population Criteria 6 represents the final score for a single hospitalization using Population Criteria 5 and the Function “TotalMalnutritionComponentsScore Eligible Denominators”, which defines the number of clinically eligible denominators for each hospitalization as 1, 2, or 4. -For the reporting facility, the Population Criteria 6 Aggregate Operator “Average” represents the aggregated score across all hospitalizations during the measurement period. “TotalMalnutritionComponentsScore Eligible Denominators” equals: 1, if Malnutrition Risk Screening was performed and a Malnutrition Screening Not At Risk Result was identified OR 2, if Nutrition Assessment was performed and a Nutrition Assessment Result of Nutrition Status Well Nourished was identified OR 4, if Malnutrition Risk Screening was not performed AND a Nutrition Assessment was not performed    OR Malnutrition Screening At Risk Result was identified AND a Nutrition Assessment was not performed AND a Malnutrition Diagnosis was not documented    OR a Nutrition Assessment Result of Moderate or Severe Malnourishment was identified […] Rationale for change This complex multi-component continuous variable eCQM has numerous rate aggregate operators that perform various functions, based on a single episode, or for the reporting facility to report aggregate performance for the measurement period. Providing additional educational information will improve measure comprehension and enhance implementation activities. The measure developer will update the Rate Aggregation and Guidance narrative in the header to clarify the intent of aggregate operators in the "Measure Observation TotalMalnutritionComponentsScore" and "Measure Observation TotalMalnutritionComponentsScore as Percentage".