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 recommends including all clinically eligible Measure Observation activities in the evaluation of Measures Observations 1, 2, 3, and 4 that are performed in an Emergency Department or Observation Services associated with the hospitalization. Measure Observation activities may be performed in pre-admission settings that meet the intent of the measure and should be considered performed activities. Ex: Admitting orders for Dietician Referral or Consultation from the Emergency Department, an Observation Status to Acute Care Admissions, and Emergency Department patients awaiting hospital bed availability seen by multi-unit admission nurses. By including the "Global.HospitalizationWithObservation" function from the MAT Global Common Library, component activities performed for hospitalizations during immediately prior Emergency Department or Observation Services care will evaluated. Goal of review Obtain technical feedback

Proposed solution Add Value Sets for “Emergency Department Visit” and “Observation Services” and update the “Global Malnutrition Encounter”. PROPOSED VALUE SETS: valueset "Emergency Department Visit" (OID: 2.16.840.1.113883.3.117.1.7.1.292) valueset "Observation Services" (OID: 2.16.840.1.113762.1.4.1111.143) CURRENT LOGIC: define "Global Malnutrition Encounter":   ["Encounter, Performed": "Encounter Inpatient"] InpatientEncounter     where InpatientEncounter.relevantPeriod during day of "Measurement Period"       and duration in hours of InpatientEncounter.relevantPeriod >= 24       and AgeInYearsAt(date from start of "Measurement Period")>= 65 define "Encounter with Malnutrition Risk Screening":   "Global Malnutrition Encounter" GlobalMalnutritionEncounter     with ["Assessment, Performed": "Malnutrition Risk Screening"] MalnutritionRiskScreening       such that MalnutritionRiskScreening.authorDatetime during GlobalMalnutritionEncounter.relevantPeriod define "Encounter with Malnutrition Screening At Risk Result":   "Global Malnutrition Encounter" GlobalMalnutritionEncounter     with ["Assessment, Performed": "Malnutrition Screening At Risk Result"] MalnutritionScreeningResult       such that MalnutritionScreeningResult.authorDatetime during GlobalMalnutritionEncounter.relevantPeriod define "Encounter with Malnutrition Assessment":   "Global Malnutrition Encounter" GlobalMalnutritionEncounter     with ["Assessment, Performed": "Malnutrition Assessment"] MalnutritionAssessment       such that MalnutritionAssessment.authorDatetime during GlobalMalnutritionEncounter.relevantPeriod define "Encounter with Nutrition Assessment Malnourishment Result":   "Global Malnutrition Encounter" GlobalMalnutritionEncounter     with "Nutrition Assessment Result of Moderate or Severe Malnourishment" AssessmentResultMalnourishment       such that AssessmentResultMalnourishment.relevantDatetime during GlobalMalnutritionEncounter.relevantPeriod define "Nutrition Assessment Result of Moderate or Severe Malnourishment":   ["Assessment, Performed": "Malnutrition Assessment"] AssessmentResultMalnourishment     where ( AssessmentResultMalnourishment.result in "Nutritional Status Moderately Malnourished"         or AssessmentResultMalnourishment.result in "Nutritional Status Severely Malnourished"     ) define "Encounter with Malnutrition Diagnosis":   "Global Malnutrition Encounter" GlobalMalnutritionEncounter     with ["Diagnosis": "Malnutrition Diagnosis"] MalnutritionDiagnosis       such that MalnutritionDiagnosis.prevalencePeriod starts during GlobalMalnutritionEncounter.relevantPeriod define "Encounter with Nutrition Care Plan":   "Global Malnutrition Encounter" GlobalMalnutritionEncounter     with ["Intervention, Performed": "Nutrition Care Plan"] NutritionCarePlan       such that NutritionCarePlan.authorDatetime during GlobalMalnutritionEncounter.relevantPeriod PROPOSED LOGIC: define "Global Malnutrition Encounter":   ["Encounter, Performed": "Encounter Inpatient"] InpatientEncounter     where HospitalizationWithObservation.relevantPeriod during day of "Measurement Period"       and duration in hours of InpatientEncounter.relevantPeriod >= 24       and AgeInYearsAt(date from start of "Measurement Period")>= 65 define "Encounter with Malnutrition Risk Screening":   "Global Malnutrition Encounter" GlobalMalnutritionEncounter     with ["Assessment, Performed": "Malnutrition Risk Screening"] MalnutritionScreening       such that MalnutritionRiskScreening.authorDatetime during Global."HospitalizationWithObservation" ( GlobalMalnutritionEncounter ) define "Encounter with Malnutrition Screening Not At Risk Result":   "Global Malnutrition Encounter" GlobalMalnutritionEncounter     with ["Assessment, Performed": "Malnutrition Screening At Risk Result"] MalnutritionScreeningNotAtRiskResult       such that MalnutritionScreeningResult.authorDatetime during Global."HospitalizationWithObservation" ( GlobalMalnutritionEncounter ) define "Encounter with Malnutrition Screening At Risk Result":   "Global Malnutrition Encounter" GlobalMalnutritionEncounter     with ["Assessment, Performed": "Malnutrition Screening At Risk Result"] MalnutritionScreeningResult       such that MalnutritionScreeningResult.authorDatetime during Global."HospitalizationWithObservation" ( GlobalMalnutritionEncounter ) define "Encounter with Malnutrition Screening Result Identified":   "Global Malnutrition Encounter" GlobalMalnutritionEncounter     with ["Assessment, Performed": "Malnutrition Screening Result Identified"] MalnutritionScreeningResultIdentified       such that MalnutritionScreeningResultIdentified.authorDatetime during Global."HospitalizationWithObservation" ( GlobalMalnutritionEncounter ) define "Encounter with Malnutrition Assessment":   "Global Malnutrition Encounter" GlobalMalnutritionEncounter     with ["Assessment, Performed": "Nutrition Assessment"] NutritionAssessment       such that MalnutritionAssessment.authorDatetime during Global."HospitalizationWithObservation" ( GlobalMalnutritionEncounter ) define "Encounter with Nutrition Assessment Malnourishment Result":   "Global Malnutrition Encounter" GlobalMalnutritionEncounter     with "Nutrition Assessment Result of No or Mild Malnourishment" AssessmentNoOrMildResultMalnourishment       such that AssessmentNoOrMildResultMalnourishment.relevantDatetime during Global."HospitalizationWithObservation" ( GlobalMalnutritionEncounter ) define "Encounter with Nutrition Assessment Malnourishment Result":   "Global Malnutrition Encounter" GlobalMalnutritionEncounter     with "Nutrition Assessment Result of Moderate or Severe Malnourishment" AssessmentResultMalnourishment       such that AssessmentResultMalnourishment.relevantDatetime during Global."HospitalizationWithObservation" ( GlobalMalnutritionEncounter ) define "Encounter with Nutrition Assessment Result Identified":   "Global Malnutrition Encounter" GlobalMalnutritionEncounter     with ["Assessment, Performed": "Nutrition Assessment Result Identified"] NutritionAssessmentResultIdentified       such that NutritionAssessmentResultIdentified.authorDatetime during Global."HospitalizationWithObservation" ( GlobalMalnutritionEncounter ) define "Encounter with Malnutrition Diagnosis":   "Global Malnutrition Encounter" GlobalMalnutritionEncounter     with ["Diagnosis": "Malnutrition Diagnosis"] MalnutritionDiagnosis       such that MalnutritionDiagnosis.prevalencePeriod starts during Global."HospitalizationWithObservation" ( GlobalMalnutritionEncounter ) define "Encounter with Nutrition Care Plan":   "Global Malnutrition Encounter" GlobalMalnutritionEncounter     with ["Intervention, Performed": "Nutrition Care Plan"] NutritionCarePlan       such that NutritionCarePlan.authorDatetime during Global."HospitalizationWithObservation" ( GlobalMalnutritionEncounter ) Rationale for change The activities evaluated by the measure observations may be performed immediately prior to admission in an emergency department or during observation admissions that meet the intent of the measure and should be evaluated for performance. ​By including all clinically eligible Measure Observation activities for Measures Observations 1, 2, 3, and 4 that are associated with the hospitalization episode, physicians or eligible clinicians are evaluated for all performed clinically eligible Measure Observation activities that would satisfy measure intent. By using the "Global.HospitalizationWithObservation" function, component activities performed for hospitalizations during immediately prior Emergency Department or Observation Services care will evaluated.