Brief Description of Measure: CMS986/GMCS: Global Malnutrition Composite Score 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. Description of Issue: The following is an overview of the 6 measure observations and details for their calculation: - Component Measure 1 (Malnutrition Risk Screening): MO1 Screen includes encounters with Malnutrition Risk Screening and Identified Result. Intended for all patients with qualifying encounter. A value of 1 is given if performed and 0 if not performed. - Component Measure 2 (Nutrition Assessment): MO2 Assess includes encounters with Nutrition Assessment and Identified Status. Only intended for patients with a completed Malnutrition Risk Screening with an At Risk Result and/or Patients with a Hospital Dietitian Referral. A value of 1 is given if performed and 0 if not performed. - Component Measure 3 (Malnutrition Diagnosis): MO3 Diagnose includes encounters with Malnutrition Diagnosis. Only intended for patients with a completed Nutrition Assessment and a “Nutrition Assessment Status Moderately Malnourished" OR "Nutrition Assessment Status Severely Malnourished". A value of 1 is given if performed and 0 if not performed. - Component Measure 4 (Nutrition Care Plan): MO4 Care Plan includes encounters with Nutrition Care Plan. Only intended for patients with a completed Nutrition Assessment and a “Nutrition Assessment Status Moderately Malnourished" OR "Nutrition Assessment Status Severely Malnourished". A value of 1 is given if performed and 0 if not performed. - Component Measure 5 (Population 5: Total Malnutrition Component Score): MO5 calculates the Total Malnutrition Component Score. For each eligible hospital encounter, sums the performance for MO1, MO2, MO3, and MO4, with results ranging from 0–4. For each reporting facility, aggregates the count of eligible hospitalizations during the measurement period. - Component Measure 6 (Population 6: Total Malnutrition Composite Score): MO6 Total Malnutrition Composite Score as Percentage or Global Malnutrition Composite Score (GMCS). For each eligible hospital encounter, divide MO5 by the number of clinically eligible denominators applicable for the encounter and multiply by 100. The GMCS result is represented as a percentage, ranging from 0–100%. For each reporting facility, aggregates the average performance of each eligible hospital encounter’s Total Malnutrition Composite Score as a percentage across all eligible hospitalizations during the measurement period. Nutrition Assessment (MO2) is intended for hospital encounters in the measure population with a Malnutrition Risk Screening (MO1) result of “At Risk” OR with a “Hospital Dietitian Referral” order. The measure does not intend for patients with a Malnutrition Risk Screening (MO1) result of “Not At Risk” to be eligible for MO2 unless there is a “Hospital Dietitian Referral” order. However, the current logic does not constrain implementers from calculating Nutrition Assessment (MO2) performance when: (1) a “Not At-Risk” result was identified from Nutrition Screening (MO1), OR (2) When a “Hospital Dietitian Referral” was not ordered. The eligible denominator is defined as 1 if the result of Nutrition Screening (MO1) is “Not at Risk” resulting in inflated GMCS (MO6) calculations. Currently, if the Malnutrition Screening results in a “Not At Risk” status, the logic continues adding numerators for Population 6 Measure Observation, but the “TotalMalnutritionCompositeScore Eligible Denominators" is counted as 1. This results in percentages that are >100%. The measure steward proposes to update performance for “Population 6 Measure Observation TotalMalnutritionCompositeScore as Percentage” to restrict values to be between 0% and 100%.

Proposed Solution: Nutrition Assessment (MO2) is intended for hospital encounters in the measure population with a Malnutrition Risk Screening (MO1) result of “At Risk” OR with a “Hospital Dietitian Referral” order. The measure does not intend for patients with a Malnutrition Risk Screening (MO1) result of “Not At risk” to be eligible for MO2 in the absence of a “Hospital Dietitian Referral”. However, the current logic does not constrain implementers from calculating Nutrition Assessment (MO2) performance when: (1) “Not At Risk” result was identified from Nutrition Screening (MO1), OR (2) When a “Hospital Dietitian Referral” was not ordered. The measure developer proposes to update performance for “Population 6 Measure Observation TotalMalnutritionCompositeScore as Percentage” to restrict values to be between 0% and 100%. Current logic: define "Encounter with Nutrition Assessment and Identified Status":   "Qualifying Encounter" QualifyingEncounter     with ["Assessment, Performed": "Nutrition Assessment"] NutritionAssessment       such that Coalesce(start of Global."NormalizeInterval"(NutritionAssessment.relevantDatetime, NutritionAssessment.relevantPeriod), NutritionAssessment.authorDatetime) during Global."HospitalizationWithObservation" ( QualifyingEncounter )         and ( NutritionAssessment.result in "Nutrition Assessment Status Not or Mildly Malnourished"             or ( NutritionAssessment.result in "Nutrition Assessment Status Moderately Malnourished" )             or ( NutritionAssessment.result in "Nutrition Assessment Status Severely Malnourished" )         ) Proposed logic: define "Encounter with Nutrition Assessment and Identified Status":   "Qualifying Encounter" QualifyingEncounter     with ["Assessment, Performed": "Nutrition Assessment"] NutritionAssessment       such that Coalesce(start of Global."NormalizeInterval"(NutritionAssessment.relevantDatetime, NutritionAssessment.relevantPeriod), NutritionAssessment.authorDatetime) during Global."HospitalizationWithObservation" ( QualifyingEncounter )         and ( NutritionAssessment.result in "Nutrition Assessment Status Not or Mildly Malnourished"             or ( NutritionAssessment.result in "Nutrition Assessment Status Moderately Malnourished" )             or ( NutritionAssessment.result in "Nutrition Assessment Status Severely Malnourished" )         ) and ( exists "Encounter with Malnutrition Screening At Risk Result"             or exists ( "Encounter with Hospital Dietitian Referral" )         ) Rationale for Change: This measure update addresses a known issue and aligns logic with the measure intent.