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  2. CQM-6994

CMS986v2 Measure Observation 1 Malnutrition Screen

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    • Icon: EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals
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    • Mayo Clinic
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      Thank you for your inquiry into CMS986, the Global Malnutrition Composite Score. The workflow described in the scenario conforms with best practice and aligns with the measure intent to provide high-quality malnutrition care. The measure logic does not specify who can complete the malnutrition risk screening, though guidance recommends appropriate eligible clinicians based on national, state, and local regulations. The current logic prioritizes a “Not at Risk” result over any “At Risk” result, regardless of the timing of either completed screening. Therefore, in the workflow described, the “Not at Risk” result would prioritize the initial “At Risk” result from the RN screening, ending measure performance calculations. However, please note that the presence of a hospital dietitian referral supersedes any screening result and allows performance measurement of measure observation 2, nutrition assessment.
      Show
      Thank you for your inquiry into CMS986, the Global Malnutrition Composite Score. The workflow described in the scenario conforms with best practice and aligns with the measure intent to provide high-quality malnutrition care. The measure logic does not specify who can complete the malnutrition risk screening, though guidance recommends appropriate eligible clinicians based on national, state, and local regulations. The current logic prioritizes a “Not at Risk” result over any “At Risk” result, regardless of the timing of either completed screening. Therefore, in the workflow described, the “Not at Risk” result would prioritize the initial “At Risk” result from the RN screening, ending measure performance calculations. However, please note that the presence of a hospital dietitian referral supersedes any screening result and allows performance measurement of measure observation 2, nutrition assessment.
    • CMS0986v2

      Hello,

      We have a question about measure observation 1 for the GMCS. 

      Our organization utilizes DTRs (Dietary Technician, Registered) as a part of our inpatient nutrition team. DTRs work under the supervision of RDs/RDNs and play an important role in the care of our patients.

      The workflow we currently have for Measure Observation 1 is to have our RNs perform this risk screening as a part of their admission navigator. When a patient is screened initially as "at risk", we would like to utilize our DTRs to rescreen these patients in an effort to help prioritize the time and resources of our RDs/RDNs. 

      If the DTR agrees that the patient is at risk, then an RD/RDN will come and perform the malnutrition assessment (Measure observation 2). If they disagree with the initial "at risk" result from nursing, they will document that the patient is not at risk, and an RD/RDN would not perform the malnutrition assessment for measure observation 2.

      Is this an acceptable workflow for completing Measure Observation 1?

            JLeflore Joelencia Leflore
            greguson.tyler@mayo.edu Tyler Greguson
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