January/February 2024

The Global Malnutrition Composite Score
By Jennifer Doley, MBA, RD, CNSC, FAND
Today’s Geriatric Medicine
Vol. 17 No. 1 P. 22

Implementation of this assessment, diagnosis, and treatment tool brings hope for improved patient care and outcomes.

An estimated 20% to 50% of hospitalized patients in the United States are malnourished or at risk of malnutrition. Malnutrition is particularly prevalent in older adults and is associated with several adverse outcomes, including increased mortality, longer hospital length of stay, impaired wound healing, higher rates of hospital readmission, and greater cost of care.1

Early identification and treatment of malnutrition are crucial to improving health outcomes and quality of life for this patient population. However, data have shown malnutrition is diagnosed in only 8% of hospitalized patients.1 Poor identification of malnutrition and its associated negative outcomes have drawn the attention of CMS, an organization that sets health care standards.

Hospital Quality of Care
In an effort to improve quality of health care, CMS established the Hospital Inpatient Quality Reporting (IQR) Program in 2003. As part of the IQR, CMS develops quality measures called electronic clinical quality measures (eCQMs), which are tracked via data from the hospital’s EHR. Hospitals are required to track three mandatory measures, as well as three self-selected measures from a list of 10. Performance is reported publicly, and participation affects Medicare payments. Hospitals that participate in the Hospital IQR program receive an increase in payment for Medicare patients’ hospital stays, while hospitals that don’t meet the minimum reporting requirements receive a decrease in payment. Adjustments to payments don’t occur immediately when an eCQM is adopted; results reported in calendar year (CY) 2024 affect payments for fiscal year 2026. These financial consequences are meant to incentivize hospitals to provide quality, evidence-based care.2

Every year, CMS releases new eCQMs and updates or retires existing measures. Measures cover many facets of health care, including patient and family engagement, patient safety, care coordination, population/public health, efficient use of health care resources, and clinical processes/effectiveness. These measures allow hospitals to track patient outcomes such as mortality and readmissions, as well as performance on the use of evidence-based guidelines for patient care. Measures often are related to specific conditions, such as myocardial infarction, heart failure, pneumonia, and joint replacements. To date, there have been no measures related to malnutrition, until now.2

The Composite Score Explained
In 2015, the Academy of Nutrition and Dietetics and Avalere Health developed four malnutrition related eCQMs, which were included in the CMS Measures Under Consideration list in 2016. Upon review of the eCQMs, CMS acknowledged that malnutrition was a significant health care problem, but requested the four measures be consolidated into one score. This new measure, the Global Malnutrition Composite Score (GMCS), was resubmitted to CMS and added to the Measures Under Consideration list in 2020. In 2021, the National Quality Forum, a nonprofit, nonpartisan organization that promotes health care improvements, endorsed the GMCS.3,4 Following this endorsement, in 2022, CMS announced the inclusion of the GMCS in the IQR program. The GMCS was scheduled to be available as an optional eCQM starting in January 2024.3

The GMCS measures four components of malnutrition care in the hospital: screening, assessment, diagnosis, and care plan (treatment). The four measures are defined as follows3:

1. Inpatient hospitalizations for patients with a current malnutrition risk screening performed at the time of admission.

2. Inpatient hospitalizations for patients with a current nutrition assessment performed from an “at risk” finding in a current malnutrition risk screening.

3. Inpatient hospitalizations for patients with a current malnutrition diagnosis as a result of a “moderate” or “severe” malnutrition status from a current nutrition assessment.

4. Inpatient hospitalizations for patients with a current nutrition care plan performed as a result of a “moderate” or “severe” malnutrition status from a current nutrition assessment.

Data elements are extracted from the EHR and assessed to determine each patient’s individual score. Scores from all qualifying patients are then averaged together for a global score. Only data from patients ≥ 65 years of age with a hospital length of stay ≥ 24 hours are used to calculate the GMCS.3

What Are the Benefits of the GMCS?
The four measures of malnutrition care reflect the importance of interdisciplinary care and communication to effectively treat patients with malnutrition. Screening usually is completed by a nurse, nutrition assessment and care planning by a registered dietitian (RD), and diagnosis by a physician. While RDs also diagnose malnutrition, for the diagnosis to “count” towards the GMCS, it must be documented by a physician. This is true for any diagnosis. The patient can’t be coded and insurance can’t be billed for a diagnosis unless it’s documented by an MD. Malnutrition documented by an MD often is referred to as a “medical diagnosis” of malnutrition, and a “nutrition diagnosis” when documented by an RD.

The interdisciplinary nature of the GMCS will help improve communication and collaboration between professionals. The consequences, prevalence, diagnosis, and treatment of malnutrition often aren’t recognized or well understood by other health care professionals. Adopting the GMCS will give RDs opportunities to educate other clinicians, elevate their role in the identification and treatment of malnutrition, and help improve patient outcomes such as readmission rates and hospital length of stay. In addition to the benefits to patients, these outcomes also are important to hospital administrators due to their financial impacts, which include costs of care and CMS payments.

Another benefit of adopting the GMCS is it also can be used as a measure of health equity, which is a new regulatory requirement.

Health Equity
Health disparities are defined by the CDC as “preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations.”5 Populations facing health care inequities have a higher incidence of malnutrition, chronic diseases that can contribute to malnutrition, and higher rates of food insecurity. Health disparities in minority and low-income communities in the United States have been widely documented.

In response to this crisis, The Joint Commission, a regulatory body that conducts surveys to ascertain hospitals’ compliance with CMS standards, has implemented new requirements to identify and address health disparities in hospitalized patients.6 Because CMS has classified the GMCS as a health equity measure, its adoption will help hospitals fulfill this new Joint Commission requirement.7

CMS also has developed the Screening for Social Drivers of Health eCQM, which was available for adoption as a voluntary measure in CY 2023 and is mandatory in CY 2024. Patients over the age of 18 must be screened for health-related social needs, which include food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety. Food insecurity is chronic or intermittent limited access to foods, both in quantity and quality. Quality foods include more healthful options that help individuals prevent and treat chronic health problems, such as diabetes and heart disease.8 Poorly managed chronic diseases are associated with a higher risk of malnutrition.

Since many cases of social/environmental-related malnutrition are a result of or exacerbated by food insecurity, it’s important for clinical RDs to be aware of their facility’s process of screening patients for health-related social needs. RDs should be notified of patients with food insecurity to better recognize social/environmental-related malnutrition. Identifying food insecurity early in the patient’s hospital stay allows time for RDs and other members of the care team to develop a discharge plan that includes referrals to low-cost or free food and nutrition resources in the community, as well as other social services and support to address all health-related social needs.

How to Get Your Hospital to Adopt the GMCS
Developing relationships and obtaining support from other members of the health care team is critical. Start with the hospital’s quality director who can tell you what eCQMs are already being measured and what plans they may have for future measures. Communicate with the hospital’s leadership team to inform them of the GMCS and its benefits. Find a physician champion who understands the importance of malnutrition and involve them in the GMCS adoption process.3,7

Engage the clinical informatics team early in the process of campaigning for the GMCS. Because eCQMs are measured using data extracted from the EHR, it’s important to ensure that documentation methods will support this process. If current documentation practices are insufficient, changes to the EHR must be made before implementing the GMCS.3,7

Start an interdisciplinary malnutrition care team and include RDs, MDs, nursing, clinical informatics, documentation specialists, and leadership representatives. As a team, assess your workflow for identifying, diagnosing, and treating malnutrition, in addition to communication processes for the RD to notify the MD of the nutrition diagnosis of malnutrition. This will help identify gaps in care and opportunities to modify current processes. Using quality improvement practices, the team should obtain baseline data, identify and implement best practices to improve performance of these measures, and share the results with relevant disciplines.3,7

Improving Care for Malnourished Patients
While the GMCS is a good measure of overall malnutrition care, as a single score, it doesn’t provide the level of detail needed to best identify specific and effective opportunities to improve malnutrition care. It’s therefore crucial to determine the hospital’s performance in each of the four components of the GMCS in order to develop effective strategies. Several best practices can be implemented to address each of the four components.

MEASURE 1: Screening
• Use a validated nutrition screening tool. Common tools used in the hospital setting include the Malnutrition Screening Tool, the Malnutrition Universal Screening Tool, and the National Risk Screening 2002.9

• Educate nursing staff on the significance of malnutrition and emphasize the importance of completing the malnutrition screen consistently and accurately.

• Make the nutrition screen a “hard stop” in the EHR, in which it must be completed before the form can be signed.

• A positive nutrition screen indicating nutrition risk automatically should generate a referral to the RD to assess the patient.

MEASURE 2: Assessment
• Adopt evidence-based malnutrition criteria. The two most commonly used are the Academy of Nutrition and Dietetics/American Society of Parenteral and Enteral Nutrition consensus characteristics and the Global Leadership Initiative on Malnutrition criteria.10,11

• Establish and monitor RD competence in correctly applying the approved malnutrition diagnostic criteria and conducting nutrition-focused physical exams to identify muscle and fat wasting and signs of micronutrient deficiencies.

• Optimize the EHR to aid in the RD’s documentation of malnutrition. Discrete fields with select/drop down options should be used to record the malnutrition diagnosis, etiology, signs/symptoms, and the plan of care to treat malnutrition.

• Ensure RD documentation is specific (measurable) and thorough. Signs and symptoms of malnutrition should include the percent change in intake or body weight, duration of these and other symptoms, location and severity of muscle and fat wasting, and malnutrition severity and etiology.

MEASURE 3: Diagnosis
• Educate MDs on the prevalence, adverse consequences, and diagnostic criteria for malnutrition to increase their awareness of the condition and improve documentation.

• Leverage the EHR to improve communication between RDs and MDs.

• Use electronic messages or notifications to inform MDs of the malnutrition diagnosis. Communications should include all relevant malnutrition criteria, as well as the care plan, so MDs are fully informed before making the medical diagnosis of malnutrition.

• Use “smart text” functions to enable MDs to import the RDs’ malnutrition documentation into their own notes.

• Improve communication between RDs and the hospital’s clinical documentation specialists, who can query MDs on the malnutrition diagnosis when it’s identified by RDs.

MEASURE 4: Care Plan
• Assess discharge needs and document anticipated discharge plans upon the initial assessment of the patient.

• Develop a treatment plan to address all etiologies of malnutrition, if possible. This includes treating chronic social, environmental, and medical issues affecting nutrition status. Addressing only the patient’s current poor oral intake doesn’t treat chronic problems that contribute to their malnutrition.

• Use the EHR to facilitate interdisciplinary discharge care plan documentation to improve communication among all disciplines. The malnutrition diagnosis and discharge plan should be communicated with practitioners at the next level of care, such as a rehabilitation or skilled nursing facility.

Even if your hospital doesn’t adopt the GMCS, an interdisciplinary malnutrition team still should be formed, as a team-based approach has been shown to be successful in improving patient outcomes and costs of care. The Malnutrition Quality Improvement Initiative, a collaboration of organizations that promote and helped develop the GMCS, has numerous resources that aid in the establishment of an interdisciplinary team and quality improvement practices to address malnutrition.1

— Jennifer Doley, MBA, RD, CNSC, FAND, is a malnutrition program manager for Morrison Healthcare. She’s been a dietitian for more than 28 years, and her previous roles include nutrition support specialist, regional clinical nutrition manager, and dietetic internship director.

References
1. Malnutrition matters. Malnutrition Quality Improvement Initiative website. https://malnutritionquality.org/malnutrition-matters. Updated March 13, 2022. Accessed April 19, 2023.

2. Hospital Inpatient Quality Reporting (IQR) Program. Centers for Medicare and Medicaid Services website. https://qualitynet.cms.gov/inpatient/iqr. Accessed April 15, 2023.

3. Malnutrition Quality Improvement Initiative. Global Malnutrition Composite Score: frequently asked questions. https://malnutritionquality.org/wp-content/uploads/GMCS_FAQs_2023.pdf. Published May 4, 2023.

4. National Quality Forum. Centers for Disease Control and Prevention website. https://www.cdc.gov/nhsn/nqf/index.html#:~:text=The%20National%20Quality%20Forum%20
(NQF,of%20care%20and%20payment%20reform. Accessed April 17, 2023.

5. Health disparities. Centers for Medicare and Medicaid Services website. https://www.cdc.gov/healthyyouth/disparities/index.htm. Updated November 24, 2020. Accessed April 20, 2023.

6. The Joint Commission. R3 report: requirement, rationale, reference. Issue 36. https://www.jointcommission.org/-/media/tjc/documents/standards/r3-reports/r3_disparities_july2022-6-20-2022.pdf. Published June 20, 2022. Accessed April 19, 2023.

7. Global Malnutrition Composite Score. Malnutrition Quality Improvement Initiative website. https://malnutritionquality.org/gmcs-for-iqr/. Accessed April 21, 2023.

8. FY 2023 Hospital Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital Prospective Payment System (LTCH PPS) final rule — CMS-1771-F. Centers for Medicare and Medicaid Services website. Published August 1, 2022. Accessed April 11, 2023.

9. Skipper A, Coltman A, Tomesko J, et al. Position of the Academy of Nutrition and Dietetics: malnutrition (undernutrition) screening tools for all adults. J Acad Nutr Diet. 2019;120(4):709-713.

10. White JV, Guenter P, Jensen G, et al. Consensus statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). J Paren Enteral Nutr. 2012;36(2):275-283.

11. Cederholm, T, Jensen GL, Correia MITD, et al. GLIM criteria for the diagnosis of malnutrition – a consensus report from the global clinical nutrition community. Clin Nutr. 2019;38(1):1-9.

Key Points
The Global Malnutrition Composite Score (GMCS) is a new CMS quality measure that affords hospital registered dietitians the opportunity to elevate their practice and highlight their role on the health care team.

The GMCS addresses four key components of malnutrition care in the hospital: screening, assessment, diagnosis, and care plan.

Measuring performance and implementing best practices to identify and treat malnutrition can reduce hospital readmissions, hospital lengths of stay, mortality, and treatment costs for this patient population.

CMS has designated the GMCS as a health equity measure; adoption of the GMCS will help hospitals meet new regulatory requirements to address health disparities.

— JD