Edge Express: The Global Malnutrition Composite Score: GMCS and the Malnutrition Quality Improvement
By Brenda Richardson, MA, RDN, LD, FAND
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The Global Malnutrition Composite Score: GMCS and the Malnutrition Quality Improvement Initiative
By: Brenda Richardson, MA, RDN, LD, FAND
MALNUTRITION CONTINUES TO BE A CRITICAL PUBLIC HEALTH AND HEALTH EQUITY ISSUE with malnutrition and its risk affecting 20-50 percent of hospitalized patients. Social risk factors and existing chronic conditions increase malnutrition risk, overly burdening vulnerable populations.
Interestingly, less than 9 percent of hospitalized patients are typically diagnosed with malnutrition, leaving many potentially undiagnosed and untreated. In addition, costs are 34 percent higher for inpatient hospital stays among malnourished patients than for non-malnourished patients.
This article discusses the Global Malnutrition Composite Score (GMCS), which is the first nutrition-focused quality measure in any Centers for Medicare & Medicaid Services
(CMS) payment program. It will be available for reporting in 2024 by hospitals that participate in the CMS Hospital Inpatient Quality Reporting (IQR) Program, and is also the first electronically-specified nutrition-focused measure.
This article defines the GMCS, how it was developed, and how it will impact payment in acute care and long-term care hospitals. As nutrition professionals in all healthcare settings, we need to embrace plans for systems and processes to prepare for reporting this quality measure. Supporting this nutrition-focused quality measure throughout the healthcare continuum is a vital step in improving nutrition outcomes.
GMCS AND THE MALNUTRITION QUALITY IMPROVEMENT INITIATIVE
In 2013 the Academy of Nutrition and Dietetics partnered with Avalere Health and other stakeholders to develop the Malnutrition Quality Improvement Initiative (MQii). The MQii developed the Global Malnutrition Composite Score (GMCS), which is an evidence-based electronic clinical quality measure with four components reflecting inpatient malnutrition identification and care. CMS adopted the GMCS as part of the Hospital Inpatient Quality Reporting (IQR) Program.
The GMCS measures the following among hospitalized individuals:
- Malnutrition Screening: This assesses the percentage of hospitalizations for adults aged 65 and older with a completed malnutrition screening at admission. (The required length of stay is greater than 24 hours.)
- Nutrition Assessment: This is the proportion of inpatient hospitalization among patients aged 65 or older identified as at risk for malnutrition with a completed nutrition assessment by a Registered Dietitian Nutritionist (RDN).
- Malnutrition Diagnosis: This is the proportion of inpatient hospitalization among patients aged 65 or older identified as malnourished with appropriate documentation of a malnutrition diagnosis.
- Nutrition Care Plan: This is the proportion of inpatient hospitalization among patients aged 65 or older identified as malnourished with a nutrition care plan.
CMS issued Final Rule 1771-F on August 10, 2022 for the FY 2023 Medicare Hospital Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital Prospective Payment System (LTCH PPS), stating they were adopting the GMCS electronic Clinical Quality Measure beginning in the CY 2024 reporting period, with payment determination in FY 2026. This would reduce payments to hospitals that do not meet the established requirements.
Patients and hospitals benefit in many ways from reporting the GMCS including:
- Support of identification and action to reduce health disparities.
- Improve patient outcomes by ensuring prompt delivery of appropriate care.
- Alignment with the latest quality measure infrastructure and interoperability standards based on close correspondence with CMS and the National Quality Forum (NQF).
RESOURCES FOR PLANNING AND IMPLEMENTING GMCS COMPONENTS
The Malnutrition Quality Improvement Initiative (MQii) is a multi-year effort that began in 2013 when the Academy, Avalere, and various stakeholder groups started highlighting gaps in existing malnutrition care and the impact of these gaps on patient outcomes. Based on the results of subsequent literature reviews, landscape assessments, engagements with key stakeholders, and best practices research, the MQii was established to provide guidance to organizations through key technical expert and advisory roles. This initiative seeks to advance evidence-based, high-quality patient-driven care for hospitalized adults who are malnourished or at risk for malnutrition.
The MQii Learning Collaborative has more than 300 participating hospitals providing learning from their experiences, resources, and guidance for implementing systems and processes that incorporate the GMCS. Recommendations include having a multidisciplinary care team that develops a work flow for the GMCS that coordinates the overall process. Not only will this guide the flow for the GMCS, it will also lead to more comprehensive discharge planning for continuity of nutritional care and referral to community resources to avoid hospital readmission.
Recommended Steps in reporting the GMCS include:
- Use of Quality Improvement (QI) to confirm that optimal care processes are in place.
- Engage your facility leadership to include (but not limited to): clinical teams, quality leaders, IT staff, administrators, and medical record staff. (Education presentations are available on the MQii website.)
- Stay informed about GMCS-related materials and training.
In addition, MQii provides a Quick Start Guide with practical resources to help hospitals plan, implement, and sustain related malnutrition tracking and improvement activities.
- Quick Start Guide:
- Step 1: Implementing malnutrition quality improvement (QI)
- Connect with your hospital’s quality improvement department to help with the workflow assessment and QI implementation.
- Identify and prioritize your top areas for malnutrition care process and documentation improvement (i.e., malnutrition screening processes within 24 hours).
- Create a plan with your care team to address prioritized areas for malnutrition care process and documentation improvement.
- Step 2: Preparing your electronic health record (EHR) for GMCS measure data collection, monitoring, and reporting
- Connect with your information technology (IT) department to ensure the necessary data elements are captured in the EHR. Documentation of the nutrition care process in the EHR is essential to evaluate QI and allow for reporting of the GMCS to CMS.
- Work with your hospital QI department to plan for 2024 reporting of the GMCS.
- Step 1: Implementing malnutrition quality improvement (QI)
PowerPoint presentations for implementation of QI and reporting of the GMCS score to CMS are available on the MQii website. See Article References for links.
PREPARING FOR IMPLEMENTATION
The Certified Dietary Manager, Certified Food Protection Professional (CDM, CFPP) needs to work closely with the Registered Dietitian Nutritionist (RDN) for successful implementation. MQii offers six key principles to guide incorporation of nutrition into the care plan with transformation of the hospital environment and guiding clinical actions.
Transform Hospital Environment:
- Create an institution culture where all stakeholders value nutrition.
- The MQii Toolkit and Quick Start Guide provide resources and tools for your organization. The Toolkit was created prior to the development of the GMCS and its inclusion in the Hospital IQR Program. Therefore, the Toolkit is being updated with GMCS-specific information. Refer to the Quick Start Guide or the full GMCS for IQR page. The MQii Toolkit is a guide for identifying and implementing clinical quality improvements for malnutrition care. It is designed to support changes among the care team’s clinical knowledge and raise awareness of best practices for optimal nutrition care delivery. Using this toolkit can help improve malnutrition care for older adults admitted to the hospital through patient-centered approaches that improve coordination across the care team.
In addition, the American Society for Parenteral and Enteral Nutrition (ASPEN) has a GMCS reporting practice tool. See Article References for link.
- Redefine clinicians’ role to include nutrition care.
- Communicate nutrition care plans.
Guide Clinical Action:
- Recognize and diagnose all malnourished patients and those at risk.
- Rapidly implement comprehensive nutrition intervention and continued monitoring.
- Develop a comprehensive discharge nutrition care and education plan.
Visit https://malnutritionquality.org/ for tools, insights, and information on improving nutrition outcomes.
IMPACT ON THE MULTIDISCIPLINARY TEAM, INCLUDING THE CDM, CFPP
Nutrition leaders in each hospital need to work closely with the multidisciplinary team for success. If the Registered Dietitian Nutritionist working with the facility is a consultant or is part time, then now is the time to make sure everyone is on board and a plan is in place. Meeting with hospital administrative leadership to present education and an overall plan is essential.
The Certified Dietary Manager, Certified Food Protection Professional has an active role as well.
The CDM, CFPP Practice Standard, Documenting in the Medical Record, Standard 1 states:
The Certified Dietary Manager, Certified Food Protection Professional (CDM®, CFPP®) shall ensure that nutritional screening data is accurately obtained and recorded in the medical record in accordance with state and federal regulations and facility policy. The CDM, CFPP shall ensure that food and fluid-related interventions are added to client care plans.
In addition to the acute care setting, all healthcare settings need to have an awareness of the GMCS and how it impacts the clients they serve. Is your long-term care facility using the same evidence-based malnutrition risk screening tool as the hospitals in your area?
Various healthcare settings should be able to work collaboratively across the care continuum for positive nutrition outcomes. Remember that frequently CMS and quality measures from acute care become a part of requirements and reimbursement models for other healthcare settings.
The time is now to be preparing and implementing systems and processes for reporting the Global Malnutrition Composite Score (GMCS). The Malnutrition Quality Improvement Initiative offers hospitals the opportunity to participate in the MQii Learning Collaborative, and provides many resources and tools to assist in overall planning and implementation.
The end goals include reducing hospital length of stay, lowering healthcare costs, identifying at-risk patients, and documenting relevant nutrition diagnosis and discharge plans to ensure continuity through care transitions. Are you on board and ready to make a difference?
About the Author
Brenda Richardson, MA, RDN, LD, FAND
Brenda Richardson is a lecturer, author, and owner/president of Brenda Richardson, LLC. She is a long-time RDN consultant in long-term care, and now serves as an Independent Auditor for the Gluten-Free Certification Organization.