Interprofessional Implementation of the Global Malnutrition Composite

Malnutrition in hospitalized patients can impact health outcomes, quality of life, and health equity. Quality improvement initiatives and quality measurement can help improve the care of those hospitalized patients with malnutrition. The new Global Malnutrition Composite Score (GMCS) was recently adopted by the Centers for Medicare & Medicaid Services (CMS) as a health equity-focused measure. Beginning in 2024, the GMCS is available for reporting through the CMS Hospital Inpatient Quality Reporting Program. The GMCS provides an opportunity to elevate the importance of patient nutrition status and evidence-based interventions throughout the interdisciplinary hospital decision-making process. To promote this opportunity, the American Society for Parenteral and Enteral Nutrition (ASPEN) held an "Interprofessional implementation of the Global Malnutrition Composite Score" webinar as part of its 2022 Malnutrition Awareness Week programming. This article summarizes the underlying rationale and significance of the GMCS measure and showcases clinical observations about integrating quality improvement and measurement into the acute care setting, as presented during the webinar.

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Learning Objectives
Upon completion of this educational activity, the learner will be able to: 1. Understand the creation and structure of the Global Malnutrition Composite Score (GMCS) and the data reflected by its 4 component measures 2. Explain how malnutrition and its risk affect health equity and how they can be addressed in tandem

Malnutrition Quality Improvement Initiative
Copyright©2022 Academy of Nutrition and Dietetics.Contact Quality Management for questions regarding reproduction or distribution.

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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.

Learning Objectives
Upon completion of this educational activity, the learner will be able to: 1. Understand the value of the treatment of malnutrition 2. Recognize the importance of inpatient reporting 3. Identify and implement quality improvement measures We will not cover the following: 1.Why is abbreviation such a long word? 2. Why is there neither pine nor apple in pineapple?3. What happens when you get scared half-to-death twice?Learning Assessment Questions Summary

TOTAL ANNUAL SAVINGS FOR CMS WITH NUTRITIONAL SUPPORT FOR GI MALIGNANCIES = POST-OP EARLY vs LATE EN FOR GI CANCER PATIENTS POST-OP ENHANCED RECOVERY AFTER SURGERY vs CONVENTIONAL GROUP FOR GI CANCER PATIENTS
• Is there value in identification and treatment of malnutrition?Assessment (within 24 hours of "at risk" screen for this data) Lessons Learned: -Timing in workflow (24 vs 48 hr) -Need to improve data granularity

Physician Diagnosis
Component Measure 3: Inpatient hospitalizations for patients with a current malnutrition diagnosed as a result of a "moderate" or "severe" malnutrition status from a current malnutrition assessment.

Care Plan
Component Measure 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 malnutrition assessment.

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Barrocas A, Malone A. Hospital Nutrition Care Betters Patient Clinical Outcomes and Reduces Costs: The Malnutrition Quality Improvement Initiative Story.J Acad Nutr Diet.2019; 119S2 (9): S11-S14.Fitall E, Jones Pratt K, McCauley SM, et al.Improving Malnutrition in Hospitalized Older Adults: The Development, Optimization, and Use of a Supportive Toolkit.J Acad Nutr Diet.2019; 119S2(9): S25-S31.Dorner B, Kriedrich EK.Position of the Academy of Nutrition and Dietetics: Individualized Nutrition Approaches for Older Adults: Long-Term Care, Post-Acute Care, and Other Settings.J Acad Nutr Diet.2018; 118(4): 724-735.Studies of nutrition screening effectiveness have demonstrated that both patient health outcomes and hospital economic outcomes are improved when malnutrition is more effectively identified and treated Appropriate nutrition assessment, intervention, and monitoring and evaluation can play a role in preventing hospital readmissions that are related to malnutrition Why Act? Copyright©2022 Academy of Nutrition and Dietetics.Contact Quality Management for questions regarding reproduction or distribution. 17 Dual Pronged Approach Academy of Nutrition and Dietetics, along with Avalere Health and other stakeholders, developed and implemented the Malnutrition Quality Improvement Initiative (MQii), a national nutrition-focused quality improvement initiative.McCauley SM, Mitchell K, Heap A. The Malnutrition Quality Improvement Initiative: A Multiyear Partnership Transforms Care.J Acad Nutr Diet.2019; 119S2(9): S18-S24.
Fitall E, Jones Pratt K, McCauley SM, et al.Improving Malnutrition in Hospitalized Older Adults: The Development, Optimization, and Use of a Supportive Toolkit.J Acad Nutr Diet.2019; 119S2(9): S25-S31.https://malnutritionquality.org/mqii-toolkit/MQii Toolkit Copyright©2022 Academy of Nutrition and Dietetics.Contact Quality Management for questions regarding reproduction or distribution.10/20/2022 10 19 • Community of clinicians committed to improving delivery of malnutrition care in hospitals and health systems across the US.• Undertake a data-driven, patientcentered, malnutrition quality improvement project at their respective institutions using a best practices Toolkit and are encouraged to use malnutrition eCQMs to track and monitor improvement.The Malnutrition Quality Improvement Initiative.Introduction to MQII Learning Collaborative.Published 2021.Accessed May 20, 2022.https://malnutritionquality.org/mqii-learning-collaborative/ 3 1 3 s i t e s i n 3 8 s t a t e s a n d P u e r t o R i c o MQii Learning Collaborative Copyright©2022 Academy of Nutrition and Dietetics.Contact Quality Management for questions regarding reproduction or distribution.Copyright©2022 Academy of Nutrition and Dietetics.Contact Management for questions regarding reproduction or distribution.Source: Academy of Nutrition and Dietetics.Quality Initiatives.Access here 10/20/2022 VALUE, REPORTING, & QUALITY: A BENEFICIAL RELATIONSHIP Interprofessional Implementation of the Global Malnutrition Composite Score Webinar IN GI MALIGNANCIES• Pimiento J, et al.J Gastrointest Oncol 2021

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To improve GI clinic access for new patients ≤ 10 days by assessing past statistics (2012), evaluating current demand (December 2012 and January 2013), implementing a plan of action to improve outcomes to >70% by March 2013.STUDY THE RESULTS: (Use Indicator Names) 1. Numerator = # of new patients ≤ 10 days 2. Denominator = # of total new patients Performance Indicator: % new patients ≤ 10 days PLAN: Access to subspecialty clinics is an extremely important healthcare issue for patient care, referring physicians, and downstream revenue.Our plan is to track current practice over the past year at the Digestive Health Center, implement changes within the system, and compare it to those performed from January 2013 to present.DO: Monitor monthly adequacy rates for 2012 pre-intervention/post-intervention (January 2013 -present) 1. Establishment of a new Director of Ambulatory Services -Matthew Bechtold MD, FASGE, FACG -12/1/12 2. Education of faculty regarding improvement of return patient intervals -12/5/12 3. Education of faculty and fellows regarding open access clinics -12/5/12 4. Creation and implementation of new clinic directive in which all PSRs are to notify new Director of Ambulatory Services is a new patient cannot be seen ≤ 10 days -12/26/12 5. Patient scheduled by Director of Ambulatory Services to met goal by asking the referred provider to overbook, overbook the Director's clinic, or by creating a special clinic after-hours to see patient (unless otherwise specified by patient) -12/26/12 6. Implementation of open access model -1/14/13 -Front-log Emphasis 7. Implementation of 60/40 rule -60% returns and 40% new -7/10/13 ACT: Education performed -12/5/12 2. Policy initiated -12/26/12 3. Open access initiated -1/14/13 For Physician Diagnosis • Improve Workflow using SmartPhrase (or similar EHR tool) ≫ Electronic health record dot phrase (.malnutritiontext) can be used to insert the assessment and present on admission status from the dietitian assessment into progress notes, and can serve as a prompt for physician documentation Also Encourage use of problem list documentation -Education on CDI (clinical documentation improvement) Data available: -Discrete problem/diagnosis list in EHR -Text not available as discrete data

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Over time, lead to development of an Advanced Nutritional Consult Service which is staffed by GI physician, dietitian, and pharmacist • Currently in the process of transitioning dietitian care plan and ONS (oral nutritional supplements) to discrete data Emphasis on practical advice on how to move forward some malnutrition QI at your institution • Automate some of the process• Make some improvement in some thing• Small things, done consistently, make major impact

Composite Score Is a Composite Measure Derived from 4 Individual eCQMs
8Global MalnutritionDenominator Exclusions: Patients with a length of stay less than 24 hours and those discharged to hospice care or who left against medical advice are excluded from the composite measure calculation "Composite Measure Scoring Algorithm."Malnutrition Quality Improvement Initiative.Accessed October 3, 2022.https://malnutritionquality.org/measurement-data/.

Component Measures Numerator Denominator Completion of a Malnutrition Screening
9Anchoring

ASPECT IMPROVEMENT ACCOUNTABILITY RESEARCH AIM IMPROVE CARE COMPARISON, CHOICE, ASSURANCE NEW KNOWLEDGE METHODS TEST OBSERVABILITY TEST OBSERVABLE NO TEST, EVALUATE CURRENT PERFORMANCE TEST BLINDED OR CONTROLLED
• Solberg LI et al.Jt Comm J Qual Improve 1997 -DEE

,583 adult discharges in a month 87 discharges/day 873 65 and older per 30 days 33
Malnutrition pilot of the new workflow on two inpatient units during a four month period (no additional FTEs required to implement).➢ Malnutrition was then identified in 42% of patients on the two pilot units.➢ Favorable impact on allowable length of stay and hospital reimbursement ➢ Hospital administration almost immediately added 6FTEs (from 25 to 31 FTEs to 33 to 37) ➢ The pilot malnutrition workflow was implemented hospital-wide.Inpatient hospitalizations for patients with a current screening for malnutrition risk performed at the time of admission.
➢ Preoperative and cancer center: no dietitian/program to dedicated dietitian/program (from "Hy-Vee grocery to comprehensive cancer center") Results of Malnutrition Pilot on Two Units .8%65andolderData set creation • Write rules to build an adult inpatient cohort from retrospective data (can also be done real time) -Some moderate effort in building a report -Worked 1 on 1 with a reporting analyst -Able to identify all hospital 54 54Screening (initial data was for within 24 hours of admit)Data available:-Questionnaire in EHR -Entered by nursing as a "hard stop"