GLOBAL MALNUTRITION COMPOSITE SCORE

The Centers for Medicare and Medicaid Services (CMS) is an insurer, but also collects and analyzes data to produce reports utilizing quality improvement and quality measurement data to improve outcomes while reducing burden on clinicians and providers.

Under the CMS umbrella of programs lies the Inpatient Quality Reporting (IQR) Program, a Pay-for-Reporting program that requires hospitals to submit data on quality and safety measures focused on reducing hospital-related complications and mortality and offering high-quality care. The results are publicly reported on the Care Compare website. 

Electronic clinical quality measures (eCQMs) are one of many programs under the IQR system. These measures use data electronically extracted directly from electronic health records (EHR) and/or health information technology (HIT) systems to measure the quality of health care provided. The facility submitting eCQM measures does so directly from the EHR or IT systems. 

The GMCS, is stewarded and currently developed, by the Academy of Nutrition and Dietetics. It was approved as an eCQM and is 1 of 9 eCQMs available measures for reporting in 2024 and 2025. Currently, Eligible Hospitals and Critical Access Hospitals must report on 6 electronic clinical quality measures for each reporting period-three mandatory and three self-selected. The GMCS is currently available as a self-selected measure. 

When preparing to implement the GMCS, it is important to keep in mind the following terms that indicate the reporting timeline (as seen in the figure below). The Reporting Period is the calendar year that the data will be collected. The data collected will then be submitted the following year, during the Submission Period. 

Ultimately, the data reported and submitted will directly be linked to the Payment Period Fiscal year that corresponds to the year after the Submission Period.

The Global Malnutrition Composite Score, or GMCS, assesses the percentage of hospitalizations for adults 65 years and older with a length of stay of at least 24 hours who received optimal malnutrition care during the current inpatient hospitalizations, emphasizing that care performed corresponds to the patient's level of malnutrition risk and severity. Expansion of the measure population age from 65 to 18 years of age will occur for Reporting Period Calendar Year 2026. 

The GMCS follows evidence-based guidance to support malnutrition care, as shown below.

The GMCS, is the first nutrition-focused electronic clinical quality measure (eCQM) to be included in the Centers for Medicare and Medicaid (CMS) Hospital Inpatient Quality Reporting (IQR) Program, under the Inpatient Prospective Payment System (IPPS) in October 2022. The measure published at that time included only those admitted patients that were 65 years of age or older on admission. In the Fall of 2023, work was started to expand the population covered by the measure from 65 years of age to all adults 18 years of age or older. This expansion was published in the Hospital Inpatient Quality Reporting (IQR) Program in the FY 2025 Inpatient Prospective Payment System (IPPS) Final Rule, with an implementation date of Reporting Period Calendar Year 2026.

The original measure was endorsed by unanimous vote of the CMS Consensus Based Entity (CBE) National Quality Forum (NQF) Consensus Standards Approval Committee (CSAC) in 2021. With the expansion in patient age coverage, CDR pursued a new endorsement of the measure in the Spring of 2024, by the new CBE, Partnership for Quality Measurement’s (PQM) Endorsement and Maintenance (E&M) Committee. The GMCS received a 5-year endorsement in the Spring 2024 cycle. The committee requested that when returning for re-endorsement, they were presented with “implementation data (to include patients 18 years and older) that examines whether the measure is associated with improved nutritional status or related clinical endpoint”. This endorsement recognizes the value of the GMCS to enhance health care in the United States, and verifies the measure is evidence-based, scientifically sound, and both safe and effective. If you would like more information on the endorsement process, click here.

For measure specifications and implementation tools click here.

Malnutrition is defined as the inadequate intake of nutrients or energy, over time. It can have many root causes, including reduced oral intake, increased energy and nutrient needs, malabsorption, and/or social determinants of health. A hospitalized patient with malnutrition can place a strain on resources, and negatively affect the quality outcomes, as shown in the figure below.

Some of the benefits observed by facilities that implemented malnutrition care processes include a reduction of 27% of 30-day readmission rates4, $4.8 million in cost savings generated by a 4-hospital system5, and 24% relative reduction in readmission risk for malnourished patients with a nutrition care plan7. 

Clinical guidelines for addressing malnutrition in acute care settings establish that a patient should first be screened for malnutrition risk, those at risk should be further assessed, and if found to have malnutrition by screening and assessment, then a nutrition support plan should be established3. Furthermore, an effective malnutrition care process benefits from interdisciplinary collaboration. This type of care offers an opportunity to develop a comprehensive and individualized assessment and treatment plan, and thus supporting accurate diagnosis and effective care. The following graphic shows the key roles different profession in a hospital can offer to help achieve successful implementation of the GMCS.

The GMCS was built following the recommended workflow of evidence-based malnutrition care. It also encourages interdisciplinary care discussions and involvement during the implementation phase and the clinical care itself. Although the GMCS was developed for the acute care setting, its proven framework can be adapted to any practice area to improve patient outcomes and quality of care. 

Benefits of Implementing the GMCS: 

• Providing care measured through the GMCS supports hospitals’ strategic plans to address social determinants of health and equity.
• All four components are often already established to a degree in all acute care facilities. 
• Addresses several clinical areas or quality indicators simultaneously, including: 
  • Nutrition Screening - The Joint Commission 
  • Social Determinants of Health and Food Insecurity - The Joint Commission, CMS, 2023 Healthcare Effectiveness Data and Information Set’s (HEDIS) Social Need Screening and Intervention Measure 
  • Health Equity Advancement - identified by CMS as a priority eCQM 
  • Rural Health Improvement- identified by NQF as a key measure** 
• Combines several quality measures into one single composite score, giving a more comprehensive picture of clinical care than a single measure.
• Promotes multidisciplinary engagement, supporting communication and employee satisfaction efforts.

• Malnutrition Quality Improvement Initiative (MQii): a project of the Academy of Nutrition and Dietetics, Avalere Health, and other stakeholders who collaborate to provide guidance and expertise for clinical malnutrition. The primary goal is to advance evidence-based, high-quality, patient-driven care for hospitalized older adults who are malnourished or at-risk for malnutrition.
  • MQii Toolkit: supports the implementation of malnutrition care best practices.
  • MQii Learning Collaborative, a community of clinicians committed to improving delivery of malnutrition care in hospitals and health systems across the US.
• Reports:  
  • Dialogue Proceedings for Advancing Patient-Centered Malnutrition Care Transitions
  • Roundtable Proceedings for Advancing Health Equity Through Malnutrition Quality Measurement
• Webinar Recordings:
  • August 2022: Global Malnutrition Composite Score
  • August 2023: Global Malnutrition Composite Score Town Hall
  • November 2023: Advancing Quality and Strengthening Interdisciplinary Collaboration (Part I) (1 free CPEU)
  • February 2024: Value of Nutrition and Dietetics Credentialed Practitioners in Optimizing Quality Outcomes from the Interdisciplinary Team Perspective (Part II) (1 free CPEU)
  • May 2024: Measuring Nutrition Practice Outcomes by Demonstrating Value in the Real World (1 free CPEU)
  • July 2024: Understanding the Global Malnutrition Composite Score: Key Insights and Major Updates for Reporting Period 2025 (1 CPEU)
• Infographics:  
  • Infographic: Hospital Value of the Global Malnutrition Composite Score (GMCS) Quality Measure
• Peer-Reviewed Articles:
  • Measuring Malnutrition and Food Insecurity to Facilitate Quality Care and Health Equity. Journal of the Academy of Nutrition and Dietetics. October 2022 Supplement.
  • The Updated Global Malnutrition Composite Score Clinical Quality Measure: Its Relevance to Improving Inpatient Clinical Outcomes and Health Equity. Journal of the Academy of Nutrition and Dietetics. February 2024.
  • The Global Malnutrition Composite Score: Impacting malnutrition care. Nutrition in Clinical Practice. June 2024.
• Additional Education Programs
  • Action Plan to Implement the GMCS
  • Business Case for Implementation of GMCS pre-recorded session (free 4.5 CPEU)
  • Malnutrition and Health Equity: Key Measures of Quality Care for Nutrition and Dietetics Practitioners (free 2.5 CPEU)
  • The Joint Commission Expert to Expert 2024 New Measure Review Webinar for the Global Malnutrition Composite Score eCQM
  • MQii August Virtual Office Hour Session
  • Click here for a list of additional CPE resources, including the Quarterly Spotlight on Quality. 

*Reporting Period is the period where data is collected. Submission Period is when data collected the prior year is submitted, usually during the Spring Quarter. Payment Period is the fiscal year the payment could potentially be affected if criteria for reporting is met or not met. 

Additional implementation resources: 

• Freely available Nutrition Care Process terms

For additional information, questions, or support with implementation needs, please email quality@eatright.org. 

References: 

1. Avalere Health. (2022). Leveraging Inpatient Malnutrition Care to Address Health Disparities. Retrieved July 27, 2023, from https://avalere.com/insights/leveraging-inpatient-malnutrition-care-to-address-health-disparities.
2. Barrett ML, B. M. (2018). Non-maternal and Non-neonatal Inpatient Stays in the United States Involving Malnutrition, 2016. U.S. Agency for Healthcare Research and Quality. Retrieved July 27, 2023, from https://hcup-us.ahrq.gov/reports/ataglance/HCUPMalnutritionHospReport_083018.pdf. 
3. Mueller C, Compher C & Druyan ME and the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors. Nutrition Screening, Assessment, and Intervention in Adults. Journal of Parenteral and Enteral Nutrition. 2011; 35 (1): 16-24. A.S.P.E.N. Clinical Guidelines (wiley.com)
4. Sriram K, Sulo S, VanDerBosch G, et al. A comprehensive nutrition-focused quality improvement program reduces 30-day readmissions and length of stay in hospitalized patients. JPEN J Parenter Enteral Nutr. 2017;41(3):384-391.
5. Sulo S, Feldstein J, Partridge J, et al. Budget impact of a comprehensive nutrition-focused quality improvement program for malnourished hospitalized patients. Am Health Drug Benefits. 2017;10(5):262- 270.
6. Tappenden, KA; Quatrara, B; Parkhurts, M; Malone, A; Fanjiang, G; Ziegler, T. (2013). Critical Role of Nutrition in Improving Quality Care: An Interdisciplinary Call to Action to Address Adult Hospital Malnutrition. J Acad Nutr and Diet. 113 (9); 1219-1237.
7. Valladares AF, Kilgore KM, Partridge J, Sulo S, Kerr KW, McCauley S. How a Malnutrition Quality Improvement Initiative Furthers Malnutrition Measurement and Care: Results From a Hospital Learning Collaborative. JPEN J Parenter Enteral Nutr. 2021 Feb;45(2):366-371.