Research shows malnutrition and mortality linked to malnutrition are on the rise in the United States, and management of malnourished patients has significant quality and reimbursement consequences.
Malnutrition is a growing public health problem in the United States.
According to a study published last year by the journal Food Science & Nutrition, mortality from malnutrition has increased by an average of 5.5% annually since 2013. The study also projects that 20% of Americans will be malnourished by 2030.
Historically, malnutrition has been underdiagnosed and inadequately documented in the inpatient setting, which has a direct impact on a hospital's quality metrics and reimbursement. This impact on key performance indicators means malnutrition among hospitalized patients should be a major concern for CMOs, according to Christopher Manasseh, MBBS, associate CMO and family medicine physician at Boston Medical Center.
"CMOs are responsible for clinical outcomes and the accuracy of quality reporting," Manasseh says. "So, consistently identifying, treating, and documenting malnutrition has emerged as part of the core responsibility of a CMO."
There is a direct link between malnutrition and the quality of care and performance of a hospital, Manasseh explains.
"We know that malnutrition can lead to longer length of stay, which is important for any hospital in terms of inpatient quality and performance," Manasseh says. "Malnutrition also impacts hospital readmissions and mortality. All of these outcomes are important for quality scores, and CMOs are starting to realize that they need to address malnutrition urgently."
Identifying, Treating, and Documenting Malnutrition
At Boston Medical Center, the hospital is using a combination of technology and staffing resources to identify malnourished patients.
"With technology such as our integrated electronic health record, we can capture a patient's body mass index, which is available to clinicians when they open a patient's chart," Manasseh says. "The EHR can flag body mass index as indicating that a patient meets criteria for malnutrition, which can prompt a clinician to order a malnutrition consult."
The hospital's documentation staff plays a key role in identifying malnourished patients.
"Our documentation staff sends care teams queries to alert them that a patient meets the criteria for malnutrition and they should document it," Manasseh says.
Once patients have been identified with malnutrition, a CMO must make sure there are processes in place to get patients treatment, according to Manasseh.
"At Boston Medical Center, if a patient's body mass index meets the criteria for malnutrition, our clinicians determine whether a patient has mild, moderate, or severe malnutrition, then a malnutrition consult is ordered," Manasseh says.
After a nutritionist evaluates a patient and provides recommendations to address malnutrition, those recommendations can either be ordered by the nutritionist or ordered by the care team. For example, a nutritionist may recommend a high-protein diet for a patient, and that order is fulfilled on a timely basis. After recommendations have been made, documentation of malnutrition is essential to receive reimbursement for services provided to malnourished patients.
"We have made thorough documentation of malnutrition a priority because it affects our reimbursement," Manasseh says. "If clinicians are not fully documenting malnutrition and attesting to it as a diagnosis, payers are rejecting our claims."
Including a diagnosis of malnutrition in clinical documentation is necessary to reflect the acuity of patients.
"If malnutrition is not documented appropriately, hospitals are underrepresenting patient acuity in CMS reporting and value-based programs," Manasseh says. "You can see this in your expected-to-observed length of stay ratio. The expected length of stay is based on the complexity of a patient and the severity of illness. Malnutrition impacts the severity of illness and if you don't document it, patient acuity will be understated."
Opportunities for Improvement
Boston Medical Center is looking for opportunities to improve the way that the hospital addresses malnutrition.
"At Boston Medical Center, which is a safety net institution, we are taking care of a fragile patient population," Manasseh says. "It is extremely important for us to identify clinical risks such as malnutrition. For us, malnutrition is not just about coding and documentation, it's more than that."
To improve the way it manages patients with malnutrition, the hospital is strongly considering the adoption of an AI tool developed by Qventus.
"Their solution for malnutrition care automation can help us identify at-risk patients and speed up malnutrition consults, so we are not spending a lot of time just to identify patients who meet the criteria for malnutrition," Manasseh says. "Reducing the need for manual chart review and surfacing the relevant clinical information for nutritionists could improve the evaluation of patients and capture the full complexity of patients."
The AI tool would be fully integrated into the hospital's electronic health record, Epic, and it would provide key capabilities, Manasseh explains.
"The Qventus AI tool assesses a patient's risk for malnutrition based on body mass index and characterizes malnutrition as mild, moderate, or severe," Manasseh says. "The AI tool not only provides that information but also prompts action to be taken by ordering a nutrition consult."
Christopher Cheney is the CMO editor at HealthLeaders.
KEY TAKEAWAYS
Malnourished patients impact key quality and performance metrics such as length of stay and hospital readmissions, which are core responsibilities for CMOs.
Identification of malnourished patients is crucial and can be achieved through technology such as electronic health records and dedication of staff resources.
Appropriate documentation of malnutrition is pivotal for hospitals to accurately reflect patient acuity and receive reimbursement for treating malnourished patients.