The Case for Malnutrition Quality Measures and Nutrition-Focused Quality Improvement Programs (QIPs) in US Skilled Nursing Facilities

Abstract

As skilled nursing in the United States moves to a value-based model, malnutrition care remains a critical gap area that is associated with multiple poor health outcomes, including hospital readmissions and declines in functional status, psychosocial well-being, and quality of life. Malnutrition is often undiagnosed/untreated, even though it impacts up to half of skilled nursing facility (SNF) residents, and COVID-19 infections/related symptoms have likely further increased this risk. In acute care, malnutrition quality measures have been both developed/tested, and nutrition-focused quality improvement programs (QIPs) have been shown to reduce costs and effectively improve care processes and patient outcomes. Less is known about such quality initiatives in SNF care. This perspective paper reviewed malnutrition-related quality measures and nutrition-focused QIPs in SNFs and nursing home care. It identified that although the Centers for Medicare & Medicaid Services (CMS) has had a nursing home Quality Assurance and Performance Improvement (QAPI) program for 10 years and has had SNF quality measures for nearly 20 years, there are no malnutrition-specific quality measures for SNFs and very few published nutrition-focused QIPs in SNFs. This represents an important care gap that should be addressed to improve resident health outcomes as SNFs more fully move to a value-based care model.

The Impact of Malnutrition on Skin Integrity and Wound Healing

“…The 38,39 Selected data points support the value of the RDN as an integral part of the Medicare Quality Initiatives and incorporated in the postacute care facilities' quality improvement program. 40 In the hospital care setting, malnutrition quality measures have been developed and tested.…”

“…This type of data is not readily available for quality initiatives implemented in postacute care. 38…”

“…Data for this report are collected through the entries made on the Minimum Data Set Assessment, information collected from the CDC National Healthcare Network, and Medicare Fee-for-Service Claims. Although the QRP does not include nutrition-specific indicators, it does include indicators related to overall nutrition status including skin integrity and changes in skin integrity and functional status; cognitive function and mental status; special services, treatments, and interventions (ie, total parenteral nutrition); and impairments (ie, dysphagia) 38,39 . Selected data points support the value of the RDN as an integral part of the Medicare Quality Initiatives and incorporated in the postacute care facilities’ quality improvement program 40…”

“…Quality improvement programs with a nutrition focus in acute care have proven to reduce the cost of care and promote positive clinical outcomes. This type of data is not readily available for quality initiatives implemented in postacute care 38 …”

Prevalence Rates and Characteristics of Malnutrition, Frailty, and Other Nutrition and Muscle Mass-Related Conditions Document Potential Quality of Care Gap for Medicare Patients in US Skilled Nursing Facilities

“…This means the registered dietitian nutritionist must rely on the interdisciplinary team to identify patients at risk for nutrition/muscle mass-related conditions. In addition, the registered dietitian nutritionist must communicate effectively with the medical director to ensure that these conditions are accurately diagnosed and have appropriate medical record documentation [45]. Another reason for the potential care gap could be lack of awareness.…”