2021 HCPR18: Unintentional Weight Loss – Risk Assessment and Plan of Care 

Measure Description

Percentage of Adult Post-acute Facility Patients that Had a Risk Assessment for Unintentional Weight Loss and a Plan of Care for Unintentional Weight Loss Documented by Provider

Denominator

• Adult patients aged ≥ 18 years evaluated by the Eligible Professional in the Post-acute Facility (E/M Codes 99304-99310, 99315, 99316)

Numerator

Adult Post-acute Facility Patients that Had a Risk Assessment for Unintentional Weight Loss, Reason for Weight Loss (If Applicable) and a Plan of Care for Unintentional Weight Loss Documented

Definitions

• Weight loss episode: A loss of weight equal to or greater than 5% within a 30-day period or 10% within a 180-day period
  • Starting with the patient’s weight closest to 30 days ago, the patient’s current weight is equal to or less than 95%. Starting with the patient’s weight closest to 180 days ago, the patient’s current weight is equal to or less than 90%
• Risk Assessment:
  • Nationally recognized tool [e.g., Minimum Data Set (MDS) Swallowing/Nutritional Status, Mini Nutritional Assessment (MNA), Malnutrition Screening] Tool (MST)] which includes the following:
    • Weight
    • Height
    • Body Mass Index (BMI)
    • Recent Weight loss
    • Recent Intake (e.g. reduced intake, nutritional approach)
    • Swallowing Disorder
    • Severity of Disease
• Plan Of Care:
  • Oral nutrition support (e.g., therapeutic diet, mechanically altered diet, condition specific diet, fortified foods, and/or supplements)
  • Parenteral feeding
  • Enteral feeding tube
  • Patient-centered and/or condition-specific considerations (e.g., prescription of orexigenic alternatives to anorectic drugs, hydration and edema status, increased nutritional needs for patients at high risk of pressure ulcers, patient preferences and availability of choices for foods and fluids, feeding assistance by staff to enhance the resident’s self-feeding ability, social stimulation throughout meal or snack period)

Numerator Options

• Performance Met (PRO11): Patients who did have a risk assessment for unintentional weight loss, reason for weight loss (if applicable) AND a plan of care for unintentional weight loss documented
• Performance Not Met (PRO12): Patients who did not have a risk assessment for unintentional weight loss, reason for weight loss (if applicable) AND a plan of care for unintentional weight loss documented

Numerator Exclusions

None

NQF ID Number

N/A

NQS Domain

Patient Safety

High Priority Measure

Yes

Includes Telehealth?

Yes

Inverse Measure

No

Proportional Measure

Yes

Continuous Variable Measure

No

Ratio Measure

No

Number of performance rates to be calculated and submitted

1

Risk-Adjusted Status?

No

Meaningful Measure

Preventive Care

Measure Type

Process

Care Settings

Post-Acute Care