Home›Nutrition & Obesity Medicine› Continuity of nutrition care for older medical inpatients shows inconsistent outcomes during hospital to home transition
Continuity of nutrition care for older medical inpatients shows inconsistent outcomes during hospital to home transitionContinuity of Care May Help Malnourished Patients After Hospital Discharge
Frontiers in MedicinePublished October 23, 2026DOI ↗Editorial oversight: Dr. Amelia Tan, PhD · Internal Medicine & Chronic Disease
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Key Takeaway
Note that evidence for nutrition care continuity in older patients during hospital-to-home transition is currently inconsistent.
This mini review examines the effectiveness of continuity of nutrition care, including individualized plans, home or telephone follow-up, food provision, and oral nutritional supplements, for older medical inpatients with malnutrition or nutritional risk during the transition from acute hospital to home. The review synthesizes evidence regarding nutritional, functional, and service outcomes.
The authors report that evidence for these outcomes is inconsistent. The review highlights significant gaps in current practice, including inadequate discharge information, low referral uptake, and insufficient support for home implementation. To address these gaps, the authors propose a six-step conceptual framework for transitioning nutrition care from hospital to home.
Several limitations are noted, including attrition, unequal contact intensity, variations in comparator care, and limited reporting of implementation outcomes. It is important to note that the proposed six-step framework is not presented as a validated pathway. Additionally, the specific contribution of nursing staff was not isolated as an independent factor. Clinical application of these findings is currently limited by the lack of consistent evidence regarding specific outcomes.
How this fits prior evidence
This review addresses a gap in the management of malnutrition in older adults by focusing on the transition from hospital to home. While prior coverage has addressed malnutrition in children, such as the 16% TB prevalence in malnourished Ethiopian children and the use of the PMSA-2025 tool for children aged 1 to 10 years, this review focuses specifically on the geriatric population. It also addresses the need for integrated nutritional support, similar to the integrated strategies that improved food access in childhood malnutrition.
This review looked at how patients with malnutrition or nutritional risks are cared for when they leave the hospital. The study focused on the transition from acute hospital care to home life. It looked at whether providing a continuous plan, including home follow-ups and nutritional supplements, improved patient health.
The results showed that the impact of these programs on nutritional and functional outcomes was inconsistent. Because the data was mixed, it is not yet clear how much these specific interventions improve health for every patient. The review also noted that many current programs have gaps in how they share information and support patients at home.
While the study did not prove a specific treatment works, it suggests that a structured framework could help. This means doctors and nurses can better coordinate care during the move home. Patients should talk to their healthcare team to see if a personalized nutrition plan is right for them.
What this means for you:
Consistent nutrition care during hospital discharge shows mixed results and requires more research to confirm.
Common questions
What is continuity of nutrition care?
Continuity of nutrition care means providing a consistent plan for patients as they leave the hospital. This can include individualized nutrition plans, telephone follow-ups, providing food, and giving oral nutritional supplements to help patients maintain their health during the transition to home life.
Does this care help patients with malnutrition?
The review looked at patients with malnutrition or nutritional risk. While the study found inconsistent results regarding nutritional and functional outcomes, it highlighted that many current programs have gaps in how they support patients during the move from hospital to home.
Is there a specific plan for home care?
The review suggests a six-step conceptual framework to help transition nutrition care from hospital to home. However, this framework is not yet a validated pathway, so patients should consult their doctors to determine the best specific plan for their needs.
Nutrition care for older adults with malnutrition or nutritional risk frequently becomes fragmented after hospital discharge. This Mini Review examines documented continuity failures, evaluated interventions, and nursing contributions within interdisciplinary care. A focused, non-exhaustive PubMed and Europe PMC search was updated through 14 September 2026, with targeted citation checks. Evidence was selected for relevance to acute hospital-to-home care; mixed populations and adjacent settings were distinguished. No formal risk-of-bias assessment or meta-analysis was performed. Audits and qualitative studies identified gaps in discharge information, referral uptake, and support for implementing plans at home. Trials of individualized plans, home or telephone follow-up, food provision, and oral nutritional supplements showed inconsistent nutritional, functional, and service outcomes. Nursing participation was documented in some multicomponent interventions, but its independent contribution was not isolated. Attrition, unequal contact intensity, comparator care, and limited reporting of implementation outcomes constrain interpretation. Drawing on these findings, we propose a literature-informed six-step conceptual framework covering readiness and goals, portable handover, acknowledged responsibility, follow-up, escalation, and audit with feedback. Its operational measures and interdisciplinary responsibilities are specified for prospective testing, not presented as a validated pathway. Evaluation should distinguish clinical effectiveness from delivery, patient adherence, and equitable access, while incorporating patient preferences and caregiver capacity.
