Going Beyond the Hospital: Nutrition and Quality Across the Care Continuum 

Nutrition is increasingly recognized as a foundational component of health, yet until recently, nutrition-focused care was treated as an add-on rather than an essential clinical service. Diet-related diseases such as type 2 diabetes, obesity, hypertension, and certain cancers now account for a substantial share of morbidity, mortality, and healthcare spending in the United States. As healthcare shifts toward value-based, whole-person models, the role of clinical nutrition care in optimizing health outcomes is being recognized and expanding into post-acute, primary care, specialty care, and community-based environments. Federal payment programs and innovation models are beginning to formally acknowledge nutrition’s role in improving outcomes, reducing fragmentation, and supporting population health. 

 This growing alignment between nutrition, healthcare quality, and clinical outcomes signals an opportunity for clinicians, health systems, and payers to strengthen care coordination across the continuum and embed nutrition within all aspects of the patient journey, including chronic disease management, preventative care, perioperative care, wound healing, and care transitions. 

Understanding Nutrition’s Expanding Footprint in Quality and Value-Based Payment 

Efforts to elevate the quality and expand the delivery of nutrition care have been fragmented, with the most notable success coming with the adoption of the Malnutrition Care Score (MCS) quality measure in 2024 for the hospital inpatient setting. While a hospital setting is well-suited to identifying patients’ nutritional needs and developing a care plan, carrying out that care plan and engaging the patient in long-term nutrition improvement must occur outside the hospital walls. However, there have been few regulatory requirements or quality incentives focused on nutritional care management or interventions beyond the hospital, and none holding providers accountable for effective communication and implementation of the nutrition care plan during patient transitions between care settings. But in 2025, the Department of Health and Human Services’s new vision to “Make America Healthy Again” through an emphasis on prevention, nutrition, physical activity, and wellness has manifested itself through several major rules and payment models that are already fueling care transformation. 

Recent announcements from CMS have underscored this shift in focus: 

• Every major Medicare payment proposed rule this year, including the inpatient, outpatient, home health, skilled nursing, and physician fee schedules, has included a Request for Information (RFI) for how CMS can incorporate well-being, prevention, and nutrition, such as quality measures on “tools and measures that assess optimal nutrition and preventive care” (inpatient and outpatient), asking “Should CMS consider creating separate coding and payment for medically-tailored meals”, (physician fee schedule), measure concepts around “tools and frameworks that promote healthy eating habits” (home health), and nutrition-focused quality measures that could be used in value-based purchasing (skilled nursing facility). 

• Recently-announced Innovation Center models are focused almost exclusively on prevention with a major emphasis on nutrition’s role in prevention. The new ACCESS model (Advancing Chronic Care with Effective, Scalable Solutions) funds the use of technology like telehealth, wearables, and healthy lifestyle apps to empower Medicare beneficiaries to better manage their health in ways that prevent chronic disease or better manage their chronic disease to prevent progression and complications. The MAHA ELEVATE model (Make America Healthy Again: Enhancing Lifestyle and Evaluating Value-based Approaches Through Evidence) will promote functional medicine and lifestyle interventions to improve population health while generating high-quality evidence for the value of those interventions. 

• The Medicare Advantage program, which administers coverage for approximately half of the nation’s Medicare-eligible beneficiaries through private insurers, issued a request for public input in its 2027 contract year proposed rule on tools and policies that promote nutrition, including mechanisms to “ensure the risk borne by MA organizations provides the adequate incentive to support beneficiaries seeking to improve their nutritional habits.” 
• NCQA, which administers the HEDIS® measure program for health plans as well as numerous quality certification programs for both public and private healthcare organizations, has indicated a new focus on wellness and prevention, forming a working group of industry experts to advise on delivery, management, and assessment of wellness and condition management programs. 

Health System Implications: Building a Cross-Continuum Nutrition Strategy 

As these payment models in Medicare, Medicaid, and commercial plans move toward accountability for total cost and long-term outcomes, nutrition is clearly seen as a high-impact intervention with strong potential for cost avoidance and quality improvement. Poor nutrition and dietary risk factors (including malnutrition, poor dietary quality, obesity, and diet-related chronic disease) remain major drivers of morbidity, complications, and readmissions, and can be particularly impactful in surgical episodes, where poor nutrition can impede recovery and wound healing. Embedding nutrition earlier in the care journey and across settings can help mitigate those risks, which is a tactic clearly being recognized by policy makers and quality leaders. Key tactics being proposed, incentivized, and/or implemented include: 

• Embedding registered dietitians and nutrition professionals within outpatient and primary care settings, where they can provide medical nutrition therapy, healthy diet counseling, and follow-up for chronic disease and post-hospital discharge care.  

• Integrating nutrition screening and social risk/food-security assessment into EHR workflows, so that diet-related risks can be identified, flagged, and addressed over time, including through referrals, community resources, and coordinated care across settings. Even if nutrition is not yet a stand-alone quality measure in non-hospital settings, such data capture creates a foundation for future measurement and improved care coordination. 

• Focusing on transitional care and post-acute follow-up, particularly for patients discharged from inpatient stays with malnutrition or other nutrition-sensitive conditions (e.g., heart failure, renal disease, chronic wounds). Outpatient teams (primary care, home health, nutrition) can collaborate to prevent readmissions, consistent with population health cost and quality objectives. 

Evidence and Policy Trends – Why Now Is the Time to Act 

A growing body of clinical evidence continues to underscore nutrition’s central role in preventing and managing chronic disease and mitigating hospital readmissions, complications, and long-term morbidity. The payment and policy shift toward prevention and chronic disease management suggests that nutrition will increasingly be part of long-term strategies for improving health outcomes and reducing costs. The administration’s vision to “Make America Health Again” creates a favorable regulatory environment for health systems to begin integrating nutrition systematically across care settings. The broader structural realignment toward value-based, integrated, and preventive care lays the groundwork for nutrition to become a standard component of care across the continuum. By proactively embedding nutrition services such as medical nutrition therapy, dietitian support, malnutrition screening, or food-is-medicine-like initiatives in ambulatory and post-acute care settings, health systems and clinicians can both improve patient outcomes and position themselves for long-term success under value-based payment models. Now is the moment to go beyond the hospital, to make nutrition an essential, visible, and measurable part of quality across settings.