The research team developed the Nutrition Support Assessment Tool (NSAT) that incorporates key patient life information (e.g., ability to cook, access to refrigerator/stove, medical conditions and nutritional status) to facilitate individualized nutrition referral. The overall goal of this study is to refine and test the NSAT as a systematic approach to provide individualized nutrition needs screening and referral for patients being discharged from the acute care setting at Jefferson Health. The investigators hypothesize the NSAT will be successful in identifying individualized nutrition referrals that are deemed acceptable and appropriate by enrolled participants.

Inclusion Criteria:

• 18 years of age or older
• Currently admitted to Thomas Jefferson University or Methodist Hospital or Emergency Department
• Has working phone number and is willing to participate in follow-up data collection
• Eats by mouth
• Lives in MANNA's geographic service area
• Patient reports food insecurity or malnutrition using existing screening tools

Exclusion Criteria:

• Unwilling to provide consent
• Unsheltered/unhoused
• Lives in or is being discharged to facility that provides daily meals (e.g., long term care, incarcerated)
• On hospice or has life expectancy of less than 4 months, per clinician
• Not consentable
• Deaf or has other major communication barriers that compromises ability to participate in study activities