Aim To determine whether the outcomes of home enteral nutrition for frail older patients can be improved by video consultation between home visiting staff and a hospital physician, specialized in clinical nutrition, during monthly home visits. Methods A randomized prospective study out of patients aged older than 65 years receiving home enteral nutrition from the Department of Clinical Nutrition of an Italian geriatric hospital in 2013 was carried. A total of 100 patients were randomly assigned to receive video consultation in addition to regular monthly home visits, 88 patients only had regular monthly home visits. Therapy outcomes – incidence rates of complications, outpatient hospital visits and hospitalizations – were compared between two groups. A logistic regression analysis was carried out to evaluate the usefulness of the video consultation to improve therapy outcomes. Results Incidence rates for metabolic and gastrointestinal complications were significantly lower for patients who received a video consultation, respectively: 0.032/year “video consultation” versus 0.055/year “no video consultation” (P = 0.0001) and 0.006/year “video consultation” versus 0.028/year “no video consultation” (P < 0.0001). No differences were found for incidence rates of mechanical complications, outpatient hospital visits and hospitalizations. Logistic regression showed that the video consultation was significantly correlated with a reduction of metabolic complications (OR 2.63, 95% CI 1.00–6.91; P = 0.049 after adjustment for duration of home enteral nutrition and diabetes mellitus 2). Conclusion The present study provides evidence that a video consultation between home visiting staff and hospital physicians specialized in clinical nutrition during monthly home visits is associated with a reduction of metabolic complications in a population of frail older patients. Geriatr Gerontol Int 2015; ●●: ●●–●●.