# Continuity of Care Across Hospital-to-Community Transitions: A Narrative Review Integrating Concepts, Measurement, and Nursing-Relevant Approaches

## TL;DR

This review highlights how poor communication and unclear responsibilities during hospital discharges lead to fragmented care, especially for older and complex patients, and suggests strategies involving nurses to improve continuity.

## Contribution

The paper integrates concepts, measurement tools, and nursing approaches to provide a comprehensive understanding of continuity of care during hospital-to-community transitions.

## Key findings

- Informational and relational gaps are major causes of fragmented care during hospital discharges.
- Nurse-led interventions with structured processes and follow-up improve patient experiences and reduce complications.
- Patient-reported measures and administrative indicators together better capture continuity of care.

## Abstract

What are the main findings?
Continuity of care during hospital-to-community transitions is a multidimensional construct encompassing informational, management, and relational continuity.Persistent gaps in information transfer and unclear professional accountability remain key contributors to fragmented transitions and negative patient experiences, particularly among older adults and people with complex conditions.

Continuity of care during hospital-to-community transitions is a multidimensional construct encompassing informational, management, and relational continuity.

Persistent gaps in information transfer and unclear professional accountability remain key contributors to fragmented transitions and negative patient experiences, particularly among older adults and people with complex conditions.

What are the implications of the main findings?
Strengthening continuity requires coordinated, multi-level strategies that combine structured transitional processes with sustained professional relationships, especially through nursing roles.Evaluating continuity should integrate patient-reported measures with administrative and clinical indicators to capture whether care is experienced as coherent, supportive, and person-centered.

Strengthening continuity requires coordinated, multi-level strategies that combine structured transitional processes with sustained professional relationships, especially through nursing roles.

Evaluating continuity should integrate patient-reported measures with administrative and clinical indicators to capture whether care is experienced as coherent, supportive, and person-centered.

Background: Continuity of care is a core component of high-quality, patient-centered health systems and a central domain of nursing practice, particularly for older adults and people living with chronic and complex conditions. Yet discontinuities remain common during transitions between hospital and community care, contributing to fragmented communication, delayed follow-up, negative patient experiences, and avoidable harm. Methods: Literature was identified through iterative searches in PubMed and CINAHL (2002–2024), complemented by citation tracking of seminal frameworks and reference-list screening. Sources were prioritized for conceptual frameworks and empirical studies/reviews addressing hospital-to-community transitions, patient experience, and nursing-relevant strategies to strengthen continuity. Results: Across the reviewed literature, continuity was most frequently conceptualized as informational, management, and relational continuity. Most empirical studies and reviews highlighted discharge information-transfer failures and unclear post-discharge responsibility as recurrent drivers of discontinuity, particularly among older adults and people with complex needs. Evidence also suggests that interventions combining structured discharge processes with proactive post-discharge follow-up and a consistent point of contact (often nurse-led) are associated with improved patient experience and fewer early post-discharge complications in high-risk groups. Patient-reported instruments (e.g., PCCQ and CAHPS-derived domains) complement administrative indicators by capturing continuity as lived experience. Limitations: As a narrative review, findings reflect interpretative synthesis rather than systematic evidence aggregation. Conclusions: Continuity of care should be understood as both a structural and relational process; strengthening it likely requires multi-level strategies that address information transfer, accountability, and sustained therapeutic relationships across care transitions.