Continuity of Care Across Hospital-to-Community Transitions: A Narrative Review Integrating Concepts, Measurement,...

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.