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March 7, 2026HealthcareOpen Access

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

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Key result

Nurse-led discharge and proactive follow-up improve experience and reduce early complications in high-risk patients.

Why the study?

Discontinuities remain common during transitions between hospital and community care, leading to fragmented communication, delayed follow-up, negative patient experiences, and avoidable harm.

Design

Narrative review

Authors

LMLiron MarkovichYSYael SelaKGKeren Grinberg

Discussion

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Overview

Warrants broader nurse-led transitional programs for high-risk discharges; reinforces consensus on multi-level continuity to cut early complications.

Key Points

  • The review aims to explore the concept of continuity of care during transitions from hospital to community settings, particularly in relation to nursing practice.
  • Conducted literature searches in PubMed and CINAHL from 2002 to 2024.
  • Prioritized sources for conceptual frameworks and empirical studies related to care transitions.
  • Included patient experience and nursing strategies to enhance continuity.
  • Continuity is often viewed through informational, management, and relational lenses.
  • Identified major issues include failures in discharge information transfer and unclear post-discharge responsibilities.
  • Found that structured discharge processes and proactive follow-up improve patient experiences and reduce complications.

Structured PICO

P
Population
Older adults and people living with chronic and complex conditions undergoing hospital-to-community transitions
I
Intervention
Nursing-relevant approaches to strengthen continuity (e.g., structured discharge processes with proactive post-discharge follow-up and a consistent point of contact)
O
Outcome
Continuity of care (informational, management, and relational), patient experience, and early post-discharge complications

Strengthening continuity of care during hospital-to-community transitions requires multi-level strategies addressing information transfer, accountability, and sustained therapeutic relationships.

Limitations

  • As a narrative review, findings reflect interpretative synthesis rather than systematic evidence aggregation.

Cite This Study

Markovich et al. (2026) studied this question. Nurse-led interventions combining structured discharge, proactive follow-up, and a consistent contact improve patient experiences and reduce early post-discharge complications in high-risk groups.

synapsesocial.com/papers/69abc2075af8044f7a4eb2a5https://doi.org/10.3390/healthcare14050656
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Also Consider

Synapse has enriched 5 closely related papers on similar clinical questions. Consider them for comparative context:

  1. 1Care Transitions: Using Narratives to Assess Continuity of Care Provided to Older Patients after Hospital Discharge2016 · 17 citations
  2. 2Missed continuity of nursing and therapy care at the point of intensive care unit step-down: A scoping review2026
  3. 3Which transitions count? A systematic hermeneutic review of the literature on transitions of care2026
  4. 4Clarifying model for continuity of care: A concept analysis2018 · 65 citations
  5. 5The Documentation Used by the Nurses During the Transition From the Hospital to the Community Setting: A Scoping Review2025 · 1 citations