Bridging the Gap in Chronic Disease Management: A Nursing Perspective on the Use of Predictive Tools and Telemedicine in the Hospital–Community Transition

Chronic diseases represent one of the most complex, costly, and significant challenges for healthcare systems. The increase in chronic conditions and multimorbidity, together with the growing demand for continuity of care makes the vulnerability of the hospital-to-community transition increasingly evident. This phase is often characterized by delays, fragmented services, and insufficient support for patients and caregivers, leading to higher rates of early readmission and substantial clinical, social, and economic impacts. This paper was developed through a narrative synthesis of international and national literature on continuity of care, integrated models, and nurse-led experiences. Based on this synthesis, an integrated six-phase nursing model is proposed, combining predictive assessment tools and telemedicine to enhance early risk identification, proactive discharge planning, and post-discharge follow-up. Evidence indicates that nurse-led interventions supported by digital solutions can reduce inappropriate hospital days, decrease hospital readmissions, and improve patient and caregiver satisfaction. The integration of predictive tools and telemedicine solutions, coordinated by nurse case managers, represents a promising strategy to strengthen continuity of care and the sustainability of the healthcare system, and the proposed conceptual model highlights practical implications while outlining future research directions for empirical validation and large-scale implementation.