Continuity of Care and Patient Experience During Hospital-to-Community Transitions: A Narrative Review

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: This narrative review synthesizes key conceptual and empirical literature on continuity of care and care transitions, with a focus on how continuity is defined, conceptualized, and strengthened across settings. Results: Continuity is presented as a multidimensional construct encompassing informational, management, and relational continuity, and its relationship to overlapping constructs such as discharge planning, care coordination, and transitional care is clarified. Evidence summarized in this review indicates that persistent gaps in information transfer and unclear professional accountability con-tinue to undermine safe and effective transitions, underscoring the importance of structured transitional processes and strong interprofessional collaboration. The review also highlights patient-reported approaches to assessing continuity and transitional care qual-ity, including validated instruments that capture the patient perspective, alongside ad-ministrative indicators. Finally, nursing-relevant approaches that may strengthen continuity including nurse-led transitional care, navigation and care-coordination roles, inte-grated care approaches, and patient-centered models in primary and community care- are discussed. Conclusions: Overall, continuity of care should be understood as both a structural and relational process that requires multi-level strategies to reduce fragmentation, improve coordination, and enhance patient experience across care transitions.