Nurse-Led Family and Community Care for Continuity Across Hospital-to-Home Transitions: An Evidence-Informed Narrative Review

Abstract

Continuity of nursing care is often disrupted during hospital-to-home transitions, when family caregivers assume complex responsibilities with limited professional support. This evidence-informed narrative review examined how nurse-led family involvement and community coordination strengthen care continuity for adults with chronic illness, multimorbidity, frailty, or disability. A purposive search of PubMed, journal and publisher sources, and World Health Organization guidance covered evidence available through 31 July 2026. Randomized trials, systematic reviews, qualitative studies, and implementation research were synthesized across relational, informational, and management continuity. Recent evidence suggests improvements in patient functioning, self-management, caregiver preparedness, and selected readmission outcomes. However, evidence certainty remains limited, findings are heterogeneous, and benefits for caregiver burden and healthcare utilization are inconsistent. The review proposes a nurse-led family–community pathway integrating predischarge assessment, collaborative education, structured information transfer, coordinated community handover, early follow-up, and escalation procedures. Effective continuity requires ongoing assessment of patient and caregiver capabilities, accessible community support, and safety monitoring. Further research should evaluate intervention fidelity, patient independence, caregiver burden, equity, and sustainability.