Nurse-Led Family and Community Care for Continuity Across Hospital-to-Home Transitions: An Evidence-Informed Narrative Review
6 affiliations
- 1Doctoral Program of Nursing, Faculty of Nursing, Universitas Airlangga; Universitas Muhammadiyah Semarang
- 2Doctoral Program of Nursing, Faculty of Nursing, Universitas Airlangga; Universitas Diponegoro
- 3Doctoral Program of Nursing, Faculty of Nursing, Universitas Airlangga; Universitas Ngudi Waluyo
- 4Doctoral Program of Nursing, Faculty of Nursing, Universitas Airlangga; Universitas Abdurrab
- 5Doctoral Program of Nursing, Faculty of Nursing, Universitas Airlangga
- 6Doctoral Program of Nursing, Faculty of Nursing, Universitas Airlangga; STIKes Gunung Maria Tomohon
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.
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BibTeX
@article{yanto2026nurseled,
title = {{Nurse-Led Family and Community Care for Continuity Across Hospital-to-Home Transitions: An Evidence-Informed Narrative Review}},
author = {Arief Yanto and Devi Nurmalia and Fiki Wijayanti and Andalia Roza and Ilkafah Ilkafah and Vina Putri Patandung},
journal = {South East Asia Nursing Research},
year = {2026},
month = oct,
doi = {10.26714/seanr.8.3.2026.146-161},
url = {https://doi.org/10.26714/seanr.8.3.2026.146-161},
note = {CC BY},
}
RIS
TY - JOUR
TI - Nurse-Led Family and Community Care for Continuity Across Hospital-to-Home Transitions: An Evidence-Informed Narrative Review
AU - Arief Yanto
AU - Devi Nurmalia
AU - Fiki Wijayanti
AU - Andalia Roza
AU - Ilkafah Ilkafah
AU - Vina Putri Patandung
PY - 2026
DA - 2026/10/01
JO - South East Asia Nursing Research
DO - 10.26714/seanr.8.3.2026.146-161
UR - https://doi.org/10.26714/seanr.8.3.2026.146-161
AB - 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.
SN - 2685-032X
ER -