Transitions from hospital to community palliative services expose patients and families to a distinctive continuity problem. Clinical information may be transferred while responsibility, follow-through, relational knowledge, and mechanisms for resolving uncertainty remain fragmented. This conceptual article develops a cross-setting continuity framework for examining that problem. It integrates informational, management, and relational continuity with clinical handover content, accountability transfer, interprofessional communication, patient and family participation, and feedback between hospital and community services. The central argument is that continuity after discharge depends on whether clinically relevant information becomes interpretable and actionable within a receiving system that has accepted responsibility and can respond when needs change. The framework therefore distinguishes transmission from receipt, receipt from enactment, and planned home care from the adaptive escalation that may become appropriate as illness, caregiver capacity, or preferences change. This approach provides a basis for analysing transition failures without treating every hospital return as evidence of failed care. It also identifies testable service-design and evaluation questions for cross-setting palliative practice.
