Discussion
A smooth transition from the hospital to the home is critical to improving posthospitalization patient outcomes. Many studies have examined the transition of patients from the hospital to the home, and have focused on discharge planning or postdischarge interventions in an effort to improve patient outcomes and reduce unscheduled readmissions. 38–46 The goal of this pilot study was to identify patient characteristics, organizational factors, and processes that impede “seamless care” and could be targeted for interventions in subsequent studies