BACKGROUND Little is known about patient perspectives of the transition from hospital to home. OBJECTIVE To develop a richly detailed, patient-centered view of patient and caregiver needs in the hospital-to-home transition. DESIGN An ethnographic approach including participant observation and in-depth, semi-structured video recorded interviews. SETTING Kaiser Permanente's Southern California, Colorado, and Hawaii regions. PATIENTS Twenty-four adult inpatients hospitalized for a range of acute and chronic conditions and characterized by variety in diagnoses, illness severity, planned or unplanned hospitalization, age, and ability to self manage. RESULTS During the hospital-to-home transition, patients and caregivers expressed or demonstrated experiences in 6 domains: 1) translating knowledge into safe, health-promoting actions at home; 2) inclusion of caregivers at every step of the transition process; 3) having readily available problem-solving resources; 4) feeling connected to and trusting providers; 5) transitioning from illness-defined experience to "normal" life; and 6) anticipating needs after discharge and making arrangements to meet them. The work of transitioning occurs for patients and caregivers in the hours and days after they return home and is fraught with challenges. CONCLUSIONS Reducing readmissions will remain challenging without a broadened understanding of the types of support and coaching patients need after discharge. We are piloting strategies such as risk stratification and tailoring of care, a specialized phone number for recently discharged patients, standardized same-day discharge summaries to primary care providers, medication reconciliation, follow-up phone calls, and scheduling appointments before discharge.