The long term objective of this research program is to improve patient outcomes and decrease health care costs by developing strategies to improve communication between continuing care providers. Poor patient outcomes, such as unplanned hospital readmissions, have been associated with flawed communication, but the role of continuing care communication (CCC) in patient outcomes is not well understood. Further, little evidence exists concerning patient and organizational factors surrounding hospital readmission while receiving home care services. To date, no studies concerning the role of CCC and patient outcomes from home health care have been found. Continuity in patient care is a series of linkages across time, settings, providers, and consumers of health care, requiring intra- and inter-organizational communication. Continuing care communication (CCC) links providers in transitional health care organizations, who send and receive patient care data along the continuum of care. A previously tested model of CCC in health services delivery integrates the conceptual and empirical components of this project. Using a retrospective descriptive design and data collection tools with established psychometric properties, 900 records of referral by hospitals and skilled care units to home care will be reviewed. The amount and type of CCC for patients who are not readmitted to the hospital and for those who are readmitted to the hospital during home care service delivery will be compared, organizational and patient characteristics as well as communication practices associated with CCC for the two patient groups will be described, and communication channels associated with better information transfer between referring and receiving agencies will be identified. Findings will have clinical application in structuring more effective strategies for communication about patient needs in a future intervention project, as well as refining the model of CCC.