Discharges from the hospital to community-based settings are more difficult for older adults when there is lack of communication, resource sharing, and viable partnerships among service providers in these settings. The researchers captured the perspectives of three different groups of participants from hospitals, independent living centers, and Area Agencies on Aging, which has rarely been done in studies on discharge planning. Findings include identification of barriers in the assessment and referral process (e.g., timing of discharge, inattention to client goals, lack of communication and partnerships between hospital discharge planners and community providers), and strategies for overcoming these barriers. Implications are discussed including potential for Medicaid and Medicare cost reductions due to fewer re-hospitalizations.