The study investigated how to improve the transition of care for sepsis survivors from hospital to home care. The research included 91 executives from 16 hospitals and 5 home health care agencies in four states. The goal was to provide patients with home health care and outpatient visits within one week of discharge from the hospital. Analysis of 61 interviews revealed 32 major themes, with care coordination, insufficient staffing, electronic health record issues, and information transfer between providers being the biggest barriers. Executives proposed specific strategies to address these issues, including changing record systems, better communication of clinical data, and staff education. Functional electronic health records, quality staffing and clear home health care processes were identified as facilitators of successful implementation. Patient education about the risks and the need for follow-up after discharge has been shown to be critical to a successful transition of care.