Patients discharged without home care referral were presented as case studies to nurses, social workers, physicians, and discharge planners experienced in discharge planning. Observations and tape-recorded interviews were used to identify patterns clinicians used when gathering information, determine information essential to discharge referral decisions, and explore why patients in need may not be referred for service. Clinicians collected information randomly, and content analysis of their interviews identified mental and functional status, treatment adherence, medical and co-existing conditions, medication management, social support, and prior hospitalization as essential information. Three themes describe why patients may not receive needed referrals: patient characteristics, workload and staffing, and educational issues. Suggestions for improved practice and further research are based on these themes.