Purpose Although previous research indicates that care transitions differ between rural and urban areas, the knowledge of challenges related to care transitions in rural areas appears limited. This study aimed to provide a deeper understanding of what registered nurses’ perceive as the main concerns in care transitions from hospital care to home healthcare in rural areas, and how they handle these during the care transition process. Methods A Constructivist Grounded Theory method based on individual interviews with 21 registered nurses. Results The main concern in the transition process was “Care coordination in a complex context”. The complexity stemmed from several environmental and organizational factors, creating a messy and fragmented context for registered nurses to navigate. The core category “Actively communicating to reduce patient safety risks” was explained by the three categories– “Collaborating on expected care needs”, “Anticipating obstacles” and “Timing the departure”. Conclusions The study shows a very complex and stressed process that includes several organizations and actors. Reducing risks during the transition process can be facilitated by clear guidelines, tools for communication across organizations and sufficient staffing.