Background Reducing hospital readmissions depends on ensuring safe care transitions, which requires a better understanding of the challenges experienced by key stakeholders. Objective Develop a descriptive framework illustrating the interconnected roles of patients, providers and caregivers in relation to readmissions. Design Multi-method qualitative study with four focus groups and 43 semi-structured interviews. Multiple perspectives were included to increase the trustworthiness (internal validity) and transferability (external validity) of the results. Data were analyzed using Grounded Theory to generate themes associated with readmission. Setting/Patients General medicine patients with same-site 30-day readmissions, their family members, and multiple care providers at a large urban academic medical center. Results A keynote generated from the multi-perspective responses was that care transitions were optimized by a well-coordinated multidiscipline support system, described as the Patient Care Circle. In addition, issues pertaining to readmissions were identified and classified into five main themes emphasizing the necessity of a coordinated support network: (1) Teamwork; (2) Health systems navigation and management; (3) Illness severity and health needs; (4) Psychosocial stability; (5) Medications. Conclusion A well-coordinated collaborative Patient Care Circle is fundamental to ensuring safe care transitions.