Objectives Healthcare expenditures in the United States have increased exponentially and hospital care accounts for one-third of these costs. Approximately 18% of hospitalized Medicare beneficiaries are being readmitted to the hospital within 30 days. Engaging patients in the discharge process can help better identify patients' postdischarge needs and implement more effective readmission prevention strategies. The objective of our study was to identify the factors that contribute to hospital readmission as seen from patients' perspectives in a large urban community hospital. Methods We evaluated all consecutive, unplanned readmissions to the hospitalist service within 30 days of discharge, using the STate Action on Avoidable Rehospitalizations diagnostic worksheet with face-to-face patient interviews and retrospective chart reviews. Results During the study period, 80 patients were readmitted within 30 days of their discharge, with 28 of them having more than one readmission. The mean age was 50.8 18.3 years. Of the 80 patients, 51% were men and 51% were black. Sickle cell disease was the leading diagnosis (11.3%) in both index admissions and readmissions. Patient interviews identified some modifiable risk factors for readmissions such as the inability to obtain medications or schedule follow-up appointments as well as problems related to transportation, housing, and social support. Despite clear discharge planning and patient understanding of the plan being recorded at discharge, almost one-third of patients appeared to lack the ability to self-manage symptoms and understand the disease process. Conclusions Our study demonstrated that engaging patients in discharge planning can help identify barriers within the process. Improvements in socioeconomic/environmental layers of population health have the potential to prevent hospitalizations and readmissions in the long term.