Effective coordination between medical and long-term services isessential to high-quality primary care for older adults, but can bechallenging. Our study assessed coordination and communication throughsemi-structured interviews with Veterans Health Administration (VHA) primarycare clinicians (n = 9); VHA-contracted home health agencies (n = 6); andhome health aides (n = 8) caring for veterans at an urban VHA medical center.Participants reported (1) establishing home health services is complex,requiring collaboration between many individuals and systems; (2)communication between medical teams and agencies is often reactive; (3)formal communication channels between medical teams and agencies are lacking;(4) aides are an important source of patient information; and (5) aidesreport important information, but rarely receive it. Removing structuralcommunication barriers; incentivizing reporting channels and informationsharing between aides, agencies, and primary care teams; and integratingaides into interdisciplinary teams may improve coordination of medical andlong-term care.