Abstract
Caring for a patient on a home ventilator requires a trained multidisciplinary home care team. Availability of home medical care support at our restructured hospitals allows timely discharge of these patients to their homes, resulting in decreased hospitalisation stay in an acute hospital; or the need of an intermediate care facility. We described a case where collaboration between two family physician-led transitional home care teams from two restructured hospitals resulted in safe transfer of care for a patient with amyotrophic lateral sclerosis requiring ventilator support. The importance of a multidisciplinary team effort in integration of medical and social care services to reduce unnecessary hospital utilisation was highlighted. The expertise and resources of home medical care teams must continually be enhanced to manage increasing number of patients with complex medical problems, including those requiring home ventilators.