Leaving hospital should not mean a plunge into uncertain, incomplete care. Too often in Australia that is the outcome where often vulnerable patients are discharged without complete medication and other records and a clear care plan, into an unorganised setting in which informed team work by different health professionals is absent. What is best for the patient requires a focus on their individual needs: consumer-centred care and good information to patient and carers provided by an integrated team that might include GPs, nurse practitioners, medical specialists and a mix of allied health practitioners such as physiotherapists, psychologists and diabetes educators.