Patients who require a stay in a community hospital usually tend to be more complex, presenting not only with biomedical issues with complications, but also with a myriad of psychological and social issues as well. If they were to be discharged from an acute hospital directly to primary care and community, the patients and caregivers may feel helpless, overwhelmed and unsure of how to navigate the healthcare system to get their complex issues sorted out. Family physicians in the community hospitals need to hone their skills in such an area of care. The SBAR4 model can be effectively used to categorise the patients’ multiple bio-psycho-social issues, coordinate the multi-disciplinary team to bring hospital and community resources to help such patients, provide holistic care for such patients, and transit them safely into the care of our family physicians in primary care and community.