Design: Workshops with all stakeholders using a collaborative design process which include reflection, analysis, and description of the problem, visualization to get a common picture, modelling and/or prototyping. Participants: People with stroke, significant others, staff from stroke units and interdisciplinary home rehabilitation teams in a series of five workshops. Data collection: field-notes, diaries and documentation of the design process. The design process comprises six phases: 1. Engage; establish relationship between the participants. 2. Plan; generate ideas and goals. 3. Explore; learning about experiences of the transition from the stroke unit to the home. 4. Develop; turning ideas into context specific improvements. 5. Decide; choose what improvements to make, and how to make them. 6. Change; put the decided improvements into action i.e., phase 3. The improvements may involve decision support for the staff, the patient and significant others and information and support with or without support by information technology.