1. Design: prospective longitudinal observational study. Participants: people with mild/moderate stroke, referred from stroke units to home rehabilitation and their significant others will be asked to participate before discharge from the stroke unit. Power calculations indicate the inclusion of 300 participants with stroke. Data collection: Baseline data on medical and socio-demographic aspects and functioning will be collected from the medical records. Data on satisfaction with the transition process will be collected with the Care Transition Measure (CTM) after discharge from the stroke unit. At 3, and 12 months people with stroke will be assessed regarding disability, perceived impact of stroke, participation in social activities, health related quality of life, perceived needs of health services and satisfaction with services received using reliable validated measures and structured interviews. Data on caregiver burden, life satisfaction and informal care will be collected from significant others. Data on use of health care will be obtained from the register at Stockholms Läns Landsting. Analyses: Statistical analyses to identify factors at baseline associated with satisfactory transitions (CTM), and associations between perceived quality of transitions (CTM) and patient and significant other outcomes at 3 and 12 months.