A coordinated system of care for stroke patients is established in the community of Fall River, Massachusetts, involving the Stroke Unit of Union Hospital, the Rehabilitation Unit of Earle E. Hussey Hospital, and the Fall River District Nurse Association. Long-Range Evaluation Summary (LRES) data collection forms developed at the Tufts University Medical Rehabilitation Research and Training Center (RT-7) are being used to reflect the functional status of the patient at any given point in time. Of 164 patients the Stroke Unit returned 49% home and the Rehabilitation Unit returned another 9% home. This systematic approach to functional assessment relates the disease-state and disability to outcomes of care. By taking into account the several-fold nature of outcome determination it is possible to analyze program effectiveness because such uniform descriptions, over time, permit us better to relate the population under care, its key characteristics for these purposes, and the comprehensiveness of problem identification and planning all at the same time.