Abstract:Background. Stroke is characterized by its complexity as a result of residual deficits, dependence in basic activities of daily living, and new needs for caregivers. The purpose of this study was to propose nursing interventions in accordance with general practice to provide continuity of care of stroke patients across the stroke-recovery trajectory and support for caregivers beyond the patient's length of stay. Methods. This is a longitudinal prospective study of a population-based cohort of all cases recorded in inpatient care of a first episode of stroke that occurred between 1 April 2006 and 31 December 2014. Results. There were 1,494 cases (54.1% male) and the mean age was 77.4±12.9 years. Only 27.9% were evaluated by their disability after hospital discharge. Ischemic stroke treated with thrombolysis had the best results in mortality (6.3%) and Barthel score (85.5). Mild dependence for thrombolysis was OR=2.5 with RRR=46%, ARR=9.4%, and NNT=10 to get a Barthel score >60 at discharge. After the episode the percentage of individuals with moderate or greater dependence increased up to 22.5%, with a loss (p=0.023) higher in women, halving the number of individuals with early independence. Of the stroke survivors 43.4% went directly home after acute care and needed a home caregiver. Age (p<0.001) and NIHSS <12 (p=0.045) were identified as the only prognostic factors associated with mild dependence (Barthel>60).Conclusions. This study recommends consideration of special interests, both standardization of a discharge report as organizing an individualized primary care plan and the unification of processes for assessment of the situation of dependency among all public administrations to facilitate the necessary support planning for the stroke patient and their family in primary care.