Every year, nearly 27,000 Belgians suffer a stroke. After discharge from the hospital there is follow-up. In this best practice, we want to discuss the initiatives that AZ Groeninge has taken over the years to achieve an integrated transmural care pathway for stroke patients after discharge from the hospital in collaboration with primary care, regional GP-associations and home care organizations. Transmural care pathway for stroke care: Prof. Dr. Peter Vanacker, neurologist AZ Groeninge, took the initiative in 2017 to roll out the transmural clinical care pathway for stroke in the south West-Flanders region together with GP-associations and neurologists from various hospitals. Other primary care partners were also involved such as the Pharmacists Association and home care organizations. Through uniform cooperation of health care providers and coordinated follow-up to support stroke patients, they succeeded in offering better care to stroke patients after discharge. Guidelines were developed for GP's, home care nurses and pharmacists. To ensure continuity of care and enhance patient empowerment, a diary was also given to the patient to record key parameters and issues. In 2020, the care pathway was expanded with the Chronic Care Project "De Brug". The following additional items were added: - commitment to communication between the care providers of the stroke team - commitment to the conversation