In 1989, a multidisciplinary consultation service devoted to providing primary care and rehabilitative care services to stroke survivors in the home was developed and tested at the University of Pennsylvania. This nurse-managed service, Post-Stroke Consultation Service, used the expertise of a nurse practitioner, geriatrician, physiatrist, physical therapists, home health care nurses, specialty care providers, families, and stroke survivors to develop and implement a plan of care that optimized health and function and would be sustainable over time. The service and its impact are described.