In this first step of the study the investigators will assess the needs, disease burden and current treatments of long-term stroke patients (phase MAS-I).

The ultimate aim of the complete MAS project (MAS I, II & III) is the development of a model of stroke aftercare delivery that can be evaluated to estimate effects in both our local and the wider stroke population.

After discharge from hospital the current healthcare system in Germany allows considerable flexibility (therefore complexity) of patient access and mobility between multiple care providers in the community setting. The investigators believe this aftercare could be better coordinated by a specialized coordinated stroke aftercare service. Comprehensive coordinated multidisciplinary care is a proven concept with proven benefits in both acute and rehabilitation care provided in stroke units and neurorehabilitation centres. In this study the investigators postulate that a similar coordinated approach to care can be extended to the phase after in-patient rehabilitation has ended (i.e. "long-term management" as opposed to "early supported discharge") for disabled patients with stroke living in the community.

Inclusion Criteria:

• Age ≥18 years
• Participation in one of the previously conducted stroke cohort studies: STRAWINSKI or PREDICT
• Modified Rankin Score (mRS) recorded as = 1 - 5 (at last follow up during cohort study)
• Informed consent signed by patient or legal representative

Exclusion Criteria:

• Unwilling to have pseudonymised data stored, analyzed & anonymously published.
• Patients participating in the previous studies recruited in centres outside Berlin

Patients in long term course after a moderate to severe ischemic stroke