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Objective: To explore how people with stroke, discharged to skilled nursing facilities before returning home, experience the chain of care and rehabilitation.

Design: Qualitative, semi-structured interview design.

Methods: Thirteen stroke survivors discharged from a stroke unit to a skilled nursing facility before returning to independent living participated. Semi-structured telephone interviews were conducted 2-5 months after stroke and analysed with content analysis.

Results: The analysis resulted in three categories, Organizational processes, critical and complex, Rehabilitation, the right support at the right time and Adaptation to the changed situation, with a total of 9 subcategories. The informants perceived low participation in planning and goalsetting and limited information. Support from the healthcare services was important to proceed with improvements although the amount of supported training varied. Factors hindering and facilitating managing everyday life were described, as well as lingering uncertainty of what the future would be like.

Conclusion: Support and rehabilitation as well as individuals' needs varied, throughout the chain of care. To enable participation in the rehabilitation, assistance in setting goals and repeated information is warranted. Tailored care and rehabilitation throughout the chain of care should be provided, followed up at home, and coordinated for smooth transitions between organizations.