Inclusion Criteria- Ischemic stroke onset [including transient ischemic attack (TIA)].
- Receiving regular consultation with their primary care physician.
- modified Rankin Scale (mRS) score from 0 to 3 at discharge.
Exclusion Criteria- modified Rankin Scale (mRS) score 4 and over at discharge .
- Patient having severe complications and the physical symptom that the contents of the program cannot carry out.
- They had medical care in medical/nursing care institutions.
- Patients with pregnancy or under terminal care.
- Dementia (scores of ≤20/30 on the Revised Hasegawa's Dementia Scale) However, when a care-giving family member living with the patient could provide self-management, patients were included even if they had dementia.