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This article explores a male first-time stroke patient who was a low-income single parent taking care of three minors. During interviews, the case's low moods were observed leading to motivation for further investigation. The nursing period was from September 3 to September 10, 2019. By providing care, conducting interviews, and using Gordon's 11 functional health patterns for assessment, a cross-disciplinary team collaborated on the care model and conducted a home visit on the day after discharge. Several health problems were confirmed: Ineffective health maintenance ability, physical activity impairment, and anxiety. Through a good nurse-patient relationship, care guidance was provided, and the patient was accompanied and listened to, which helped improve anxiety, encouraged rehabilitation, and achieved seamless home care and rehabilitation. During the home visit, the home environment was found to be dirty and disorganized. Through community resources, the environment was improved and more social resources were obtained. It is suggested that hospitals should establish care teams to deepen community involvement, provide assistance through home visits, ensure proper home care for the patient, reduce the chance of rehospitalization, enhance the quality of home care, and reduce the consumption of medical resources. [ABSTRACT FROM AUTHOR]