This 30-month feasibility study will assess a “model of care” supported by a mobile health technology in a real-world setting involving 40 individuals recovering from stroke. The mobile health technology (mHealth) is called the “My Stroke Team” (MyST) app. It is a tablet-based app that provides real-time information to improve coordination of care and more comprehensive assessments of patient and family needs. The results of the project will inform a future multi-site randomized controlled trial to take place across Canada. The ultimate goal of this line of work is to contribute to health system transformation for home and community care in ways that will improve outcomes for patients – especially seniors with multiple chronic conditions – and make more efficient use of healthcare resources.