This study evaluated the effectiveness of systematically integrating biopsychosocial interventions with coordinated delivery of care for outpatients recovering from stroke. Care coordination coordinates resources across the health care system and routinely addresses the psychological and social risks affecting patient outcomes, while monitoring patient progress. A randomized pre-post comparison group design evaluated the model's effectiveness with 28 patients (16 intervention group; 12 control group) over a three-month period. The model's effectiveness was evaluated by monitoring changes in patient quality of life, patient depression, patient psychosocial functioning, and patient adherence to self-care and in meeting patient service needs. Repeated-measures ANOVA showed significant improvement for the intervention group in mental quality of life, depressive symptoms, and adherence to self-care practices. This study provides preliminary data that a standardized, problem-solving care coordination model can improve patient care.