Doctors and nurses of University of Pittsburgh Medical Cente(r UPMC) Stroke Institute developed the integrated health management for stroke patients including health education, warning education and primary prevention in a variety of ways with the help of three-tier system of Pittsburgh, and they carried out emergency treatment after disease occurred in patients by taking advantage of the optimized strategy as well as facilities, and they implemented treatment and nursing care by multidisciplinary steric cooperation mode. Nurses have played many roles in medication management, health assessment and rehabilitation assistance to promote the rehabilitation of patients. Nurses provide targeted and detail discharge instructions before patients leave the hospital, and carry out aspects of work in continuous nursing after discharge such as telephone follow-up, outpatient review and health management. This paper introduced the pre-hospital prevention, continuous nursing in and after hospital of UPMC Stroke Institute in many ways so as to provide a basis for making nurses attend health management for stroke patients in China.