A 69-year-old man with atrial fibrillation, chronic obstructive pulmonary disease, and stage III chronic kidney disease was admitted for post-acute care (PAC) program due to right middle cerebral artery territory infarction with left side weakness, dysarthria, and dysphagia. After individualized training in different stages, his cognitive status, self-care ability, and upper limb movement improved significantly. PAC program can maintain high-intensity rehabilitation and more sustainable treatment. However, the participation period in the PAC program cannot be determined in advance. By planning an individualized treatment plan and the medical care team's support, the problem of a sudden return to the community due to the difference of plan periods can be avoided. Besides, paying attention to the patient's depression and developing appropriate cognitive assessments helps develop treatment plans.