In this study, we propose a methodological framework to provide a road map to clinicians and system planners in developing chronic disease management strategies, and designing community-based care. We extend the analytical epidemiologic model by utilizing a patient flow approach, in order to model the multiple care-provider visit patterns of patients with a specific chronic illness. The patterns of care received by a group of patients are represented in compact form by means of a Markov model that is based on a disease-specific state space. Our framework also reflects the case-mix biases as well as the care-provider level clustering of the patients. By using this approach, we identify the patterns of care, determine the care provider and patient characteristics associated with optimal management of care, and estimate the potential influence of various interventions. The framework is applied to the data of 4000+ stroke patients discharged from the acute care hospitals of Quebec to their homes. Our findings provide a basis for designing community-based care initiatives for stroke survivors in the province.