Abstract: The aim is to introduce and offer personalized and one-to-one health management information to signatory stroke patients of Fangzhuang Community Health Service Center by their family doctor service team, based on the Intelligent Family doctors Optimized Coordination model to integrate community resources as well as data from the Community Health Management Platform. The two-way referral channel has been established to build a "hospital-community-home" continuation of care platform, in order to address the present and potential issues for those discharged signatory stroke patients, and provide schemes and ideas to practice of the combination of medical treatment and endowment. After preparation and practice in advance, the two-way referral channel has been applied well, and the "hospital-community" dual referral system has been achieved, so as to verify the path is effective. Meanwhile, the concept of "up and down linked, continual nursing and multiparty cooperation" has been put into practice.