关键词: 脑卒中；整合护理；随访平台；康复；自我管理

Abstract: Objective: To evaluate the effectiveness of a smart follow-up platform for stroke survivors in an integrated hospital-community care model. Methods: From March to July 2024, 186 patients with first-episode stroke hospitalized in neurology department were recruited as research participants by convenience sampling. The participants were randomly divided into the control group and the observation group equally, with 93 cases in each group. The control group was given transitional care by routine telephone follow-up and outpatient follow-up, while the observation group was given transitional care by a smart follow-up platform in an integrated hospital-community care model. Both groups received 6-month interventions. The scores of mRS and Barthel Index at 1/3/6 months, self-management ability, blood pressure, blood glucose, and LDL-C levels at 6 months, were compared. Results: At 3/6 months, the observation group showed better mRS scores (3.35±1.05)/(2.02±1.33) and Barthel Index (73.58±6.93)/(88.93±8.61) compared to the control group (P<0.05). At 6 month, the scores of self-management ability, systolic BP control, fasting glucose and LDL-C were better than those in the control group (P<0.05). Conclusion: Implementation of the smart follow-up platform within hospital-community integrated care model promotes neurological recovery and enhances self-management capacity in stroke survivors.

Key words: stroke; integrated care; follow-up platform; rehabilitation; self-management