探讨脑心健康管理师主导的互联网+延续性护理策略对脑卒中患者自我管理行为的影响。

采用便利抽样法，选取2022年8—12月在常州市第一人民医院住院的脑卒中患者为研究对象，使用随机数字表法将患者分为对照组和干预组，每组35例。对照组患者采用常规健康教育及随访策略；干预组患者采用由专职脑心健康管理师主导的个体化、全流程的院内健康管理及互联网+延续性护理策略，干预持续至出院后12个月。采用单因素分析（独立样本t检验、非参数秩和检验或χ²检验）比较2组患者入院24 h内、出院前1 d及出院后12个月的自我管理行为、血脂达标率和美国国立卫生研究院卒中量表（NIHSS）评分的差异，以及入院24 h内、出院前1 d和出院后3、6、12个月血压、血糖达标率与改良Rankin量表（mRS）评分的差异。

最终，干预组、对照组各34例患者完成研究。出院前1 d、出院后12个月，干预组患者的卒中自我管理行为量表评分均显著高于对照组患者[（221.38±15.34）分vs（204.88±19.07）分；（241.97±10.77）分vs（188.56±26.04）分]，差异均有统计学意义（t=3.931、11.054，P均<0.001）。出院后12个月，干预组患者的血压、血脂达标率均显著高于对照组患者（88.24% vs 55.88%；79.41% vs 44.12%），差异均有统计学意义（χ²=8.838、8.967，P=0.003、0.006）。出院后3、6、12个月，干预组患者的血糖达标率均显著高于对照组患者（91.18% vs 70.59%；85.29% vs 64.71%；85.29% vs 41.18%），差异均有统计学意义（χ²=4.660、3.843、14.233，P=0.031、=0.049、<0.001）。干预组和对照组患者出院前1 d及出院后3、6、12个月mRS评分比较，差异均无统计学意义（P均>0.05）。干预组和对照组患者出院前1 d及出院后12个月NIHSS评分比较，差异均无统计学意义（P均>0.05）。

脑心健康管理师主导的互联网+延续性护理策略可明显改善脑卒中患者的自我管理行为，提高患者的血压、血糖、血脂达标率。

To explore the effect of an internet plus (internet+) transitional care strategy led by brain-heart health managers on self-management behaviors of stroke patients.

Using convenience sampling, stroke patients hospitalized at the First People's Hospital of Changzhou from August to December 2022 were included as the study subjects. Patients were randomly divided into a control group and an intervention group (35 cases each) using a random number table. The control group received routine health education and follow-up strategies. The intervention group received individualized, full-process in-hospital health management and an internet+ transitional care strategy led by dedicated brain-heart health managers; the intervention lasted until 12 months after discharge. Univariate analysis (independent samples t-test, non-parametric rank-sum test, or χ² test) was used to compare differences between the two groups in: (1) self-management behavior, blood lipid target achievement rate, and National Institutes of Health stroke scale (NIHSS) scores within 24 hours of admission, on the day before discharge, and at 12 months after discharge; and (2) blood pressure/blood glucose target achievement rates and modified Rankin scale (mRS) scores within 24 hours of admission, on day 1 before discharge, and at 3, 6, and 12 months after discharge.

Finally, 34 patients in each group completed the study. On the day before discharge and at 12 months after discharge, the self-management behavior scale for stroke scores in the intervention group were significantly higher than those in the control group (221.38±15.34 vs 204.88±19.07; 241.97±10.77 vs 188.56±26.04; t=3.931, 11.054, both P<0.001). At 12 months after discharge, the blood pressure and blood lipid target achievement rates in the intervention group were higher than those in the control group (88.24% vs 55.88%, χ²=8.838, P=0.003; 79.41% vs 44.12%, χ²=8.967, P=0.006). The blood glucose target achievement rates in the intervention group were higher than those in the control group at 3, 6, and 12 months after discharge (91.18% vs 70.59%, χ²=4.660, P=0.031; 85.29% vs 64.71%, χ²=3.843, P=0.049; 85.29% vs 41.18%, χ²=14.233, P<0.001). No statistically significant differences were found in mRS scores between the intervention and control groups on the day before discharge and at 3, 6, and 12 months after discharge (all P>0.05). No statistically significant differences were found in NIHSS scores between the intervention and control groups on the day before discharge and at 12 months after discharge (both P>0.05).

The internet+ transitional care strategy led by brain-heart health managers can significantly improve the self-management behavior of stroke patients and enhance their blood pressure, blood glucose, and blood lipid target achievement rates.