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.