Construct a smart cloud platform for stroke within the medical community, and explore the establishment and application of an integrated stroke care system supported by the general hospital of the medical community, relying on township health centers and community health service stations, and based on home care.

A prospective non-concurrent controlled study was adopted. A total of 291 stroke patients discharged from the Department of Neurology, Tiantai People's Hospital between October 2023 and September 2024 were enrolled as research subjects, including 168 males and 123 females, aged 35~80 years [(65.59±9.50) years]. Subjects were divided into an observation group (n=146) and a control group (n=145) according to discharge sequence. The control group received routine discharge guidance, with follow-up conducted via telephone combined with outpatient visits after discharge. Supported by an intelligent cloud platform, the observation group received continuous nursing under an integrated stroke care system within the medical community consortium. Real-time online interaction was performed through the stroke cloud platform, supplemented by home visits and home-based care. After intervention, the compliance of healthy behaviors including regular medication, rational diet and rehabilitation training was compared between the two groups. The control status of high-risk factors such as blood pressure, blood glucose and blood lipids was analyzed. The Modified Barthel Index (MBI) scale was used to evaluate the quality of life of patients in both groups.

At 6 months after discharge, the observation group obtained higher compliance scores of medication adherence, rational diet and rehabilitation training than the control group (P<0.001). Statistically significant differences in high-risk factor control status and readmission rate were identified between the two groups at 6 months after discharge (P<0.05), with better indicator improvements observed in the observation group. MBI scores of both groups were improved at 6 months after discharge compared with the values at discharge; the observation group had significantly higher MBI scores than the control group at the 6-month follow-up (P<0.001). During follow-up, the incidence of adverse events was 8.28% in the control group, while no adverse events occurred in the observation group, suggesting good safety of this model.

The integrated stroke care model based on the smart cloud platform of the medical consortium can effectively improve patients' compliance with health behaviors, facilitate the control of high-risk factors, and thereby enhance patients' quality of life.