Abstract
BACKGROUND: Effective health management for high-risk stroke populations is essential. The hospital-community-home (HCH) collaborative health management (CHM) model leverages resources from hospitals, communities, and families. By integrating patient information across these three domains, it facilitates the delivery of tailored guidance, health risk assessments, and three-in-one health education. AIM: To explore the effects of the HCH-CHM model on stroke risk reduction in high-risk populations. METHODS: In total, 110 high-risk stroke patients screened in the community from January 2019 to January 2023 were enrolled, with 52 patients in the control group receiving routine health education and 58 in the observation group receiving HCH-CHM model interventions based on routine health education. Stroke awareness scores, health behavior levels, medication adherence, blood pressure, serum biochemical markers (systolic/diastolic blood pressure, total cholesterol, and triglyceride), and psychological measures (self-rating anxiety/depression scale) were evaluated and compared between groups. RESULTS: The observation group showed statistically significant improvements in stroke awareness scores and health behavior levels compared to the control group (P < 0.05), with notable enhancements in lifestyle and dietary habits (P < 0.05) and reductions in postintervention systolic blood pressure, diastolic blood pressure, total cholesterol, triglyceride, self-rating anxiety scale, and self-rating depression scale scores (P < 0.05). CONCLUSION: The HCH-CHM model had a significant positive effect on high-risk stroke populations, effectively increasing disease awareness, improving health behavior and medication adherence, and appropriately ameliorating blood pressure, serum biochemical marker levels, and negative psychological symptoms.