A smart healthcare-supported, IMB-guided transitional care package integrated with traditional Chinese and Western nursing care was associated with improved discharge readiness, quality of life, and functional recovery, with fewer early readmissions.
Key Findings
Results
The experimental group showed significantly higher discharge-readiness scores compared to the control group.
60 stroke patients with 2 or more comorbidities were randomly assigned to experimental (n=30) or control (n=30) groups
Patients were admitted between January and June 2025
Difference in discharge-readiness scores was statistically significant (P<0.05)
The control group received routine nursing care while the experimental group received an IMB-based transitional care program supported by smart healthcare technology
Results
The experimental group demonstrated significantly improved stroke-specific quality of life at 1 month post-discharge compared to the control group.
SS-QOL scores at 1 month: 171.20±26.21 (experimental) vs 146.55±31.25 (control)
Difference was statistically significant (P<0.001)
Quality of life was measured using the Stroke-Specific Quality of Life (SS-QOL) scale
Results
The experimental group demonstrated significantly improved stroke-specific quality of life at 3 months post-discharge compared to the control group.
SS-QOL scores at 3 months: 186.25±31.35 (experimental) vs 150.21±21.34 (control)
Difference was statistically significant (P<0.001)
The improvement in SS-QOL scores was greater at 3 months than at 1 month in the experimental group (186.25 vs 171.20)
Results
The experimental group showed better functional recovery outcomes across all measured scales.
Functional outcomes were measured using the Barthel Index, Fugl-Meyer Assessment, and National Institutes of Health Stroke Scale (NIHSS)
All functional outcome comparisons were statistically significant (all P<0.05)
The study population specifically included stroke patients with multimorbidity (2 or more comorbidities)
Results
The 30-day hospital readmission rate was significantly lower in the experimental group than in the control group.
30-day readmission rate: 6.6% (experimental group) vs 26.6% (control group)
Difference was statistically significant (P=0.041)
The absolute risk reduction was approximately 20 percentage points
Conclusions
The independent contribution of the IMB framework to outcomes cannot be isolated because the intervention was multicomponent.
The intervention combined smart healthcare technology, IMB model principles, traditional Chinese nursing care, and Western nursing care
The authors explicitly acknowledged this limitation: 'Because the intervention was multicomponent, the independent contribution of the IMB framework cannot be isolated'
This limitation is noted in both the abstract conclusions and the paper itself
What This Means
This research suggests that stroke patients who have multiple other health conditions (such as diabetes or heart disease) may benefit from a structured, technology-supported program to help them transition from hospital to home. The study tested a care program combining a behavioral framework called the Information-Motivation-Behavioral Skills (IMB) model with smart healthcare technology and elements from both traditional Chinese and Western nursing practices. Thirty patients received this enhanced program while another thirty received standard nursing care, and the groups were compared on several outcomes.
The results suggest the enhanced program was associated with meaningful improvements across multiple areas. Patients in the program felt more ready to leave the hospital, reported better quality of life both one and three months after discharge, showed better physical and neurological recovery, and were far less likely to be readmitted to the hospital within 30 days (about 7% readmission rate compared to about 27% in the standard care group). These differences were statistically significant, meaning they are unlikely to be due to chance alone.
However, because the intervention combined several different elements at once — technology, a behavioral model, and two different nursing traditions — it is not possible to determine which specific part of the program drove the improvements. This research suggests that integrated, structured transitional care programs may help stroke patients with complex health needs recover more successfully at home and avoid early return trips to the hospital, but further research would be needed to identify which components are most essential.
Li J, Zhang Y, Zhang W, Liu J, Ma Z, Duan P. (2026). Smart Healthcare-Enabled Information-Motivation-Behavioral Skills Model for Stroke Multimorbidity Rehabilitation: A Transitional Care Study.. Medical science monitor : international medical journal of experimental and clinical research. https://doi.org/10.12659/MSM.951687