BACKGROUND
Patients with stroke and multimorbidity face complex rehabilitation challenges during the hospital-to-home transition. This study evaluated a smart healthcare–enabled Information–Motivation–Behavioral Skills (IMB) model integrated with traditional Chinese and Western nursing care for its effects on discharge readiness and recovery outcomes.
MATERIAL AND METHODS
Sixty stroke patients with 2 or more comorbidities admitted between January and June 2025 were randomly assigned to an experimental group (n=30) or control group (n=30). The control group received routine nursing care, while the experimental group received an IMB-based transitional care program supported by smart healthcare technology and integrated nursing interventions. Outcomes included discharge readiness, quality of life (Stroke-Specific Quality of Life [SS-QOL]), functional recovery (Barthel Index, Fugl-Meyer Assessment, National Institutes of Health Stroke Scale), and 30-day readmission rate.
RESULTS
The experimental group showed significantly higher discharge-readiness scores (P<0.05), improved SS-QOL at 1 month (171.20±26.21 vs 146.55±31.25; P<0.001) and 3 months (186.25±31.35 vs 150.21±21.34; P<0.001), and better functional outcomes across all scales (all P<0.05). The 30-day readmission rate was lower in the experimental group (6.6% vs 26.6%; P=0.041).
CONCLUSIONS
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. Because the intervention was multicomponent, the independent contribution of the IMB framework cannot be isolated.

Keywords: Stroke Rehabilitation; Rehabilitation; Multimorbidity