数字健康视角下卒中患者康复衔接管理模式的构建及应用研究进展

Digital Health-Based Rehabilitation Transition Management Model for Stroke Patients: Construction and Application Research Progress

摘要: 卒中具有高发病率、高致残率的特点，患者从医院到家庭或社区的康复衔接不畅是影响其远期功能恢复的关键问题。数字健康技术的发展为优化卒中康复衔接管理提供了新的契机。本文从数字健康的视角，综述了卒中患者康复衔接管理的需求现状、基于数字健康的衔接管理模式构建要素(包括技术平台、多学科团队、标准化流程与数据驱动决策)、具体应用方式(如远程康复指导、可穿戴设备监测、数字化认知与言语干预、二级预防教育与心理支持)及效果，并深入分析了当前在数字鸿沟、数据安全、技术标准、支付机制及人员素养等方面面临的挑战。文章最后对未来发展方向进行了展望，提出应致力于开发适老技术、建立标准规范、探索可持续模式并加强人才培养，以推动该模式的规范化与个性化发展，为构建科学、高效的卒中康复衔接管理模式提供理论参考与实践指引。

Abstract: Stroke is characterized by high incidence and disability rates, and poor continuity of rehabilitation from hospital to home or community is a key issue affecting long-term functional recovery. The development of digital health technologies provides new opportunities to optimize stroke rehabilitation transition management. From a digital health perspective, this article reviews the current demands for rehabilitation transition management in stroke patients, the construction elements of digital health-based transition models (including technical platforms, multidisciplinary teams, standardized processes, and data-driven decision-making), and specific applications (e.g., telerehabilitation guidance, wearable device monitoring, digital cognitive and speech interventions, secondary prevention education, and psychological support). It also analyzes challenges such as the digital divide, data security, technical standards, payment mechanisms, and professional training. Finally, future directions are discussed, emphasizing the need for age-friendly technology development, standardized protocols, sustainable models, and capacity building to promote standardized and personalized stroke rehabilitation transition management.