Construction and application of proactive health service for discharged patients based on internet hospital platform

Objective To construct the proactive health management service based on the Internet hospital platform, and apply it to the follow-up management of discharged patients, to evaluate patients' satisfaction with proactive health services and monitor the patients' health status, thereby providing suggestions for continuous optimization of patients' health management after discharge. Methods Based on the Internet hospital platform, the proactive health management service team is composed of specialized medical teams and operation teams. In the way of project management, the proactive health service management service items of different specialties are developed, and the health management service items are applied after discharge. A retrospective longitudinal cohort study was used to select patients who participated in the proactive health management service project as the intervention group, and those who did not participate in the project as the control group. A general information sheet, satisfaction survey, specialized rehabilitation indicators and laboratory indicators were used. Results By the end of September 2025, three types of specialized proactive health management services such as health management, chronic disease management and postoperative management have been formed, providing post-hospital health management for 279 discharged patients. The covered medical conditions for proactive health services include: breast cancer surgery, diabetes, hepatobiliary surgery, gestational diabetes, ostomy surgery, and complicated wound, etc. The satisfaction of patients ranged from 84.38% to 100%. In diabetes management, in terms of blood glucose, compared with the control group, blood glucose declined significantly over time in the intervention group (β = -0.088 mmol/L/month, 95% CI, −0.108 to −0.067; P < 0.001). In terms of glycosylated hemoglobin (HbA1c), with a significantly greater decline in the intervention group (group-by-time interaction: β = -0.661% /month, 95%CI, -0.910 to -0.412; P < 0.001). Among patients who underwent breast cancer resection combined with axillary sentinel lymph node biopsy (SLNB) and those receiving breast cancer resection combined with axillary lymph node dissection (ALND), the reduction in Quick DASH scores was greater in the intervention groups than in the control groups, with adjusted differences of −14.66 (95%CI: −17.29, −12.03) and −3.13 (95%CI: −4.79, −1.47), and corresponding P values of <0.001 and 0.002, respectively. Measurements of the seven ROM dimensions demonstrated that shoulder range of motion recovered better in the intervention groups than in the control groups for both surgical procedures. For patients undergoing SLNB, the between-group difference in the reduction of VAS scores was −1.76 (95%CI: −2.23, −1.30) (P < 0.001). Conclusions The proactive health management service project based on the Internet hospital platform can be effectively applied to discharged patients. Patients were satisfied with the proactive health services, and the project can promote the formation of patients' health behavior and improve patient outcomes. Clinical trial number Not applicable.