Objective To enhance the daily living ability of stroke patients in rural areas and to improve the rehabilitation effect. Methods A total of 116 stroke patients in rural areas were randomized into a control group of 59 and an intervention group of 57. Patients in the control group were given routine discharge guidance and telephone follow-ups, while their counterparts in the intervention group were subjected to a continuing care program during the first 6 months after discharge. We developed an information system, formulated three-level rehabilitation follow-up system involving general hospital, community hospital, and village doctors, and provided continuing rehabilitation through a self-designed smart-phone application. The village doctors were asked to give on-site health education and follow-ups. Results Finally, 53 patients in the control group and 52 in the intervention group completed the study. After 6 months of intervention, the incidence of pressure injury in the intervention group was significantly lower than that in the control group (7.69%vs.32.08%), whereas the Functional Independence Measure score and Simple Test for Evaluating Hand Function score in the intervention group were significantly higher compared with the control group (P<0.01 for all). Conclusion The development and implementation of an information system to manage rehabilitation during the transitional period from the hospital for stroke patients in rural areas can enhance their hand function and activities of daily living, as well as reduce the occurrence of pressure injury.