关键词: 脑卒中, 康复, 信息化医联体管理, 社区卫生服务, 日常生活活动

Abstract: Objective　To explore the methods and effect of applying information-based medical collaborative management and family cooperative management in stroke patients taking rehabilitation at home, and to provide references in building a complete stroke rehabilitation management model. Methods　From June 2020 to June 2021, 60 first-time stroke patients hospitalized at the ward of Department of Neurology, Weihai Central Hospital were selected as the research objects. The 30 qualified stroke patients from three communities under collaborative stroke rehabilitation management were enrolled into an experimental group, while the 30 qualified stroke patients from other communities were recruited as a control group. The control group had 19 males and 11 females who were 50-70 (63.72±3.97) years old, and received regular discharge guidance and health education. The experimental group had 18 males and 12 females who were 51-70 (64.21±3.54) years old, and were under information-based medical collaborative management and family cooperative management. The activity abilities of daily living (Barthel index) when they were discharged and 6 months after discharge were compared between the two groups. The patients' rehabilitation cognition and compliance to rehabilitation treatment were compared between the two groups. The patients and caregivers' satisfaction with clinical care and family contracted doctors and nurses was inquired. The data were analyzed by t, t^,, and χ² tests. Results　There were no statistical differences in the Barthel Index scores between these two groups when they were discharged (all P>0.05). Six months after discharge, the total score of Barthel Index in the experimental group was higher than that in the control group [(80.77±6.76) vs. (70.53±6.35)], with a statistical difference (P<0.001). Six months after discharge, the scores of knowledge about early signs and emergency treatment, on-time medication, and scheduled rehabilitation exercise were (27.48±1.28), (26.52±1.36), and (29.07±0.34) in the experimental group, and were (19.50±0.79), (20.16±0.88), and (20.52±0.50) in the control group, with statistical differences (t=28.994, 21.497, and 77.420; all P<0.001). When the patients were discharged, the patients and caregivers in both groups were satisfactory with doctors and nurses, with no statistical difference between these two groups (P>0.05). Six months after discharge, the patients and caregivers in the experiment group had higher overall satisfaction than those in the control group [96.67% (29/30) vs. 83.33% (25/30)], with a statistical difference (χ²=8.819, P=0.012). Conclusions　Information-based medical collaborative management and family cooperative management are helpful in integrating medical resources, and can provide continuous, systematic, comprehensive, and full rehabilitation interventions for patients and caregivers, and has a positive effect on improving patients' activities of daily living.

Key words: Stroke, Rehabilitation, Information-based medical collaborative management, Community health service, Daily living activity