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

摘要： 目的　探讨信息化医联体管理与家庭协同管理在脑卒中患者居家康复中的应用方法及效果，为构建完善的脑卒中康复管理模式提供参考。方法　选取2020年6月至2021年6月在威海市中心医院神经内科病区住院的首发脑卒中患者60例作为研究对象，将来自进行脑卒中康复联动管理的3个社区符合纳入标准的30例脑卒中患者列入试验组，将来自其他社区符合纳入标准的30例脑卒中患者列入对照组。对照组中男19例，女11例，年龄50～70（63.72±3.97）岁，接受常规出院指导和健康宣教。试验组中男18例，女12例；年龄51～70（64.21±3.54）岁，接受信息化医联体管理与家庭协同管理。比较两组患者出院时、出院6个月后的日常生活活动能力（Barthel指数），比较两组患者的康复认知和对康复治疗的依从性，征求患者和照顾者对临床医护及家庭签约医生和护士的满意度。数据分析采用t、t^，、χ²检验。结果　两组患者出院时日常生活活动能力评分比较，差异无统计学意义（P>0.05）；干预6个月后，试验组患者日常生活活动能力总评分为（80.77±6.76）分，高于同期对照组的（70.53±6.35）分，两组比较差异有统计学意义（P<0.001）；试验组患者6个月后早期症状和应急处理认识、按时服药、定期康复锻炼评分分别为（27.48±1.28）分、（26.52±1.36）分、（29.07±0.34）分，均高于同期对照组［分别为（19.50±0.79）分、（20.16±0.88）分、（20.52±0.50）分］，两组比较差异均有统计学意义（t=28.994、21.497、77.420，均P<0.001）；出院时两组患者和照顾者对医护人员很满意，差异无统计学意义（P>0.05），出院6个月后试验组患者和照顾者总满意度高于对照组［96.67%（29/30）比83.33%（25/30）］，差异有统计学意义（χ²=8.819，P=0.012）。结论　信息化医联体管理与家庭协同管理模式有助于整合医疗资源，为患者和照顾者提供连续、系统、全面及全程的康复干预，对提高患者日常生活活动能力具有积极作用。

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