| Objective:On the background of innovating medical treatment alliance and senior nurses sink into the community,to adapt to medical reform and to meet the diversified service needs of patients with community stroke,a comprehensive health management scheme for patients with stroke was established.The practice verifies that the scheme is beneficial to improve the health management level of stroke patients,and promote the adaptation of patients from hospital to community and family,To improve efficiency in the use of health services and to explore the effect of comprehensive health management scheme for stroke patients.Methods:The first part:Construct the ACGN team management model of stroke patients.By using the convenient sampling method,there are 240 community stroke patients were investigated by questionnaire,which is about the main health problems and the status of receiving health service;According to the questionnaire survey results and literature review,the Individualized contract service package for stroke patients was designed.Guided by the needs of stroke patients,revise and standardize the content of contracted medical care services,organize and compile the Patient Edition propaganda Handbook,compile the Medical edition unified training book;Based on the innovative medical conjoined platform,with the high seniority nurses of the sinking community as the leading,using the management synergy theory,large hospitals and community health service centers in the Medical Association will be closely linked,coordinated and promoted,a clear division of labor,the organization of multi-disciplinary cooperation of stroke management team to implement contractual services.The second part:The stroke patients ACGN team management model practice and effect evaluation.In the intervention group,the intervention program of ACGN team management mode,namely taking the senior nurses of the community in the General Hospital as the leading,combined with the patients'condition and needs,provides the contracted comprehensive care service,mainly including 4 visits to the view intervention and 6 telephone intervention.The control group was treated with routine community therapy plus follow-up management.To compare the blood pressure of two groups of stroke patients at different time nodes after intervention,the control of fasting blood glucose,triglyceride and total cholesterol index,whether the patient's daily life activity ability,life quality,medication compliance,function exercise compliance,self-management efficiency,health service utilization situation and so on are different.To verify whether the management model of the ACGN team under the innovative medical consortium can better meet the needs of stroke patients,improve the quality of continuous care,promote patients'rehabilitation and adaptation,and improve the efficiency of health service utilization in stroke patients.Results:1.The survey results showed that community stroke patients had complex health problems and diversified service demands.Professional rehabilitation services have not been fully promoted in stroke patients,and the health management of stroke patients requires the participation of professional teams.The role of community health service center in the health management of stroke patients was not prominent.The health management of stroke patients lacks the necessary connection between hospital-community-family.In view of this,a unified and standard contract type comprehensive care service program was established,which mainly consisted of four visits and six telephone interventions.Led by senior nurses from sinking community of general hospital,a multi-disciplinary stroke management team was established in collaboration with community family doctor group and multi-specialist experts of general hospital.High frequency intervention activities mainly focus on the first three months after discharge.The program is implemented by trained senior nurses according to the case management procedure,and connects with the referral community or family to provide whole-process tracking support for patients.2.Intervention results.Fifty-five cases were included in the control group and fifty-seven cases were included in the intervention group.There was no statistically significant difference between the general conditions and baseline data of the two groups(p>0.05),which was comparable.After the implementation of the ACGN team management plan for stroke patients for six months,the results showed:(1)The ACGN team management program intervention failed to show significant effects on blood glucose control(t=0.898,P=0.371),and had significant effects on lowering blood pressure and blood lipids,,especially at 6 months after discharge.(2)The intervention of ACGN team management program can effectively improve the changes of patients'ability of daily life activities.There was significantly statistical difference in changes in the BI index(92.11±13.53)the intervention group and the control group(82.82±19.79),P=0.004.(3)The ACGN team management program intervention failed to show a significant effect in reducing the rate of rehospitalization(?~2=0.132,P>0.05),and showed a positive effect in increasing the rate of outpatient follow-up(?~2=14.308,P<0.001)and reducing the rate of emergency visits(?~2=7.054,P=0.008).(4)The intervention of ACGN team management program can improve the quality of life after stroke.The SS-Q0L score(188.60±5.78)in the intervention group was superior to that in the control group(150.45±15.72),P<0.001.(5)The ACGN team management program intervention can effectively improve stroke patients'medication compliance and rehabilitation exercise compliance.The scores of MMAS-8 in the intervention group(7.91±0.34)were better than those in the control group(6.53±1.26),P<0.001.EAQ score(41.95±3.26)of the intervention group was better than that of the control group(35.42±3.49),P<0.001.Conclusions:This study established a ACGN team management program for stroke patients,which was validated by randomised trials to improve the index of blood pressure and blood fat,improve the patient's daily life activity,quality of life after stroke,compliance with medication,and compliance with rehabilitation exercises.A number of indicators to reduce the utilization of medical services show positive results to achieve the project design objectives.This study is a positive exploration of the health management model of stroke patients in China,and the results provide a new way of intervention and practical basis for improving the health management level of stroke patients.the random test in improving the index of blood pressure and blood fat,improve patients'... |
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