关键词: 护士主导；脑卒中；个案管理；日常生活自理能力；功能结局

Abstract: Objective: To establish a nurse-led case management for discharged stroke patients and evaluate its practical effect. Methods: Totally 182 patients who met the inclusion criteria were randomly divided into two groups. The intervention group (n=93) were given case management, while the control group (n=89) were provided regular follow-up. We compared differences in MBI, mRS scores and use of health service between the two groups after the patients discharged from hospital for 1 month, 3 months, 6 months respectively. Results: The MBI scores between the two groups were statistically significant after they discharged from hospital for 1 months, 3 months and 6 months (Ftime=784.447, P<0.001; Fgroup=21.942, P<0.001; Ftime*group=11.145, P=0.001 respectively). The differences of mRS scores were also statistically significant (Ftime=52.019, P<0.001; Fgroup=3.980, P=0.049; Ftime*group=12.312, P<0.001 respectively). The numbers of out-patient and emergency visits between two groups were significantly different (P<0.05). Conclusion: Nurse-led case management can facilitate the nurses to provide continued care to patients after they discharged from hospital. It can improve the patients' ability of daily living and use of medical resources as well.

Key words: nurse-led; stroke; case management; ability of daily living; functional outcome