关键词: 老年人；老年综合评估；脑卒中；健康管理；社区护理

Abstract: Objective: To explore the application effects of community elderly health service work model in home health management of stroke patients. Methods: By using convenient sampling method, 60 stroke patients who had established personal health records in Fangzhuang Community Health Service Center and signed a family doctor service agreement were selected as the research participants, and they were randomly divided into control group and intervention group. The control group received routine home care service mode, and the intervention group received community geriatric health service mode of Comprehensive Geriatric Assessment and multidisciplinary health management. The differences in the scores of Modified Barthel Index (MBI) and the MOS 36-item Short Form Health Survey (SF-36) were compared between the two groups after 4 months. Results: The scores of MBI and SF-36 in the intervention group were higher than those in the control group, and the differences were statistically significant (P<0.05). Conclusion: The community elderly health service work model based on Comprehensive Geriatric Assessment and multidisciplinary health management effectively improve the activities of daily living and quality of life of stroke patients, and improve the rehabilitation and long-term care of stroke patients at home. Health management has a positive effect and is worth popularizing in the community.

Key words: elderly; Comprehensive Geriatric Assessment; stroke; health management; community care