Abstract: Objective: To construct the multidisciplinary care model during ICU-Rehabilitation Transitional period for stroke patients and explore its application effect. Methods: The ICU-Rehabilitation Transitional Care Model was built from five aspects: multidisciplinary team formation, working environment, working mode, personnel training, and quality control. The specific implementation contents of multidisciplinary care during the transition period was formulated. The indicators of multidisciplinary teamwork efficiency, functional outcome and quality and safety management level were used to evaluate the application effect. Results: The ICU-Rehabilitation Transitional Care Model not only improved the efficiency of multidisciplinary teamwork, and significantly improved motor, lung, gastrointestinal, and bladder function in stroke patients, but also reduced adverse event rates, ICU readmission rates, and average length of stay, and ultimately improved patient satisfaction. Conclusion: Through the implementation of the ICU-Rehabilitation Transitional Care Model, we have solved the problem of coordination and continuity of healthcare and improved the functional outcome and quality of life of stroke patients. It has also accumulated a lot for exploring transitional care models suitable for the national conditions.

Key words: stroke; transitional care; multidisciplinary management; rehabilitation