目的 探索脑卒中患者三阶段个案管理模式的实施方法及效果,为构建完善的脑卒中诊疗管理模式提供参考。方法 根据脑卒中不同阶段划分为急诊、病房、社区三阶段个案管理,选取神经内科病房2016年9月—2017年8月符合入选条件的129例脑卒中患者为对照组,实施临床护理,主要包括急诊护理和病房内责任护士的健康教育及患者出院后的电话随访;2017年9月—2018年9月符合入选条件的140例脑卒中患者为试验组,实施个案化管理模式,包括急诊阶段的溶栓时间管理方案、病房阶段的用药及心理治疗方案和社区阶段的延续性护理方案。比较两组患者的静脉溶栓时间、平均住院日、神经功能缺损和日常生活能力。 结果 试验组各阶段的随访率均达到100%,试验组静脉溶栓时间、平均住院日较对照组缩短,试验组神经功能、生活质量均优于对照组,差异有统计学意义（P<0.05）。结论 脑卒中患者三阶段个案管理模式有助于整合资源,为患者及家属提供持续性的照护服务,促进脑卒中患者神经功能的恢复,缩短平均住院日,提高其生活质量。

Objective To explore the effects of three-stage case management model for stroke patients. Methods According to the different stages of stroke,the three-stage case management of emergency department,ward and community was selected. One hundred and forty cases of stroke patients who met the inclusion criteria from September 2017 to September 2018 were assigned to the experimental group. Intervention provided to the experimental group included time management during emergency phase,medication and psychotherapy during ward phase,and community-based continuous care. A total of 129 stroke patients who met the inclusion criteria from September 2016 to August 2017 were assigned to the control group,and the clinical routine care was provided to them including routine health education from nurses in the ward and telephone follow-up after discharge. The door-to-needle time（DNT）,average length of stay in hospital,deficit of neurological function,and daily living ability were compared between the two groups. Results The follow-up rate in the experimental group was 100%. The DNT time and average length of stay in hospital the experimental group were shorter than those of the control group,and the neurological function and quality of life were improved. The differences were statistically significant（P<0.05）. Conclusion The three-stage case management model for stroke patients helps to maximize resources,provide continuous care for patients and their families,promote the recovery of neurological function in stroke patients,shorten the average hospitalization day,and improve quality of life.