关键词: 脑卒中, 跌倒, 家庭医生团队, 社区卫生服务

Abstract: Background　According to the literature，47% of stroke patients in community have fallen more than once.Falling is considered as a serious complication of cerebrovascular diseases.Therefore，it is urgent to strengthen the fall prevention management of stroke patients in community.Objective　To explore the effects of family doctor team service model on fall prevention of stroke patients in community.Methods　A total of 163 stroke patients registered in Pengpu Xincun Community Health Service Center in Jingan District of Shanghai from January to December 2016 were selected and treated under family doctor team service model for one year.Family doctor team service model was used to intervene in preventing falls among stroke patients and caregivers at home.The cognitive level of fall prevention，scores of fall risk assessment and the incidence of falls among stroke patients and caregivers in 2016 and 2017 were compared at the first-time，six，and 12 months of follow-up.Results　At the first-time，six and 12 months of follow-up，there were significant differences in the cognitive level of fall prevention and scores of fall risk assessment among patients and caregivers（P<0.001）．At six and 12 months，the cognitive level of fall prevention and scores of fall risk assessment among patients and family caregivers were higher than those at first-time follow-up；the cognitive level of fall prevention and scores of fall risk assessment among patients and family caregivers at 12 months were higher than those at six months（P<0.05）．The incidence of falls was 14.9%（24/161） in 2017，which was significantly lower than 32.5%（53/163） in 2016（χ2=13.86，P<0.01）．Conclusion　Family doctor team service model can effectively control the risk factors of falls among community stroke patients，improve the awareness of fall prevention among patients and family caregivers，and reduce the incidence of falls.

Key words: Cerebral stroke, Fall, Family doctor team, Community health services