Abstract: Background　It is difficult for the orthopedic department in general hospitals to manage increased workload associated with out-of-hospital rehabilitation for increasing elderly patients after total hip replacement（THR）. As out-of-hospital rehabilitation may directly affect the surgical effect and functional rehabilitation outcome，it still needs to be studied to develop a feasible long-term management plan involving hospital-community-home collaboration with efforts ensuring its implementation，to improve patients' functional recovery and reduce medical expenses in the long term. Objective　To develop a hospital-community-home three-stage rehabilitation scheme for elderly patients after THR by representative members from the community general practice team and representative family members of the patients led by the orthopedic team from general hospitals. Methods　The development of hospital-community-home rehabilitation strategy was divided into 3 stages：1. theoretical stage：During August to October 2018，the initial scheme was developed using focus group discussion by 10 members of our research team. 2. clinical trial stage：a randomized controlled trial（RCT） involving totally 60 patients admitted to Shanghai Fourth People's Hospital，Tongji University from January to August 2019 and their family members or carers was conducted to compare video-feedback interventions and regular health interventions in two equal groups of patients randomly divided in terms of efficacy evaluated by Harris Hip Score and Barthel Index at discharge，1 and 3 months after discharge. 3. improving stage：During June to August 2020，our research group determined the contents and predicted the cost of community interventions using literature review，and then formulated the final version of hospital-community-home rehabilitation process for elderly patients after THR using focus group discussion. Results　1. Among the hospital-community-home rehabilitation process，the hospital acts as the "source of technologies and information"，and shoulders the responsibility of efficiently providing professional skills and information for community- and home-based postoperative rehabilitation. The community acts as the "family doctor station"，and shoulders the responsibility of providing post-discharge rehabilitation services including outpatient and inpatient care，home-based visits，in-home medical care，and management of other chronic diseases via integrating various community resources by the family doctor team. In terms of home-based rehabilitation，pre-discharge rehabilitation services could be provided by the orthopedic department of a general hospital or workers engaging in pre-discharge nursing and patient transferring，and other challenging and time-consuming services such as looking for rehabilitation resources and disease management could be provided by the family doctor team. 2. The RCT showed that patients receiving video-feedback interventions had statistically higher Harris Hip Score and Barthel Index at discharge，1 and 3 months after discharge（P<0.05），indicating that the video-feedback interventions were feasible and effective. 3. After once again clarifying the prerequisites for ensuring the sustainable participation of all parties in the collaboration process，specific calculations indicated that the hospital-community-home three-stage out-of-hospital rehabilitation strategy for elderly patients after THR could be implemented via organically integrating the resources of hospitals，communities，and families to satisfy the patients' needs. Among the services，important management services delivered by family doctors should be paid reasonably，such as pooling sources，coordination，consultation and follow-up，and the estimated cost during the rehabilitation period would not exceed 25.3 yuan per day. Conclusion　This rehabilitation strategy has proved to be applicable in terms of both technology and process，and the preliminary exploration is expected to be implemented. Services delivered by family doctors are important and core component of the rehabilitation services，which should to be paid appropriately. As these services are not included in the current medical payment system，a proper payment system reducing the overall long-term cost should be established.

Key words: Arthroplasty, replacement, hip；Rehabilitation；Aged；Hospital-community-family

摘要： 背景　老年全髋关节置换术（THR）患者越来越多，综合医院专科难以管理院外康复，但其院外康复直接影响手术效果和患者功能康复结局，如何在患者出院前后就做好覆盖医院-社区-家庭三段式协作体系的长程管理计划并确保计划可落实执行，以提高患者功能康复程度并节约远期医疗费用还需进一步研究。目的　本研究以综合医院骨科团队为发起人，召集社区全科团队代表和患者家属代表共同研究老年THR后患者医院-社区-家庭三段式康复的具体落地方案。方法　流程开发阶段，于2018年8—10月由成立的服务体系开发项目小组10名成员采用焦点小组访谈法开发“老年THR患者术后院外康复医院-社区-家庭三环节协作流程”。临床试验阶段，以本研究所在机构2019年1—8月收治的60例THR患者及其家属/陪护为研究对象，采用随机对照试验验证医院环节康复训练技术下沉的手段——“老年THR患者术后康复分阶段视频回授法”的有效性。具体采用随机数字表法生成分配方案，对照组30例采用常规健康教育，干预组30例采用视频回授法分阶段实施健康教育，分别于出院时、出院后1个月、出院后3个月测量Harris评分和Barthel指数评分。流程优化阶段，于2020年6—8月由服务体系开发项目小组采用焦点小组访谈开发“医院-社区-家庭三段式老年THR患者术后康复流程”，并基于文献查阅计算社区环节的干预内容及其预估成本。结果　首先，开发出了医院、社区、家庭三者之间的协作流程。其中，医院环节的主要责任是形成“技术信息源”，并可实现高效下沉；社区环节的主要责任是构建“家医驿站”，即家庭医生团队可以通过整合社区各类资源为患者提供集门诊、病房、上门访视、家庭病床等多种形式为一体的院后康复，且承担患者其他慢性病的管理；家庭环节的“康复空间”，可在出院前由综合医院骨科或出院前的护送供应体系来完成，而其承担的其他较高难度且耗费时间的资源寻找、病程管理等工作可以全部移交给家庭医生团队来处理。其次，验证医院环节开发的下沉技术，结果表明干预组患者与对照组相比，出院时、出院后1个月、出院后3个月Harris评分和Barthel指数评分均更高，差异有统计学意义（P<0.05），“老年THR患者术后康复分阶段视频回授法”是可行且有效的。最后，再次明确协作流程中确保各方可持续参与的前提条件并进行具体测算，结果表明医院-社区-家庭三段式的老年THR患者术后院外康复策略可以通过有机整合医院、社区、家庭三方的需求和资源来落地运行，其中，家庭医生的驿站功能，即统筹、协调、咨询、随访等重要的管理服务工作需要得到合理的支付，预计康复期内成本不超过25.3元/d。结论　本研究提出的老年THR后患者医院-社区-家庭三段式康复策略从技术到流程均可行，初探有望落地。其中，家庭医生团队是关键环节和核心枢纽，需要为其超出当前医疗支付体系的专业服务内容建立合适的支付体系，最终是患者受益，且有望降低远期总体费用。

关键词: 关节成形术, 置换, 髋；康复；老年人；医院-社区-家庭