Abstract: Background　Rehabilitation is an important part of work in community health service institutions.The unsound rehabilitation network system has increased the needs of stroke rehabilitation in communities.Building a community stroke rehabilitation service system is in line with the health service needs of community residents，and it is also the functional embodiment of primary health care institutions in the medical and health system.Objective　To establish a standard for admission and discharge of strokes in communities in Shanghai，so as to guide the community to screen out the population that is truly in the category of stroke rehabilitation and urgently needed care，and to regulate admission and discharge of patients with stroke in rehabilitation at all levels.Methods　A total of 18 managers and executors related stroke rehabilitation from general hospitals and community health service centers were invited to participate in the two rounds of Delphi consultation from April to July 2018.Experts' advice about the admission and discharge standards of patients who needed stroke rehabilitation in community center wards，nursing institutions，community center outpatient clinics and home-based rehabilitation services were collected.Results　The positive coefficient of both rounds of experts consulting was 100.0%，and the final round of expert authority was 0.74.According to the definition of admission and discharge standard for service targets，the criteria for rehabilitation of stroke patients in communities were sorted out from the aspects of intervention time，neurological function，motor dysfunction，tactile and proprioceptive disorders，cognitive impairment，mood disorder，language and communication disorders，dysphagia，urinary and fecal disorders，daily living ability and quality of life，and social support.Conclusion　The standards for admission and discharge which were established for the community center wards，nursing institutions，center outpatient clinics，and home-based rehabilitation services have a high degree of credibility.The standards have practical application for community rehabilitation，which has also laid the foundation for the operation of the rehabilitation and referral mechanism of stroke at all levels in the community.

Key words: Stroke, Rehabilitation, Community health services, Admittance criterion, Discharge criteria, Delphi technique

摘要： 背景　康复是社区卫生服务机构职能的一个重要组成部分，康复网络体系的不健全，加剧了社区的脑卒中康复需求。构建社区脑卒中康复服务体系，符合社区居民的卫生服务需求，也是基层医疗卫生机构在医疗卫生体系中功能定位的体现。目的　构建上海市社区脑卒中各级康复准入及准出标准，以指导社区筛选真正属于脑卒中康复范畴并亟须照护的人群，规范各级脑卒中患者的准入及准出。方法　于2018年4—7月，邀请18位综合医院心脑血管和康复领域专家、社区卫生服务中心脑卒中康复相关管理者和执行人代表，通过两轮Delphi专家咨询，采集各位专家对社区中心病房康复、养老机构康复、社区中心门诊康复和居家康复的脑卒中康复服务对象的准入及准出标准的意见。结果　两轮咨询专家的积极系数均为100.0%，且最后一轮专家权威程度为0.74。根据服务对象准入及准出标准的界定原则，从介入时间点、神经功能、运动功能障碍、触觉及本体感觉障碍、认知障碍、情绪障碍、语言和交流障碍、吞咽障碍、尿便障碍、日常生活活动能力和生活质量、社会支持度等方面梳理出了社区脑卒中患者各级康复的准入及准出标准。结论　本研究构建的社区中心病房、养老机构、社区中心门诊、居家四级康复服务对象的准入及准出标准可信度较高，可供社区开展脑卒中康复工作时借鉴及实际应用，同时为社区各级脑卒中康复转介机制的有序运行奠定了基础。

关键词: 卒中, 康复, 社区卫生服务, 准入标准, 准出标准, 德尔菲技术