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

摘要： 背景　据文献报道47%的社区脑卒中患者有超过1次的跌倒，跌倒被认为是脑血管疾病的一种严重并发症。为此，加强社区脑卒中防跌倒管理已迫在眉睫。目的　探索家庭医生团队服务模式对社区脑卒中患者防跌倒的影响。方法　选取2016年在彭浦新村街道社区卫生服务中心登记的163例脑卒中患者为研究对象。采用家庭医生团队服务模式对居家脑卒中患者及照顾者进行防跌倒干预，干预时间1年。比较首次、第6个月、第12个月入户随访时脑卒中患者及其家庭照顾者防跌倒相关知识认知度、跌倒风险评估得分及2016年与2017年跌倒发生率等指标。结果　首次、第6个月、第12个月入户随访时，患者及照顾者防跌倒相关知识认知度、跌倒风险评估得分比较，差异均有统计学意义（P<0.001）；其中，第6个月、第12个月入户随访时患者及照顾者防跌倒相关知识认知度、跌倒风险评估得分均高于首次入户时，第12个月入户随访时患者及照顾者防跌倒相关知识认知度、跌倒风险评估得分均高于第6个月入户随访时（P<0.05）。2017年研究对象跌倒发生率为14.9%（24/161），低于2016年的32.5%（53/163）（χ2=13.86，P<0.01）。结论　运用家庭医生团队服务模式能有效控制社区脑卒中患者跌倒发生的风险因素，提高患者及照顾者防跌倒相关知识认知度，减少跌倒的发生率。

关键词: 脑卒中, 跌倒, 家庭医生团队, 社区卫生服务