基于社区的卒中全生命周期健康管理模式研究进展

doi:10.3969/j.issn.1673-5765.2025.03.006

摘要/Abstract

摘要： 我国脑卒中防治“百万减残工程”提出卒中的全生命周期管理服务理念，致力于将卒中防治工作从传统的“疾病治疗”模式转变为“健康管理”模式。本文立足于社区在卒中防治中的独特优势，系统梳理了国内外基层社区卒中防治的服务实践、实施模式及干预策略，旨在为构建卒中全生命周期健康管理模式提供科学依据和实践参考。基于社区的卒中全生命周期健康管理模式可通过整合资源和技术，在动员社区参与、营造健康环境、早期预防与筛查、急性期快速响应、康复期整合型管理、动态随访以及提供心理和社会支持等方面形成创新性模式。该模式不仅有助于改善卒中患者的生活质量，还能有效减轻家庭及社会负担。

文章导读： 本文系统分析了基于社区的卒中全生命周期健康管理模式，包括预防、急性期识别、过渡期和康复期管理。提出通过政策协同创新、加强社区科普、整合服务网络、强化科技赋能等策略，推动卒中防治从“疾病治疗”模式向“健康管理”模式转变。

关键词: 卒中防治; 社区; 全生命周期; 健康管理

Abstract: The Stroke Prevention and Control “Million Reduction Disability Project” in China proposes the concept of full life-cycle health management services for stroke, aiming to transform stroke prevention and treatment from the traditional “disease treatment” model to the “health management” model. This paper, based on the unique advantages of communities in stroke prevention and treatment, systematically reviews the service practices, implementation models, and intervention strategies of stroke prevention and treatment in primary communities at home and abroad, aiming to provide scientific evidence and practical references for constructing a full life-cycle health management model for stroke. The community-based full life-cycle health management model for stroke can integrate resources and techniques to form an innovative model in mobilizing community participation, creating a healthy environment, early prevention and screening, rapid response during the acute phase, integrated management during the rehabilitation, dynamic follow-up, and providing psychological and social support. This model not only improves the quality of life for stroke patients but also effectively reduces the burden on families and society.

Key words: Stroke prevention and treatment; Community; Full life-cycle; Health management

中图分类号:

常丹凤, 申斗, 曹欣, 马可菲, 杨燕绥, 张玉哲, 池枫, 刘跃华, 高月霞. 基于社区的卒中全生命周期健康管理模式研究进展[J]. 中国卒中杂志, 2025, 20(3): 298-304.

CHANG Danfeng, SHEN Dou, CAO Xin, MA Kefei, YANG Yansui, ZHANG Yuzhe, CHI Feng, LIU Yuehua, GAO Yuexia. Research Progress on a Community-Based Full Life-Cycle Health Management Model for Stroke[J]. Chinese Journal of Stroke, 2025, 20(3): 298-304.

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