脑卒中康复服务体系与转诊机制建设的国际经验  

International experiences in the construction of stroke rehabilitation service systems and referral mechanisms

作　　者：王旭 朱碧帆 陈多[1] 侯晓慧 覃湫珺 李芬 WANG Xu;ZHU Bifan;CHEN Duo;HOU Xiaohui;QIN Qiujun;LI Fen(Shanghai Health Development Research Center/Shanghai Medical Information Center,Shanghai 200040,China;Financial Management Affairs Center,Shanghai Municipal Health Commission,Shanghai 200040,China)

机构地区：[1]上海市卫生和健康发展研究中心/上海市医学科学技术情报研究所,上海200040 [2]上海市卫生健康委员会财务管理事务中心,上海200040

出　　处：《卫生软科学》2025年第4期86-94,共9页Soft Science of Health

基　　金：国家自然科学基金青年项目-基于真实世界数据的脑卒中整合防治体系评价实证研究(72004138);上海市卫生健康委员会科研项目(20224Y0101);上海市卫生健康委卫生行业临床研究专项(20244Y0118)。

摘　　要：本文以美国、加拿大和英国为例,梳理脑卒中康复服务体系与转诊机制建设的国际经验。美国、加拿大和英国脑卒中康复服务发展较为成熟,通过明确各类康复医疗机构的职责分工,设立清晰的转诊条件,建立规范化的转诊路径,实现不同级别医疗机构的贯通对接。我国康复服务体系建设仍处于起步阶段,在机构功能定位、患者入院要求、康复服务强度等方面仍缺乏明确界定,规范化、标准化的脑卒中康复综合评估工具与转诊规范尚未形成。建议未来我国应进一步明确各级各类康复医疗机构的职责分工、患者准入要求及服务内涵;研制符合国情的脑卒中康复评估工具,制定脑卒中患者康复服务转诊标准与规范,并优化康复服务医保支付方式;通过医联体建设、信息平台搭建、出院规划师配置等多种形式,完善不同级别康复医疗机构间的协调联动与有序转诊。Taking the United States,Canada and the United kingdom as examples,this paper reviews international experiences in the construction of stroke rehabilitation service systems and referral mechanisms.Stroke rehabilitation services in the United States,Canada,and the United Kingdom are relatively well-developed.Medical institutions at different levels can be connected by clearly defining the responsibilities of various hospitals for rehabilitation,establishing clear referral conditions,and building standardized referral paths.The construction of rehabilitation services system in China is still in its initial stage,and there is still a lack of clear definitions in terms of the functional positioning of institutions,criteria for patient admission,and the intensity of rehabilitation services.Standardized and comprehensive assessment tools and referral standards for stroke rehabilitation have not yet been formed.In the future,it is necessary to further clarify the responsibilities of various hospitals for rehabilitation at different levels,criteria for patient admission,and connotations of services;to develop assessment tools for stroke rehabilitation in line with national conditions,formulate referral standards and norms of rehabilitation services for stroke patients,and optimize payment methods for medical insurance for rehabilitation services.Through the construction of medical alliances and information platforms,the allocation of discharge planners and other forms,the coordination,interaction and orderly referral between hospitals for rehabilitation at different levels are improved.

关 键 词：脑卒中 康复服务 组织体系 转诊流程 国际经验 

分 类 号：R743.3[医药卫生—神经病学与精神病学] R197[医药卫生—临床医学]