构建脑卒中个案管理模式临床实践体系，并评价其对脑卒中患者的干预效果。

选取2018年7月至2019年6月在清华大学附属北京清华长庚医院神经内科住院的脑梗死患者100例，随机分为试验组和对照组，每组各50例。对照组接受常规诊疗护理，试验组在常规诊疗护理基础上采取个案管理模式。采用χ²检验比较2组出院后1个月、6个月复诊率的差异以及出院1年后用药依从性和血压控制达标率的差异。

出院后1个月、6个月试验组复诊率分别为88%、64%，对照组分别为68%、42%，试验组均高于对照组，差异具有统计学意义（χ²=5.828，P=0.016；χ²=4.857，P=0.028）；出院后1年试验组抗血小板药物、他汀类药物的用药依从性分别为94%、94%，对照组分别为72%、72%，试验组均高于对照组，差异具有统计学意义（χ²=8.58，P=0.003；χ²=8.58，P=0.003）；出院1年后试验组血压控制达标率为86.2%，对照组为58.1%，试验组高于对照组，差异具有统计学意义（χ²=5.844，P=0.016）。

脑卒中个案管理模式可有效提高脑卒中患者复诊及用药依从性，提升血压控制达标率。

To discuss the clinical practice of stroke case management model and evaluate its interventional effect.

From July 2018 to June 2019, 100 patients with cerebral infarction were randomly divided into the interventional group and the control group at Beijing Tsinghua Changgung Hospital, Affiliated to Tsinghua University, with 50 cases in each group. The control group received routine medical care management, and the interventional group were given routine care plus case management. The follow-up rates at 1, 6 months after discharge, medication compliance and blood pressure control compliance rate were compared between the two groups.

The follow-up rate at the 1 and 6 months after discharge was 84% and 64% in interventional group verses 64% and 42% in the control group, showing the number of the interventional group was significantly higher than that of the control group (χ²= 5.828, P=0.016; χ²=4.857, P=0.028, respectively). The medication compliance of antiplatelet and statins in the interventional group was 94% and 94% verses 72% and 72% in control group (χ²=8.58, P=0.003; χ²=8.58, P=0.003,respectively). The percentage of patients with controlled blood pressure was 86.2% in the interventional group verses 58.1% in control group (χ²=5.844, P=0.016).

Stroke case management model can effectively improve the compliance of stroke patients with timely follow-up, medication compliance, and blood pressure management. Stroke case management model is an effective medical care model.