To investigate the effect of hospital-community-family transitional rehabilitation care model on patients with brain trauma and explore an economic, effective, all-sided rehabilitation approach.

A total of 82 in-patients with brain trauma were recruited from January 2018 to June 2019 in Shanghai Yang Zhi Rehabilitation Hospital (Shanghai Sunshine Rehabilitation Center). The participants were allocated into 2 groups based on randomized digital tables. Forty patients in the observation group received the hospital-community-family transitional rehabilitation care, and forty-two patients in the control group received routine rehabilitation care. All the participants completed assessments with the Fugl-Meyer Assessment Scale (FMA), the Barthel Index for the Activities of Daily Living (BI) and the Hamilton Anxiety Scale (HAMA) before the intervention, at discharge, 1 month, 4 months, 6 months and 10 months after discharge, respectively.

Before the intervention, no statistical significance was identified in the total scores of FMA, BI and HAMA between the two groups (P>0.05). Compared to the control group, the total scores of FMA, BI and HAMA in the observation group were significantly improved at the discharge, 1 month, 4 months, 6 months and 10 months after discharge, respectively (t values were -13.82 - 10.28, all P<0.05). Significant differences were observed in the level of FMA, BI and HAMA between the two groups across 6 time points (F_time×group=20.34, 18.34, 19.55, F_time=183.24, 184.30, 179.09, F_group=28.86, 32.19, 26.63, all P<0.05).

The hospital-community-family transitional rehabilitation care model which is based on medical consortium effectively improved traumatic brain-injured patients′motor function, the level of activities of daily living, and patients′anxiety. In addition, the model also improved the quality of medical services.

Traumatic brain injury; Rehabilitation; Transitional care; Medical consortium; Hospital-community-family