背景與目的：台灣國家健康保險局中風急性後期整合照護計畫(PAC-CVA)於住院期之臨床效益已獲證實，然而長期的效益則未被完全探討。本研究之目的在探討其一年期追蹤之日常活動表現、認知能力、平衡、和心肺表現等功能性恢復。方法：共有13位受試者參與本研究。他們皆接受PAC-CVA之復建計畫，並於病發後之3、6、12月接受成效評估。以功能獨立量表、動作活動量表、柏格氏平衡量表、六分鐘行走測驗、聲音數字廣度測試、空間數字廣度測試、和符號數字測驗進行功能量測。結果：本研究於聲音數字廣度測試、柏格氏平衡量表、六分鐘行走測驗測驗皆發現顯著的持續功能進步，然而在動作活動量表品質分量表和總分量表則呈現顯著的退步。結論：根據長期觀察指出，個案的聲音工作記憶、平衡、和心肺能力等在一年之內由持續進步。PAC-CVD復健計畫改善個案之平衡、心肺功能、和聽覺工作記憶能力，然而在一年之長期評估中亦發現未促進患側肢體之使用。

Background and purpose: The clinical effectiveness of a post-acute care cerebrovascular disease program (PAC-CVD) in Taiwan’s National Health Insurance (NHI) system has been evidenced during hospitalization, but the long-term effectiveness has not been thoroughly investigated. The purpose of this research was to investigate functional recovery in daily living performance, cognitive ability, balance, and cardiorespiratory capacity at one-year follow-up. Methods: Thirteen participants were recruited. Participants received rehabilitation according to the PAC-CVD program, and outcome measures were collected at 3 months, 6 months, and 12 months after onset. Several functional measurements were used: the Functional Independent Measurement (FIM) and motor activity log (MAL) for daily living performance, the Berg Balance Scale (BBS) for balance, and the 6-minute walk test (6-MWT) for cardiorespiratory capacity. Cognitive ability was measured with the auditory digit span test (DS–auditory), spatial digit span test (DS–visual), and Symbolic Digit Modalities Test (SDMT). Results: The DS–Auditory, BBS, and 6-MWT indicated significant improvements in function over time, but the MAL-Quality subscale and MAL-total subscale revealed significant declines. Conclusion: Long-term observation indicated functional recovery in auditory working memory, balance, and cardiorespiratory capacity that persisted for one year. At the 12-month follow-up, improvements in balance, cardiorespiratory capacity, and auditory working memory, could be ascribed to the PAC-CVD program, but no treatment effect was found on the use of the affected upper extremity.