Objective To investigate the effect of hospital-community-family graded referral care in patients with acute coronary syndrome（ACS） with different risk stratification to provide a reference for rehabilitation management of other acute and severe chronic diseases. Methods The global registry of acute coronary events（GRACE） tool was used to risk stratify ACS conditions. Continuous cardiac rehabilitation management intervention was carried out in 60 ACS patients with different risk stratification using the hospital-community-family graded referral care model. Cardiac function

laboratory parameters

and self-efficacy were assessed at discharge and at different time points after discharge. Results The scores of the general self-efficacy-schwarzer（GSES） at discharge

6 months and 1 year after discharge were（24.11±4.67）

（27.07±3.67） and（30.43±4.06）

respectively. The scores of GSES were significantly higher than those at discharge

and the scores of GSES increased with the passage of follow-up time（all P<0.05）. There were significant differences in fasting blood glucose and low-density lipoprotein levels between patients at different time periods（all P<0.05）. Over time

low-density lipoprotein levels in patients at 6 months and 1 year after discharge were significantly lower than those at discharge（all P<0.05）; fasting blood glucose levels in patients at 1 quarter

6 months

and 1 year after discharge were significantly lower than those at discharge（all P<0.05）. Conclusion The GRACE risk-stratified-based hospital-community-family referral care for ACS patients with different risk stratification can markedly improve the clinical prognosis of patients and raise their self-efficacy.