“医社联动”：北京市西城区家庭医生与医务社工协作模式探索

“Medical-Social Collaboration”: Exploring a Collaborative Model between Family Doctors and Medical Social Workers in Xicheng District, Beijing

摘要: 在人口老龄化与居民健康需求多元化背景下，北京市西城区家庭医生服务存在人力短缺、服务同质化、居民参与度低等问题。医务社工凭借专业优势，为改善服务提供新路径。本研究基于“问题识别–协作探索–机制构建”逻辑，通过分析家庭医生团队现状及协作痛点，提出“职责专业化分工–沟通平台化建设–协作制度化保障”的三维策略框架，包括制定职责清单、搭建信息化沟通渠道、建立联合培训机制等措施。这些策略推动“医社联动”从临时合作转向系统协作，显著提升慢性病管理等服务质量，为完善基层卫生服务体系及“健康中国”战略实施提供实践范例。

Abstract: Against the backdrop of an aging population and diversifying health needs among residents, family doctor services in Xicheng District, Beijing, face challenges such as shortages of personnel, homogenization of services, and low resident participation. Medical social workers, leveraging their professional expertise, offer new avenues for improving service quality. This study is based on the logic of “problem identification-collaborative exploration-mechanism construction.” By analyzing the current status of family doctor teams and the pain points of collaboration, it proposes a three-dimensional strategic framework of “specialized division of responsibilities-platform-based communication-institutionalized collaboration,” including measures such as establishing a list of responsibilities, building information-based communication channels, and establishing joint training mechanisms. These strategies drive the transition of “medical-community collaboration” from ad-hoc cooperation to systematic collaboration, significantly improving the quality of services such as chronic disease management, and providing a practical model for enhancing the primary healthcare system and implementing the “Healthy China” strategy.