基于多元协同的失能老人延续护理社会支持体系研究

Research on the Social Support System for Transitional Care of Disabled Older Adults Based on Multi-Actor Collaboration

摘要: 在人口老龄化加速与家庭照护能力弱化的背景下，失能老人长期照护问题日益突出。延续护理作为连接医院、社区、家庭与养老服务的重要方式，能够在老年人出院后持续提供健康管理、康复指导、生活照料与心理支持，但在现实推进中仍面临服务主体分散、家庭支持不足、社区承接能力有限、信息衔接不畅等问题。基于社会支持理论与协同治理视角，本文围绕失能老人延续护理的支持主体、支持内容与协同机制展开分析，探讨政府、医疗机构、社区、家庭、养老服务机构及数字平台在延续护理中的功能定位。研究认为，失能老人延续护理社会支持体系应以政府制度供给为保障，以医疗机构专业支持为基础，以社区嵌入式服务为枢纽，以家庭照护支持为重点，通过信息共享、资源整合、服务转介和质量评价等机制实现多元协同。为此，应完善制度衔接机制，强化社区照护能力建设，提升家庭照护者支持水平，优化数字技术辅助路径，从而构建更加连续、可及和稳定的失能老人延续护理社会支持体系。

Abstract: Against the background of accelerated population ageing and the weakening of family caregiving capacity, the issue of long-term care for disabled older adults has become increasingly prominent. Transitional care, as an important approach connecting hospitals, communities, families, and elderly care services, can continuously provide health management, rehabilitation guidance, daily life care, and psychological support after older adults are discharged from hospital. However, in practice, it still faces problems such as fragmented service providers, insufficient family support, limited community-based service capacity, and poor information linkage. Based on social support theory and the perspective of collaborative governance, this paper analyzes the supporting subjects, support contents, and collaborative mechanisms involved in transitional care for disabled older adults. It also explores the functional positioning of the government, medical institutions, communities, families, elderly care service institutions, and digital platforms in transitional care. The study argues that the social support system for transitional care of disabled older adults should be guaranteed by governmental institutional provision, grounded in professional support from medical institutions, centered on community-embedded services, and focused on family caregiving support. Multi-actor collaboration should be achieved through mechanisms such as information sharing, resource integration, service referral, and quality evaluation. To this end, it is necessary to improve institutional linkage mechanisms, strengthen community care capacity, enhance support for family caregivers, and optimize digitally assisted care pathways, thereby constructing a more continuous, accessible, and stable social support system for transitional care of disabled older adults.