老年照护服务连续性的现实梗阻与整合路径研究

Research on Practical Obstacles and Integration Paths of Continuity in Elderly Care Services

摘要: 在人口老龄化背景下，失能老年人的健康照护需求日益增长，但急性医疗服务与长期照护服务之间长期存在制度性脱节，导致服务链条在“治疗–康复–维持”的过渡阶段出现断裂，造成服务重叠与资源内耗。本研究引入制度耦合理论，剖析两大服务体系在规则、组织与功能三个维度上的脱耦逻辑，并以“治疗–康复–维持–生活照料”的老年健康需求为基础，重新厘定两者功能边界。在借鉴德国、日本、荷兰医养服务协同经验的基础上，提出以统一需求评估为枢纽、服务清单为工具、个案管理和信息整合为支撑的协同路径。研究认为，从条块分割走向有序整合，是化解照护服务内耗、实现老年人连续照护的关键选择。

Abstract: In the context of population aging, the demand for health care among disabled elderly individuals is growing. However, there has long been a systemic disconnect between acute medical services and long-term care services, leading to a fracture in the service chain during the transition phase from “treatment-rehabilitation-maintenance”, resulting in service overlap and resource depletion. This study introduces the theory of institutional coupling to analyze the decoupling logic of the two service systems in terms of rules, organization, and function. Based on the elderly health needs of “treatment-rehabilitation-maintenance-life care”, it redefines the functional boundaries between the two. Drawing on the collaborative experience of medical and elderly care services in Germany, Japan, and the Netherlands, this study proposes a collaborative path centered around unified needs assessment, using service checklists as a tool, and supported by case management and information integration. The study believes that moving from compartmentalization to orderly integration is a key choice to resolve internal depletion in care services and achieve continuous care for the elderly.