本书主要应用健康经济学等相关理论，沿用“需求—行为—能力”分析框架，并结合浙江和康医疗集团这一典型案例，对社区植入式医养结合模式进行了系统性学术探索和总结，内容涵盖社区植入式医养结合模式的基本概念和理论、主要约束条件、实施路径和多元社会支持系统等方面，既有深入的理论分析，也有丰富的实践案例讨论，对于当前背景下如何引入社会办医力量，以及在更深的服务层次上和更广的产品范围内，开展以社区为单位的居民健康促进，进一步推动社区治理长效机制建设等，均具有理论参考价值与实践指导意义。

本书可作为高等院校健康产业管理、老年服务与管理等专业的参考用书，亦可供相关领域的企业和政府决策管理人员参考。

序 一

社区植入式医养结合模式研究是清华大学“一带一路”战略研究院的一项重

大科研课题，该研究成果得以出版有着较大的理论意义与实践价值。社区植入式

医养结合是一种创新型的养老模式，在社区层面植入医养结合服务是有益的开拓

性实践与尝试，能带给我们很多启发与思考。

在健康中国战略“共建共享，全民健康”的理念倡导下，让老年人享有健康

幸福的高质量晚年生活，是社会共同的责任与期盼。健康中国追求人人健康，尤

其需要特别关注老年群体的健康问题。老年群体对健康服务的需求也愈发迫切，

我们亟须探索出健康老龄化的实现路径，以实际行动推动人类卫生健康共同体的

构建。

目前，有限的医疗卫生和养老服务，以及彼此相对独立的服务体系，远远不

能满足我国老年人口日益增长的健康服务需求。医养结合的提出与实施是缓解这

一问题的重要举措，其“以老年人为中心”的服务理念能够切实有效地为老年群

体提供医疗卫生与养老相结合的健康养老服务。注重医养结合的新型养老模式已

是大势所趋。

医养结合是我国应对老龄化挑战的一项基础工程。

首先，是“谁来做？”的问题。由谁来为老年群体提供医养结合服务是个值

得思考的问题。正如书中强调的：“在品质有保证的前提下，医养结合服务由谁

提供不应是一个有争议的问题；在管理有效率的前提下，医养结合服务不由谁提

供也不应是一个有争议的问题。”在政府引导下，应支持社会力量参与提供多样

化、多形式的医养结合服务。积极培育并整合从事老年健康照护服务的各类社会

办医力量、养老服务机构、社会组织等社会资源，发挥各自的专业优势，共同为

老年人提供高品质、高质量的健康养老服务。

其次，是“在哪儿做？”的问题。这也是个关键性的问题。社区是居民日常

活动的主要场所，在社区获得各类针对性的健康服务是广大居民的共同需求。社

区医养结合服务是健康养老服务体系建设的关键，是重点，更是难点。立足社区，

建立以社区为基础、逐渐延伸至家庭并联合机构的医养结合服务体系，是满足老

年群体日益增长的健康养老需求的必然选择。



社区植入式医养结合：理论、模式及应用——以和康医疗集团为例

IV

最后，是“怎么做？”的问题。这是一个在具体实施过程中要格外关注的问

题。本书为读者详尽介绍了社区植入式医养结合模式得以实现的基本条件、具体

路径、支持系统、标准化建设等核心内容，为业界开展此项业务提供了不可多得

的理论借鉴和方法参考。

我同课题组成员曾多次参访浙江和康医疗集团并进行实地考察，也有幸参与

了课题的阶段性研究。我认为，社区医养结合事业的长足发展，仍需继续细化医

养结合相关政策的实施细则，健全完善法律法规，以保障供需双方的合法权益，

并探索多渠道、多形式的经费支持，继而推动社区医养服务资源与各类机构组织

的融合发展，共同致力于提供医养一体化的整合照护服务，以满足老年群体多层

次、多样化的健康服务需求。

本书的研究极具前沿性与独创性。在课题组成员全程浸入式扎实实地调研的

基础上，精细翔实地剖析了和康医疗集团社区植入式医养结合模式案例，既有深

度的理论探讨又有具体的实务操作细节分析，研究成果具有科学性、有效性与适

用性，是一本值得推荐且有参考价值的学术著作。

 

 2020年10月26日



序 二

随着我国老龄化程度的持续加深，空巢、高龄、失能、失智老年人数量剧增，

老年群体的健康养老问题不容忽视。老年人对健康的追求是为了改善带病生存的

状态，延长健康寿命。传统以生活照料为主的养老服务和以急救治疗为主的医疗

服务很难再满足老年群体的健康养老需求。

老年群体日益增长的健康需求与供给不足或失衡之间的矛盾日益突出，该矛

盾将对未来医疗和养老产业的发展产生深远影响。通过合理配置有限的医疗卫生

资源来最大限度地满足老年人的健康需求，为老年人提供医养结合的整合式照护

服务，是实现健康老龄化社会的必然选择。

医养结合是促进社区居民健康水平提升的一项基础工程，社区居家老年群体

的健康照护是庞大而又刚性的需求。在现有条件下，实现医疗服务与养老服务在

社区层面上的有机结合，协同整合社区各类健康资源并精准供给，确保老年群体

在社区获得各类高质高效的健康照护服务，进而提高其整体生活质量和健康福利，

是推动老年健康服务发展的着力点。

立足社区为老年人提供社区居家的医养结合服务必要且迫切，基于多年深耕

老年健康领域研究的经验，我认为好的社区居家医养结合模式应该注重发挥社区

疾病预防和康复功能，在保障老年人合理营养膳食、科学安全运动的前提下，用

积极健康的生活方式引导其主动进行自我防控和健康管理，最大程度地维持和恢

复老年人的身体能力。

清华大学“一带一路”战略研究院研究团队基于浙江和康医疗集团社区植入

式医养结合模式的研究，正是一种立足社区，为社区居家老年人提供整合式、一

站式健康照护服务的有益探索与实践。

本书中所介绍的社区植入式医养结合模式是一种创新型的医养结合模式，社

会力量将医疗与养老资源同时“植入”社区，并下沉至社区和家庭，为社区老年

人提供精准的医养结合产品与服务。

社区植入式医养结合模式与我所认为好的社区居家医养结合模式一样，其所

提供的医养结合产品与服务能较好地发挥社区医养结合服务功能，在为老年人提

供不同层次且高质高效的个性化、定制化、差异化健康服务的同时，也切实有效



社区植入式医养结合：理论、模式及应用——以和康医疗集团为例

地满足了老年群体多层次、多样化的健康需求，进一步推进实现为老年人提供无

病期主动康养、急病期住院治疗、稳定期康复照护、终末期安宁疗护一体化的健

康照护服务。

作为清华大学“一带一路”战略研究院专家指导委员会专家，我认为在老龄

化问题日趋严峻的大背景下，社区植入式医养结合模式具有一定的普适价值，值

得推广和复制。此外，本书有着扎实的实地调研分析和深度的理论探讨，研究视

角独具前瞻性和前沿性，可供各相关行业的从业者们学习借鉴，能够为中国应对

老龄化问题提供一定的启示与借鉴。

 

 2020年10月18日



目 录

第一部分 医养结合：背景、需求及相关调查

第一章 植入模式概述 ········································································3

第一节 什么是医养结合？ ··································································4

第二节 什么是社区植入式医养结合？ ···················································7

第三节 本书概况 ············································································13

第二章 医养结合的背景与需求 ···························································19

第一节 人口老龄化现状与挑战 ··························································19

第二节 老年群体疾病负担分析 ··························································21

第三章 老龄化及社区老年人情况调查 ··················································26

第一节 杭州市老龄化趋势 ································································26

第二节 社区老年人总体情况 ·····························································29

第四章 社区医养结合现有模式调查 ·····················································41

第一节 “医”的视角：基层医疗卫生服务现状 ·····································42

第二节 “养”的视角：社区居家养老服务模式 ·····································47

第二部分 理论探索：植入模式的本质与价值

第五章 社会办医力量植入社区的可行性与必要性 ···································57

第一节 双重有限性讨论 ···································································58

第二节 多元社会支持系统 ································································67

第三节 社区健康全覆盖服务 ·····························································74

第六章 植入模式的特性与意义 ···························································81

第一节 植入模式的主要特性 ·····························································81

第二节 植入模式的关键意义 ·····························································88



社区植入式医养结合：理论、模式及应用——以和康医疗集团为例

XII

第七章 和康案例综述及分析 ······························································91

第一节 康复医疗资源 ······································································91

第二节 医养联动策略 ······································································92

第三部分 植入模式的主要内容、基本条件与路径选择

第八章 市场定位与产品服务 ······························································97

第一节 服务对象细分与定位 ·····························································97

第二节 产品服务组合与边界 ····························································102

第九章 个案管理与服务团队 ····························································112

第一节 个案管理与定制化服务 ·························································112

第二节 个案管理服务团队组合 ·························································125

第十章 核心技术与信息管理 ····························································133

第一节 康复治疗及护理技术 ····························································133

第二节 医养结合信息管理 ·······························································136

第十一章 植入模式实现的基本条件 ···················································142

第一节 制度整合 ···········································································142

第二节 管理依据 ···········································································146

第三节 精细化与品质化 ··································································148

第四节 效益优化的有效途径 ····························································151

第十二章 植入模式的战略实施路径 ···················································156

第一节 医养产业联动 ·····································································156

第二节 目标、主体与方向 ·······························································158

第三节 标准—模式—复制 ·······························································162

第四部分 植入模式的多元化社会支持系统

第十三章 政府支持·········································································170

第一节 医养结合险 ········································································170

第二节 效果评价 ···········································································182



目 录

XIII

第十四章 产业支持·········································································188

第一节 健康科技与智慧医养 ····························································188

第二节 医养结合类人才培养 ····························································193

第十五章 社区支持·········································································197

第一节 智慧社区建设 ·····································································197

第二节 社会工作职业化 ··································································201

第十六章 商业支持·········································································207

第一节 商业伙伴选择 ·····································································207

第二节 投融资机制探索 ··································································209

第五部分 未来展望

第十七章 创新发展路径 ··································································221

第一节 合作模式探索 ·····································································221

第二节 SMART商业模式 ································································225

第三节 标准化体系建设 ··································································229

参考文献························································································235

附录：医养结合相关政策梳理 ····························································242



老龄化时代背景下医养结合的创新经典之作

黄德海，清华大学社会科学学院经济学研究所，西安交通大学经济与金融学院产业经济学专业博士毕业，长期从事医院管理和医疗养老产业研究，代表作有《严密组织、分层负责与效益分享：经营之神王永庆的创心管理》等。钱培鑫，浙江和康医疗集团董事长、浙江省社区研究会会长、中国国际经济发展研究中心高级研究员。

何蓓婷，清华大学社科学院理论经济学流动站博士后。李阳，清华大学社科学院理论经济学流动站博士后。