关键词: 医养结合, 出院计划, 医务社会工作

Abstract: The promotion of integrated medical and nursing care is a positive initiative for addressing the health needs of the ageing population，as well as for achieving the goals of "Healthy China" and boosting the development of China's elderly care industry.Discharge planning is made by health professionals based on assessing the patient's needs，which aims to ensure the patient achieve good health and quality of life by receiving integrated and continued care from the institution to which he is admitted after discharge from hospital.It enhances the coordination of services after discharge from hospital，bridges the gap between hospital and the place to which the patient is discharged，guaranteeing the patient access to continued care for improving rehabilitation.The delivery of integrated medical and nursing care is favorable for the implementation of discharge planning，which makes the access to continued care after hospital discharge possible.Medical social workers involved in the formulation and implementation of discharge planning plays a vital role in assessing the overall health needs of older people，increasing the professional inter-institutional communication and cooperation and improving the rehabilitation after discharge from hospital.It is urgent to develop a discharge planning by professionals involving medical social workers based on the national conditions and national implementation status of integrated medical and nursing care.We discussed the importance of discharge planning whose formulation and implementation involve medical social workers，and analyzed its feasibility，hoping to offer an important reference for assessing the general health needs of the elderly，strengthening the communication and cooperation between multidisciplinary professionals，and following up geriatric rehabilitation after hospital discharge.

Key words: Combination of medical care and pension, Discharge planning, Medical social work