Discharge preparation can help patients smoothly transition from one health care environment to another. In the medical institutions of foreign countries, discharge preparation is one of the main responsibilities of medical social workers. However, in China, there is currently relatively little involvement of social workers in discharge preparation.

To understand the intervention space and realistic challenges faced by medical social workers in the field of discharge preparation, and provide reference basis for improving social work in discharge preparation.

Using purposive sampling method from March to June 2023, based on a multidisciplinary perspective, adopt the qualitative interview method to conduct in-depth interviews with 20 medical personnel (including doctors, nurses, medical social workers, and medical management personnel). The interview data is organized and analyzed using Nvivo 12.0 software and the Colaizzi seven step analysis method.

Medical social workers mainly carry out psychological and social assessments, develop professional service plans, provide social work interventions, and conduct follow-up in the field of discharge preparation services. While accumulating some local practical experience, they also face many realistic challenges, including insufficient access to social resources, multiple obstacles to the linkage between hospital and community, the lack of a standardized mechanism, inadequate interdisciplinary collaboration, a shortage of human resources for social workers, the need to improve their comprehensive abilities.

Promote the development of social work services for discharge preparation in China, by advocating for the construction of the social policy system and mechanism, building a multidisciplinary cooperation platform for hospitals, promoting the comprehensive capacity building of medical social workers.

出院准备工作可以帮助患者顺利地从一个照护环境进入另一个照护环境。在国外医疗机构中，出院准备是医务社工的主要职责之一。而在我国目前医务社工介入出院准备工作相对较少。

了解医务社工在出院准备工作领域的介入空间及面临的现实挑战，为完善出院准备社会工作提供参考依据。

基于多学科视角，采用目的抽样法于2023年3—6月对20名医务人员（包括医生、护士、医务社工、医疗管理人员）进行深度访谈，借助Nvivo12.0软件，并运用Colaizzi七步分析法对访谈资料进行整理和分析。

医务社工在出院准备服务领域主要开展心理社会评估、制订专业服务计划、提供社会工作干预、进行跟踪随访等，在积累一些本土实践经验的同时也面临许多现实性挑战，包括社会资源可及性不足、医社联动存在多重障碍、医院尚未建立常态化机制、多学科协作不够完善、社工人力资源短缺、综合能力有待提升等。

通过倡导社会政策体系机制建设，搭建医院多学科合作平台建设，促进医务社工综合能力建设，推动我国出院准备社会工作服务的发展。