【摘要】 在大健康背景下，医务社会工作如何在出院计划中充分发挥专业角色和价值，建立跨团队整合的出院计划服务体系，成为今后我国医务社会工作发展的一个重要方向。在国外，医务社会工作经历了主导出院计划、边缘化出院计划与跨领域整合发展出院计划的角色变化，并在整合与发展连续性照护服务等方面发挥了重要价值。在借鉴其他国家及我国港澳台地区经验的基础上，医务社会工作者可将倡议开展出院计划，建立早期筛选机制，加强与医护合作，以及建立院内—院外连续性照护服务体系等方面作为今后实践发展的方向。更多还原

【Abstract】 Under the background of comprehensive health development,how to play the professional roles and values of medical social work in discharge planning,and promote the establishment of cross-team integrated discharge planning system has become an important development direction of medical social work in China in the future.In foreign countries,medical social work mainly undertakes the role tasks of evaluation,education,consultation,resource development and coordination,and plays an important role in the integration and development of continuous care services.Base on the experience of foreign countries and the regions of Hong Kong and Taiwan in China,medical social work can take the advocate to carry out discharge planning,establish the early screening mechanism,strengthen cooperation with medical care,and establish the continuous care service system from hospital to community as the development direction of discharge planning in the future.更多还原