In the context of population ageing, the number of elderly patients with dementia is increasing day by day. This disease seriously affects the quality of life of the elderly and causes huge burdens and pressures on families and society. At this stage, issues such as low level of attention at the national and social levels, weak ability of active screening and identification, high treatment and care costs, and fragmented social service system are prominent in the elderly dementia. It is imperative to actively explore the construction of a care system that covers the entire life cycle of dementia in the elderly, which is composed of multiple welfare subjects such as the government, community, family, market, and civil society organizations. Based on the practice of the full-cycle support project for elderly patients with dementia and their families in Beijing X Hospital, the research takes the theory of welfare pluralism as the framework, and constructs the implementation path and mechanism of the welfare pluralism care system for the elderly with dementia through action research. Based on the portrayal of the reality of the elderly with dementia, health social workers break through the shortcomings of the original medical social work service, such as the single service object, the confinement of the service place, the disconnection of the needs of patients with different disease cycles, and the poor effect of the resource link, etc., turn to the perspective of health social work to use the method of action research to try to break the situation from four directions: in the stage of early detection of dementia, we can clarify the responsibilities of service subjects and maximize service effectiveness; in the stage of early treatment of dementia, we can break down barriers between service subjects and realize the value of resources flow; in the stage of self-management of patients with dementia, we can mobilize the subjective initiative of service subjects to achieve positive transformation of target group; in the dementia friendly advocacy stage, we can respond to the internal needs of service subjects and achieve sustainable development of the care system.

随着我国人口老龄化进程的加快，老年认知障碍患病人数与日俱增，这一疾病严重影响了老年人的生活质量并给家庭和社会造成巨大的负担与压力。现阶段，老年认知障碍在国家及社会层面关注度低、主动筛查和识别能力弱、治疗及照护成本高、社会服务体系碎片化等问题凸显，积极探索构建由政府、医疗机构、社区、慈善团体、市场及民间社会组织等多元福利主体构成的覆盖老年认知障碍病程全周期的照护体系势在必行。研究基于北京市X医院老年认知障碍患者及家庭全周期支援项目实践，以福利多元理论为框架，通过行动研究构建老年认知障碍福利多元照护体系的实施路径与机制。基于老年认知障碍群体现实样态的描绘，健康社会工作者打破原有医务社会工作服务存在的服务对象单一、服务场所禁锢、患者不同疾病周期需求割裂及资源链接成效欠佳等弊端，转而使用健康社会工作的视角，利用行动研究的方法尝试从认知障碍疾病管理的4个阶段进行破局：在认知障碍疾病早发现阶段，能够明确服务主体的职责，实现服务成效的最大化；在认知障碍疾病早治疗阶段，能够打通服务主体间的壁垒，实现资源的价值化流动；在认知障碍患者疾病自我管理阶段，能够调动服务主体的主观能动性，实现服务对象的积极转变；在认知障碍友好化倡导阶段，能够回应服务主体的内在需求，实现照护体系的可持续化发展。