Abstract: Background　At present，the health problems of the elderly at home in the community have gradually become an important issue of widespread concern in the society，and it is urgent for multiple subjects to intervene in order to build a scientific and effective health support system. Objective　To understand the health status and influencing factors of the elderly at home in the community，and to explore the service strategies of medical social workers to improve the physical and mental health of the elderly at home in the community. Methods　From January to April 2024，620 elderly people living at home were selected in Shipingqiao Sub-district，Jiulongpo District，Chongqing. The physical and mental health status of the elderly was measured by the Chronic Disease Prevalence and Activities of Daily Living Scale，the Anxiety Self-rating Scale（SAS） and the Geriatric Depression Scale（GDS），and the influencing factors of the physical and mental health of the elderly at home were explored from five dimensions：personal characteristics，lifestyle，economic status，intergenerational support and community service. Results　A total of 606 valid questionnaires were retrieved，and the effective recovery rate of the questionnaires was 97.7%. The results showed that in terms of physical health，85.6%（519 cases） of the elderly were patients with chronic diseases，and the average scores of PSMS and IADL were（15.6±0.4） and（16.1±0.4），respectively. In terms of mental health，the average score of anxiety was（4.41±0.02） points，the average score of depression was（4.49±0.03） points，and the detection rate of moderate to severe anxiety was 56.3%（341/606），and the detection rate of moderate to severe depression was 28.7%（174/606）. The results of multiple linear regression showed that age，prevalence of chronic diseases，smoking，alcohol consumption，regular physical exercise，annual personal income，frequency of contact with children，financial support of children，health knowledge/health education services，spiritual comfort/psychological counseling services，and social interaction/recreational activities services all had significant effects on the physical and mental health of the elderly（P<0.05）. Conclusion　It is necessary to establish a long-term and stable multi-faceted collaborative empowerment service team with medical social workers as the main body and the community as the backing，and further design the medical social worker empowerment strategy to promote the improvement of the health level of the elderly at home in the community.

Key words: Home-based elderly, Geriatric assessment, Social workers, Health services needs and demand, Health services for the aged

摘要： 背景　社区居家老年群体的健康问题已逐渐成为社会广泛关注的重要议题，亟须多元主体协同介入以构建科学且有效的健康支持体系。目的　了解社区居家老年人的健康状况及影响因素，探讨医务社工赋能社区居家老年人身心健康提升的服务策略。方法　于2024年1—4月，在重庆市九龙坡区石坪桥街道抽取620名居家老年人。通过问卷调查收集数据，分别采用慢性病患病情况和日常生活活动能力量表、焦虑自评量表（SAS）和老年抑郁量表（GDS）测量老年人的生理、心理健康现状。采用多元线性回归，基于Grossman健康需求模型，从个人特征、生活方式、经济状况、代际支持、社区服务5个维度探讨居家老年人身心健康水平的影响因素。结果　共回收有效问卷606份，问卷有效回收率为97.7%。在生理健康方面，519名（85.6%）的老年人为慢性病患者，平均躯体生活自理量表（PSMS）和工具性日常生活活动能力量表（IADL）得分分别为（15.6±0.4）、（16.1±0.4）分；在心理健康方面，606名老年人的平均SAS得分为（4.41±0.02）分，平均GDS得分为（4.49±0.03）分，中重度焦虑检出率为56.3%（341/606），中重度抑郁检出率为28.7%（174/606）。多元线性回归分析结果显示，年龄、慢性病患病情况、吸烟、饮酒、规律体育锻炼、个人年收入、与子女联系频率、子女经济支持情况、保健知识/健康教育服务、精神慰藉/心理咨询服务、社会交往/娱乐活动服务等因素均对老年人的身心健康状况具有明显影响（P<0.05）。结论　社区居家老年人的身心健康状况不佳且影响因素众多，保障其健康是一项复杂的系统工程，需要组建一支以医务社工为主体、社区为依托的长期且稳定的多元协同赋能服务团队，并进一步设计医务社工赋能策略，以推动社区居家老年人健康水平提升。

关键词: 居家老年人, 老年人身心健康评价, 社会工作者, 卫生服务需求, 老年人保健服务