Abstract: Background　Under the bio-psycho-social medical model, medical social work is expected to play an integral role in primary healthcare, yet in practice medical social workers often face role ambiguity and marginalization. Objective　This study examines how medical social workers are functionally positioned and operationally integrated within multidisciplinary teams (MDTs) in primary care, drawing on a case study from Chengdu, China. Methods　A qualitative study was conducted between April and July 2025 at a community health service center. Data were generated through focus group interviews (n=14) and semi-structured interviews (n=19) with family doctor team members, medical social workers, administrators, and patients. Results　Findings show that effective integration does not rely on formal professional equality. Instead, medical social workers are embedded as a supporting team through three mechanisms: organizational embedding into internal service structures, process integration across pre-, during-, and post-consultation stages, and outcome validation through observable improvements in patient satisfaction and care efficiency. Conclusion　A pragmatic, value-oriented integration strategy enables medical social work to move from peripheral participation to institutionalized embedding in primary care. This study provides an empirically grounded pathway for strengthening MDT collaboration in primary healthcare settings.

Key words: Quality assurance, health care；Primary healthcare；Medical social work；Multidisciplinary team collaboration；Community health service center；Case study

摘要： 背景　在“生物-心理-社会”医学模式转型背景下，医务社会工作被视为完善基层医疗服务体系的重要力量。然而，医务社工在理论上被寄予厚望的核心角色期待，在实践中却常面临专业边缘化与功能模糊化的困境，其理论角色期待与现实运行之间存在显著张力。目的　本文以成都市武侯区玉林社区卫生服务中心为案例，系统分析基层多学科协作（MDT）实践中医务社工的功能定位与运行机制，提炼兼顾可行性与有效性的整合路径。方法　于2025年4—7月，以成都市武侯区玉林社区卫生服务中心为研究场域，采用质性研究方法，研究对象包括参与基层多学科协作的家庭医生团队成员、医务社工、医疗机构管理者及患者等相关利益方。第一阶段通过焦点小组访谈（n=14），构建并优化了家庭医生团队与医务社工的协作机制；第二阶段通过对管理者、医护人员、医务社工及患者等多方利益相关者开展半结构化访谈（n=19），聚焦医务社工在MDT中的角色定位、作用机制与实践成效。结果　研究发现，玉林模式并未追求专业平等，而是将医务社工策略性地定位为“支撑团队”，通过三大机制实现了有效整合，（1）组织嵌入：通过制度化路径将医务社工由外部协作者转变为内部成员；（2）流程整合：将医务社工系统性嵌入“诊前—诊中—诊后”全服务流程，实现由被动响应向主动管理的转变；（3）效能证实：医务社工的介入在患者满意度、健康管理效率等多方面呈现出可量化改善，其专业价值得以显性化呈现。结论　基层医务社工实现有效融入的关键，在于摒弃理想化的角色设定，转而采取以价值产出为导向的务实整合策略。该路径始于回应医疗体系的核心关切，通过可量化的成效证实自身价值，推动医务社工由项目式合作向制度化嵌入的转变。本研究提出的渐进式协作模型为破解基层医务社工的实践困境提供了具有现实可操作性的本土化经验，并有助于推动我国基层医疗服务体系的完善。

关键词: 质量保证, 卫生保健；基层医疗；医务社会工作；多学科协作；社区卫生服务中心；个案研究