Abstract: Under the background of the global transformation of Primary Health Care (PHC) systems, the PatientCentered Medical Home (PCMH) model, with its core philosophy of "people-centered, integrated, continuous, and teambased care", has emerged as a significant paradigm for enhancing PHC service quality. In China, community health services are undergoing a critical transition from a disease-treatment focus towards health management. The deepening implementation of systems such as contracted family doctor services and hierarchical diagnosis and treatment provides fertile ground for adopting and integrating PCMH concepts. This paper systematically reviews the core elements of PCMH and international practical experiences. By comparing these with the current state of China's community health service system, it identifies structural discrepancies and transformational challenges across six key dimensions: payment incentives, information technology, human resources, service culture, organizational management, and systemic collaboration. Corresponding synergistic reform strategies are proposed. Building on this analysis, the study constructs a progressive, four-stage implementation pathway comprising "organizational preparation, process re-engineering, comprehensive scaling, and continuous improvement". The aim is to provide a reference that combines theoretical systematicity and practical operability, thereby to promote the high-quality development of China's contracted family doctor services with the emphasis shifting from "quantity of contracts" to "quality of service", and from "fragmented" to "integrated"care.

Key words: Community health services, Patient-centered care, General practitioners, Delivery of health care, integrated, Primary health care

摘要： 在全球初级卫生保健（PHC）体系转型的背 景下，“以患者为中心的医疗之家”（PCMH）以其“以人为本的整合式连续化团队服务”的核心理念，已成为提升 PHC 服务质量的重要范式。我国社区卫生服务正处于从疾病治疗向健康管理深度转型的关键阶段，家庭医生签约服务与分级诊疗等制度的深入推进，为吸收并融合 PCMH 理念提供了实践土壤。本文系统梳理 PCMH 的核心要素与国际实践经验，通过对比我国社区卫生服务体系现状，识别出在支付激励、信息技术、人力资源、服务文化、组织管理与系统协同六个关键维度的结构性差异与转型挑战，进而提出相应的协同改革策略。在此基础上，研究构建了一个包含“组织准备、流程重塑、全面推广、持续改进”四个阶段的、循序渐进的实施路径，以期为推动我国家庭医生签约服务实现从“重签约”到“重服务”、从“碎片化”到“整合化”的高质量发展，提供兼具理论系统性与实践操作性的参考。

关键词: 社区卫生服务, 以病人为中心医护, 全科医生, 联合卫生保健系统, 初级卫生保健