One of the important reasons for the slow progress of hierarchical diagnosis and treatment since its implementation is the lack of comprehensiveness in the analysis of multiple subjects and stakeholders.

To explore mechanism innovation solutions that combine both top-down and bottom-up paths by analyzing the interest relationships among diverse stakeholders in the hierarchical medical diagnosis and treatment system, and facilitate collaborative governance among diverse stakeholders through policy innovation and path innovation, to optimize the order of hierarchical patient flow.

From October 10, 2022, to March 20, 2023, two advanced urban districts in China (S district in X city and H district in N city) were selected as typical research areas. A total of 36 different stakeholders (involving municipal health administrative departments, tertiary hospital administrators, tertiary hospital specialists, community health service center administrators, general practitioners, health social workers, and patients) were selected as the study subjects for the in-depth interviews through snowball and purposive sampling methods. The stakeholder theory analysis method was employed to analyze the interests and constraints among the seven major stakeholder groups and their constraints on the healthy development of the order of hierarchical medical diagnosis and treatment, and explore the dilemma of the mechanism of hierarchical diagnosis and treatment. Furthermore, textual analysis of interview records of typical stakeholders in the pilot and non-pilot areas of the implementation of health social workers and community smart health huts in S district in X city and H district in N city was conducted to compare the effects before and after the implementation.

The results of the in-depth interviews showed that four main dimensions, including the degree of interest, willingness to implement, the extent of impact by implementation, and the influence on implementation, are the major factors affecting the implementation of hierarchical medical diagnosis and treatment by the seven major stakeholder groups. These seven stakeholder groups hold varying interest positions and play different roles in facilitating or obstructing the implementation of the hierarchical medical diagnosis and treatment. The difficulty of forming a collaborative mechanism among diverse stakeholders is the key to the problem. In pilot areas, through the implementation of the community smart health huts and health social workers, and the resulting medical-social collaboration, the relevance of the seven major stakeholder groups can be enhanced and the hierarchical medical diagnosis and treatment order can be improved.

The community smart health huts serve as a physical space for the new medical-social collaboration mechanism, while health social workers act as the connectors and enablers of this new mechanism. With the help of the new carrier of community smart health huts and the new power of health social workers, the construction of a new path of medical-social collaboration centered on health social work can realize the front entrance of medical treatment and play the role of"energy enhancer"to form the order of hierarchical medical diagnosis and treatment.