关键词：医养结合服务、可持续发展、模糊集定性比较分析
Keywords: Integrated medical and elderly care services, sustainable development, fuzzy set qualitative comparative analysis

1引言
1 Introduction

截止2023年，中国65岁及以上人口数量为21709万，占总人口的15.4%。根据《中国老龄化研究报告》预测，2057年中国65岁及以上人口将达4.25亿，占总人口的32.9%～37.6%，人口老龄化将成为中国社会的常态。老年人的身体机能逐渐衰退，慢性疾病的发生率增加，健康水平下降影响到生活质量；慢性疾病带来的长期的疼痛和经济压力引发心理问题；因此在医疗保健、生活照料与精神关爱等方面的需求更加突出。医养结合涵盖疾病诊断、护理与康复，并延伸至心理和社会层面的健康管理，是积极应对老龄化的关键路径。
As of 2023, the number of people aged 65 and over in China is 217,090,000, accounting for 15.4% of the total population. According to the "China Aging Report," by 2057, the number of people aged 65 and over in China is expected to reach 425,000,000, accounting for 32.9% to 37.6% of the total population. Aging will become a norm in Chinese society. As people age, their physical functions gradually decline, the incidence of chronic diseases increases, and health levels decline, affecting their quality of life. Chronic diseases bring long-term pain and economic pressure, leading to psychological issues. Therefore, the demand for medical care, daily care, and spiritual care is more prominent. Integrated medical and elderly care covers disease diagnosis, nursing, and rehabilitation, and extends to health management at the psychological and social levels, making it a key path to actively address population aging.

在积极应对人口老龄化的战略背景下，国家卫生健康委等十一个部门于2022年7月21日联合发布的《关于进一步推进医养结合发展的指导意见》（国卫老龄发〔2022〕25号）凸显了开展医养结合的重要性和必要性。促进医养结合服务可持续发展已然成为新时代积极应对人口老龄化的重要抓手。
Under the strategic background of actively addressing population aging, the National Health Commission and ten other departments jointly issued the "Guiding Opinions on Further Promoting Integrated Medical and Elderly Care Services" (Guo Wei Lao Jie Fa [2022] No. 25) on July 21, 2022, highlighting the importance and necessity of promoting integrated medical and elderly care services. Promoting the sustainable development of integrated medical and elderly care services has become an important handle for actively addressing population aging in the new era.

然而，中国各地区资源禀赋不同，影响医养结合服务可持续性发展的诸多因素尚不明确，限制了其对积极应对人口老龄化的贡献。尽管已有研究分析了基层护理、医保支付、卫生人力资源等单因素对医养结合服务的影响，但尚未阐明这些因素如何组合协同推动医养结合服务可持续性，导致实践中的政策效果差异显著。目前关于医养结合服务领域的案例研究局限于描述性分析，且多以个案研究为主，缺少多案例的联合研究，亟需系统的前沿性方法进行深入研究。
However, different regions in China have varying resource endowments, and many factors influencing the sustainability of integrated medical and elderly care services remain unclear, limiting their contribution to addressing population aging proactively. Although existing research has analyzed the impact of single factors such as community nursing, medical insurance payments, and health human resources on integrated medical and elderly care services, it has not yet elucidated how these factors combine and synergize to promote the sustainability of such services, leading to significant differences in policy effects in practice. Currently, case studies in the field of integrated medical and elderly care services are primarily descriptive analyses and are mostly single-case studies, lacking multi-case joint research. There is an urgent need for systematic and cutting-edge methods to conduct in-depth research.

因此，本研究采用模糊集定性比较分析（fsQCA）方法，通过组态视角揭示多因素复杂互动对医养结合服务可持续性的影响机制，为政策制定者、服务机构提供可持续的路径，为促进医养结合服务供需匹配，提升医养结合服务服务可持续性提供理论依据。本研究主要解决四个关键问题：（1）政策与资金机制的协同作用：长期护理保险和基本医疗保险在医养结合服务中的角色及其可持续性的影响机制；（2）组织能力与资源配置的优化：核心人力资源和服务能力建设的可持续性提升路径；（3）实现需求精准匹配：如何通过技术手段优化供需匹配以及需求评估对高可持续性的意义；（4）区域差异化路径设计：为不同地区提供适配的发展路径的建议。
Therefore, this study adopts the Fuzzy Set Qualitative Comparative Analysis (fsQCA) method to reveal the mechanisms by which multiple factors interact to influence the sustainability of integrated medical and elderly care services from a configurational perspective. This will provide sustainable pathways for policymakers and service providers, and offer theoretical foundations for promoting the matching of supply and demand in integrated medical and elderly care services and enhancing their sustainability. The study primarily addresses four key issues: (1) the synergistic role of policy and funding mechanisms: the roles of long-term care insurance and basic medical insurance in integrated medical and elderly care services and their impact mechanisms on sustainability; (2) optimization of organizational capacity and resource allocation: pathways for enhancing the sustainability of core human resources and service capabilities; (3) achieving precise demand matching: how to optimize supply-demand matching through technological means and the significance of demand assessment for high sustainability; (4) regional differentiated pathways: suggestions for tailored development paths for different regions.

以上问题从宏观政策与微观实践层面逐层深入分析了提升医养结合服务可持续性的问题，为解答以上问题，本文基于社会生态系统的视角分析影响医养结合服务可持续性的因素。社会生态系统理论（Society Ecosystems Theory），认为个体的发展受多种因素的影响，这些因素被分为微观、中观、宏观三个层面。近年被运用于健康领域的研究。
These issues are analyzed in depth from both macro-policy and micro-practice perspectives to address the above problems. To address these issues, this paper analyzes the factors influencing the sustainability of integrated medical and elderly care services from the perspective of a social ecosystem. The Social Ecosystem Theory (Society Ecosystems Theory) posits that individual development is influenced by multiple factors, which are categorized into micro, meso, and macro levels. This theory has been applied in health-related research in recent years.

微观系统，即个体所处的社会环境系统，主要融合了生物、社会和心理元素，注重个人的需求、问题及优势；中观系统指任何群体，主要涉及政府、企业、社会组织、家庭等群体的联合互动，注重评估家庭及周围群体对个体发展的影响；宏观系统则指更大范围的社会系统，包括制度、文化、习俗等。
The microsystem refers to the social environment system in which an individual is situated, primarily integrating biological, social, and psychological elements, focusing on individual needs, problems, and strengths. The mesosystem refers to any group, involving interactions among government, enterprises, social organizations, families, and other groups, emphasizing the assessment of the impact of families and surrounding groups on individual development. The macrosystem refers to broader social systems, including institutions, culture, and customs.

然后采用模糊集定性比较分析（fsQCA），相比于传统的案例分析法，更适合中小样本案例组态分析，其基本思想是识别前因条件的特定组合如何导致结果的出现，从而揭示复杂原因组态与同质结果变量之间的潜在互动机制，主要步骤包括准备数据、校准；构建真值表、求解、分析逻辑构造。
Then, fuzzy set qualitative comparative analysis (fsQCA) was adopted, which is more suitable for the analysis of small and medium-sized sample case configurations compared to traditional case analysis methods. Its basic idea is to identify how specific combinations of causal conditions lead to the occurrence of a result, thereby revealing potential interaction mechanisms between complex cause configurations and homogeneous outcome variables. The main steps include data preparation, calibration; constructing a truth table, solving, and analyzing logical construction.

2理论框架与变量设计
2 Theoretical Framework and Variable Design

理论框架
Theoretical Framework

医养结合服务可持续发展的影响因素众多且作用机制复杂，本研究整合社会生态系统理论，构建了医养结合服务可持续性影响因素组态模型。社会生态系统理论将医养结合服务系统划分为宏观的政策与制度环境、中观的组织与服务网络和微观的个体需求特征三个层次，为理解不同层次因素的相互作用提供了理论基础。理论运用的创新体现在三个方面：首先，阐明了宏观政策需要通过中观组织能力才能有效响应微观需求的作用路径；其次，识别了不同因素组合均可实现可持续性；最后，拓展了社会生态系统理论在养老场景中的应用。
The factors influencing the sustainable development of integrated medical and elderly care services are numerous and their mechanisms are complex. This study integrates the social ecological system theory to construct a configurational model of the factors affecting the sustainability of integrated medical and elderly care services. The social ecological system theory divides the integrated medical and elderly care service system into three levels: macro policy and institutional environment, meso organizational and service network, and micro individual needs characteristics. This provides a theoretical foundation for understanding the interactions among factors at different levels. The innovation in the application of the theory is manifested in three aspects: first, it elucidates the path by which macro policies can effectively respond to micro needs through meso organizational capabilities; second, it identifies that different combinations of factors can achieve sustainability; finally, it expands the application of the social ecological system theory in the context of elderly care.

变量选择与操作
Variable Selection and Operations

本研究采用fsQCA方法探索影响因素对医养结合服务可持续性的组态效应，从宏观、中观和微观三个层次选取7个条件变量和1个结果变量。变量选择遵循理论适配和政策相关的原则，即每个变量对应理论模型的关键维度，同时参考既往的实证研究，变量反映中国医养结合政策关注的核心要素。
This study employs fsQCA methods to explore the configurative effects of influencing factors on the sustainability of integrated medical and elderly care services. Seven condition variables and one outcome variable are selected at the macro, meso, and micro levels. Variable selection follows the principles of theoretical fit and policy relevance, meaning each variable corresponds to key dimensions of the theoretical model, while also referencing previous empirical studies, reflecting the core elements of China's integrated medical and elderly care policies.

宏观层面，制度维度聚焦政府治理体系创新，条件变量选取监管政策、长期护理保险资金支持、基本医疗保险资金支持。制定服务标准、建立质量评价体系等监管措施，有利于促进服务的完善与发展。长期护理保险的试点和推广能够有效缓解老年人医疗和养老的经济压力，提升服务的可持续性。将医养结合服务纳入医保报销范围，能够显著提升服务的可及性和可持续性。
At the macro level, the institutional dimension focuses on innovations in the government governance system. Condition variables include regulatory policies, long-term care insurance fund support, and basic medical insurance fund support. Regulatory measures such as setting service standards and establishing quality evaluation systems promote the improvement and development of services. The pilot and promotion of long-term care insurance effectively alleviate the economic pressures of medical care and elderly care for the elderly, enhancing the sustainability of services. Including integrated medical and elderly care services in the scope of medical insurance reimbursement significantly improves the accessibility and sustainability of services.

中观层面，条件变量选取医养服务核心人力资源配置、服务能力建设。区域核心人力资源配置是医养结合服务能力建设的关键。以全科医生为代表的核心人力资源，直接解决老年人的日常照护与医疗需求，在“家庭-社区-医疗机构”建立联系，保障服务的可及性与连续性。区域医养结合服务能力建设，包括老年医学、康复护理、安宁疗护等专科建设，关系到老年人群的生命质量与服务满意度。
At the meso level, condition variables include the core human resource allocation and service capacity building for integrated medical and elderly care. Regional core human resource allocation is crucial for the capacity building of integrated medical and elderly care services. Core human resources represented by general practitioners directly address the daily care and medical needs of the elderly, establishing connections between "home, community, and medical institutions" to ensure the accessibility and continuity of services. Regional capacity building for integrated medical and elderly care includes specialized construction in geriatric medicine, rehabilitation nursing, and palliative care, which are related to the quality of life and service satisfaction of the elderly population.

微观层面，从关注个体需求的角度出发，选取区域老年人口需求评估、区域人口老龄化程度作为条件变量。精准的需求评估能够有效提升服务的针对性和满意度^[10]。老龄化程度较高的地区医养结合服务的供需矛盾更加突出。然而，在实践过程中存在着机制体系不完善的问题，亟需通过政策引导和资源整合来优化配置。
At the micro level, starting from the perspective of individual needs, we select regional elderly population demand assessment and the degree of regional population aging as conditional variables. Precise demand assessment can effectively enhance the relevance and satisfaction of services ^[10] . Areas with higher levels of aging face more pronounced supply-demand contradictions in integrated medical and elderly care services. However, in practice, there are issues with an incomplete mechanism system, which urgently require optimization through policy guidance and resource integration.

前六项变量采用二元赋值法（满足条目赋1分，否则0分）进行量化。区域人口老龄化程度以2023年末各地区65周岁以上常住老龄人口占区域内常住人口总数比例作为观测值¹。核心人力资源配置以2023年末各地区每万人口全科医师数作为观测指标²。
The first six variables are quantified using a binary scoring method (1 point if the criterion is met, otherwise 0 points). The degree of regional population aging is measured by the proportion of residents aged 65 and over at the end of 2023 out of the total resident population in each region ¹ . Core human resource allocation is measured by the number of general practitioners per 10,000 residents at the end of 2023 in each region ² .

结果变量医养结合服务可持续性用“积极应对人口老龄化城市能力指数”来表示。这一指标数据来源于国家信息中心发布的《中国积极应对人口老龄化城市能力指数2024》，该项指数报告测算了全国337个地级及以上城市积极应对人口老龄化综合能力指数。由于国家层面已将发展医养结合服务纳入积极老龄化战略部署，因此这一指标能够充分代表城市医养结合服务可持续发展水平（表1）。
The sustainability of integrated medical and elderly care services is represented by the "Capacity Index for Proactively Responding to Population Aging in Cities." This index data comes from the National Information Center's "China Capacity Index for Proactively Responding to Population Aging 2024." This index report calculates the comprehensive capacity index for proactively responding to population aging for 337 prefecture-level and above cities across the country. Since the development of integrated medical and elderly care services has been included in the national strategy for proactive aging, this index can adequately represent the level of sustainable development of integrated medical and elderly care services in cities (Table 1).

表1 条件变量与结果变量说明
Table 1: Description of Conditional Variables and Result Variables

3数据与方法
3 Data and Methods

数据收集
Data Collection

资料来源于《中国医养结合示范项目典型案例集（第一批）》（以下简称案例集），该案例集覆盖中国23个省份，是由国家卫生健康委老龄健康司联合中国健康教育中心对近年来全国各地医养结合的先进经验进行总结和推广，具有权威性、真实性、可靠性等特征，对我国医养结合实践具有诊断、示范与激励作用。结合研究主题，本研究从中挑选出来自我国东、中、西不同经济发展程度地区的的96个地级市的案例作为本次研究的研究对象，并通过权威的政府官方网站、新闻报道、期刊论文、出版专著等多种方式进行案例文本资料补充（表2）。
The data sources are from the "典型案例集（第一批）——中国医养结合示范项目案例集" (hereinafter referred to as the Case Study Collection), which covers 23 provinces in China. This collection was compiled by the National Health Commission's Department of Aging and Health in collaboration with the China Health Education Center, summarizing and promoting the advanced experiences of medical and elderly care integration in recent years. It possesses characteristics of authority, authenticity, and reliability, and plays a diagnostic, exemplary, and motivating role in the practice of medical and elderly care integration in China. In line with the research theme, this study selected 96 prefecture-level cities from different economic development levels across the eastern, central, and western regions of China, and supplemented the case text materials through various means such as authoritative government official websites, news reports, journal articles, and published monographs (Table 2).

表2 本研究纳入的案例信息表
Table 2 Information Table of Cases Included in This Study

变量校准
Variable Calibration

为确保模糊集定性比较分析（fsQCA）结果的可解释性，需对原始观测值进行数据校准，通过隶属度函数转换将其纳入预设模糊集合，该过程构成因果推断的必要预处理步骤——将原始数据点从线性测量空间映射至[0,1]隶属度区间，以精确刻画案例在因果组合中的隶属状态。参照QCA原理及操作惯例，结合数据分布特点，将样本95％、50％、５％分位数设置完全隶属点、交叉点、非完全隶属点，将该变量转化为[0，1]之间的数值（表2）。
To ensure the interpretability of the results from fuzzy set qualitative comparative analysis (fsQCA), it is necessary to calibrate the original observed values by transforming them into predefined fuzzy sets through membership functions. This process constitutes a necessary preprocessing step in causal inference—mapping the original data points from a linear measurement space to the [0,1] membership interval to precisely characterize the case's membership status in the causal combination. Following the principles and operational conventions of QCA, and considering the characteristics of the data distribution, the 95th, 50th, and 5th percentiles of the sample are set as fully membership points, cross points, and non-full membership points, respectively, converting this variable into a numerical value between [0,1] (Table 2).

表2 条件变量与结果变量校准阈值设置
Table 2 Calibration Thresholds for Conditional and Outcome Variables

如表2所示，对于“区域人口老龄化程度”这一变量，运用外部标准法进行校准，即根据联合国对区域老龄化程度的划分标准“如果65岁及以上老年人口占比达到7%，属于老龄化社会的初期阶段；如果占比达到14%，属于老龄化社会的中期；如果占比达到14%，属于超级（重度）老龄化社会”中的21%、14%、7%分别设置为这一变量的上、中、下锚点；对于“核心人力资源配置—每万人口全科医师数”这一变量用全国2023年末全部地区的每万人口全科医师数的上四分位数、中位数、下四分位数对其三个锚点进行设置，对结果变量“医养结合服务可持续性”选择内部依赖法校准，即直接选择数据集的上四分位数，中位数/均值，下四分位数进行锚点设置；对于“能力建设”指标的最终得分，本研究采用直接校准法；其余二分类变量则不需要进行锚点设置。
As shown in Table 2, for the variable "degree of regional aging population," the external standard method was used for calibration, setting the upper, middle, and lower anchor points based on the United Nations' classification standards for regional aging: 21%, 14%, and 7% respectively, representing the initial stage, middle stage, and super (severe) aging society. For the variable "core human resource allocation—number of general practitioners per 10,000 people," the upper quartile, median, and lower quartile of the number of general practitioners per 10,000 people across all regions at the end of 2023 were used to set the three anchor points. For the result variable "sustainability of integrated medical and elderly care services," internal dependency calibration was chosen, directly selecting the upper quartile, median, and lower quartile of the dataset as the anchor points. For the final score of the "capacity building" indicator, this study used direct calibration; the remaining dichotomous variables did not require anchor point setting.

单个条件的必要性分析
Analysis of the necessity of individual conditions

按照fsQCA方法论，在进行组态分析前需开展前因条件的必要条件检验（Necessary Condition Analysis），通过计算覆盖度（coverage）与一致性（consistency）系数，评估各前因条件作为独立必要条件（INUS条件）的因果效力。如表4必要性检验结果所示，一致性系数（Consistency）均未达0.9的阈值标准，表明医养结合服务可持续发展能力水平提升不存在具有充分必要性的单一主导变量，需通过组态分析（Sufficient Configuration Analysis）来解构变量间的联合效应。
According to the fsQCA methodology, before conducting configuration analysis, it is necessary to conduct a necessary condition analysis (Necessary Condition Analysis) to evaluate the causal power of each causal factor as an independent necessary condition (INUS condition) by calculating the coverage and consistency coefficients. As shown in the results of the necessity analysis in Table 4, the consistency coefficients (Consistency) did not reach the threshold standard of 0.9, indicating that there is no single dominant variable with sufficient necessity for the improvement of the sustainability level of integrated medical and elderly care services. Therefore, configuration analysis (Sufficient Configuration Analysis) is needed to deconstruct the joint effects among variables.

表4 必要性分析结果
Table 4 Results of Necessity Analysis

高可持续性的条件组态分析
Analysis of Configurations for High Sustainability

研究依据上述结果进一步构建真值表进行组态分析。将案例频数阈值（Frequency Threshold）设为１，一致性阈值（Consistency Threshold）设为0.80。通过布尔最小化算法（Boolean Minimization）生成的解集类型中，
The study further constructs a truth table for configuration analysis based on the aforementioned results. The case frequency threshold (Frequency Threshold) is set to 1, and the consistency threshold (Consistency Threshold) is set to 0.80. Among the solution sets generated through Boolean minimization,

中间解与简约解的交集条件判定为核心条件，其存在对结果产生因果必要性（Necessity），存于中间解的条件变量识别为边缘条件。过往研究表明，中间解具有较好的代表性和普适性，因此，本研究着重分析中间解。如表5所示，最终得到五种主要的医养结合服务高持续发展性的驱动路径。这些组态路径呈现显著的多维协同效应。
The intersection conditions between intermediate solutions and minimal solutions are the core conditions, which are necessary for the results (Necessity) and are identified as marginal conditions in the intermediate solutions. Previous research has shown that intermediate solutions have better representativeness and universality, so this study focuses on analyzing intermediate solutions. As shown in Table 5, five main driving paths for high sustainability in integrated medical and elderly care services are ultimately identified. These configuration paths exhibit significant multidimensional synergistic effects.

路径H1表明：完善医养结合服务监管政策体系且具有长期护理保险资金支持的区域老年人口老龄化程度较高的地区，辅以加强区域老年人口需求评估、增加全科医师等核心人力资源配置、增强区域医养结合服务能力建设（加强医疗专科建设、建立医养结合多部门协作工作机制、促进医养结合人才队伍建设、构建医养结合远程协同智慧化信息平台）都能提升医养结合服务的可持续性。
Path H1 indicates that in regions with high elderly population aging, where the regulatory policy system for integrated medical and elderly care services is improved and long-term care insurance funds are supported, enhancing regional elderly population demand assessment, increasing the allocation of core human resources such as general practitioners, and strengthening the construction of integrated medical and elderly care service capabilities (including strengthening medical specialty construction, establishing a multi-departmental collaborative mechanism for integrated medical and elderly care, promoting the construction of integrated medical and elderly care talent teams, and building a remote collaborative intelligent information platform for integrated medical and elderly care) can all enhance the sustainability of integrated medical and elderly care services.

路径H2表明：在缺乏区域老年人口需求评估和长期护理保险制度缺位的情况下，对于区域人口老龄化程度深的地区通过加强基本医疗保险资金支持医养结合服务，辅以优化医养结合服务核心人力资源配置、增强医养结合服务能力建设（加强医疗专科建设、建立医养结合多部门协作工作机制、促进医养结合人才队伍建设、构建医养结合远程协同智慧化信息平台）也可以推动服务的可持续发展。
Path H2 indicates that in regions with deep elderly population aging where there is a lack of regional elderly population demand assessment and long-term care insurance systems, by strengthening basic medical insurance fund support for integrated medical and elderly care services, and enhancing the allocation of core human resources and the construction of integrated medical and elderly care service capabilities (including strengthening medical specialty construction, establishing a multi-departmental collaborative mechanism for integrated medical and elderly care, promoting the construction of integrated medical and elderly care talent teams, and building a remote collaborative intelligent information platform for integrated medical and elderly care), the sustainability of service development can also be promoted.

路径H3表明：在不考虑区域是否开展老年人口医养服务需求评估和是否具有长期护理保险资金支持的情况下，区域人口老龄化程度较深、监管政策体系健全、基本医疗保险资金支持医养结合工作、医养结合服务核心人力资源配置工作完善，无论是否增强区域医养结合服务能力建设（加强医疗专科建设、建立医养结合多部门协作工作机制、促进医养结合人才队伍建设、构建医养结合远程协同智慧化信息平台），都能够推动医养结合服务的可持续性提升。
Path H3 indicates that in regions with deep elderly population aging, where the regulatory policy system is well-established, basic medical insurance funds support integrated medical and elderly care work, and the allocation of core human resources for integrated medical and elderly care services is complete, regardless of whether the construction of integrated medical and elderly care service capabilities (including strengthening medical specialty construction, establishing a multi-departmental collaborative mechanism for integrated medical and elderly care, promoting the construction of integrated medical and elderly care talent teams, and building a remote collaborative intelligent information platform for integrated medical and elderly care) is enhanced, it can still promote the sustainability of integrated medical and elderly care services.

路径H4表明：在人口老龄化程度相对不深、医养结合服务监管政策体系尚未建立健全的情况下，无论是否优化区域医养结合服务核心人力资源配置、是否实行长期护理保险制度，基本医疗保险基金能够支持医养结合工作开展，医养结合服务能力建设工作完善（加强医疗专科建设、建立医养结合多部门协作工作机制、促进医养结合人才队伍建设、构建医养结合远程协同智慧化信息平台）同样可以促进区域医养结合服务的可持续性的提升。
Path H4 indicates: In regions with relatively shallow aging and an incomplete regulatory policy system for integrated medical and elderly care services, regardless of whether the regional allocation of core human resources for integrated medical and elderly care services is optimized or whether a long-term care insurance system is implemented, the basic medical insurance fund can still support the conduct of integrated medical and elderly care work. The improvement of integrated medical and elderly care service capabilities (such as strengthening specialized medical construction, establishing a collaborative mechanism among multiple departments for integrated medical and elderly care, enhancing the team of integrated medical and elderly care professionals, and building a remote collaborative intelligent information platform for integrated medical and elderly care) can also promote the sustainable development of integrated medical and elderly care services in the region.

路径H5表明：在不考虑区域老龄化程度的情况下，无论该地区是否建立健全监管政策体系抑或基本医疗保险资金是否支持医养结合服务工作开展，通过加强区域老年人口需求评估、优化医养服务核心人力资源配置工作、加强区域医养服务能力建设、长期护理保险资金支持医养服务开展的核心条件驱动，医养结合服务都能实现可持续发展。除核心条件驱动外，H5a在基本医保缺位的约束下，辅以政策监管规范服务流程，提升供给质量；H5b则在监管政策缺位的情况下，辅以医保资金支持，不断满足老年人日益增长的健康养老服务需求。
Path H5 indicates: Without considering the degree of regional aging, regardless of whether the regulatory policy system is established or whether the basic medical insurance fund supports the work of integrated medical and elderly care services, through strengthening the assessment of elderly population needs in the region, optimizing the allocation of core human resources for integrated medical and elderly care services, enhancing the construction of regional integrated medical and elderly care service capabilities, and supporting the conduct of integrated medical and elderly care services with long-term care insurance funds, integrated medical and elderly care services can achieve sustainable development. In addition to core condition drivers, H5a, under the constraint of a basic medical insurance system, can improve service quality by standardizing service processes through policy regulation; H5b, in the absence of regulatory policies, can continuously meet the growing health service needs of the elderly through the support of medical insurance funds.

表5 医养结合服务高可持续性组态分析结果
Table 5: Results of High Sustainability Configuration Analysis for Integrated Medical and Elderly Care Services

注：●表示核心条件存在；·表示边缘条件存在；▲表示核心条件缺失；○表示边缘条件缺失。
Note: ● indicates the presence of core conditions; · indicates the presence of marginal conditions; ▲ indicates the absence of core conditions; ○ indicates the absence of marginal conditions.

4稳健性检验
4 Robustness Testing

鉴于模糊集定性比较分析（fsQCA）的解具有显著的条件组合依赖性与结论不确定性特征，实施稳健性检验（如参数校准阈值调整、案例删减测试及解的一致性阈值校验）是验证研究结论可靠性不可或缺的方法论环节。本研究依据方法学规范，实施参数敏感性分析以验证结论稳健性。具体包括：（1）案例频数阈值调整：将原案例数截断值从1上调至2，剔除单一案例的偶然性影响；（2）一致性阈值优化：将一致性临界值由0.80严格化至0.85，强化组态解释力要求。基于修正后的参数体系，对医养结合服务高可持续性的条件组态再次进行布尔最小化运算，再次得到简约解、中间解，结果发现在调整案例数截断值和调整一致性阈值后产生的组态与原始组态一致，说明组态分析结果具有稳健性。
Given the significant dependency on condition combinations and the inherent uncertainty in conclusions of fuzzy set qualitative comparative analysis (fsQCA), robustness testing (such as parameter calibration threshold adjustment, case deletion tests, and consistency threshold validation of solutions) is an indispensable methodological step to verify the reliability of research conclusions. This study, in accordance with methodological norms, conducted parameter sensitivity analysis to validate the robustness of the conclusions. Specifically, this included: (1) adjustment of case frequency threshold: increasing the original case number cutoff value from 1 to 2 to eliminate the 偶然性 influence of single cases; (2) optimization of consistency threshold: strictly setting the consistency critical value from 0.80 to 0.85 to enhance the configurational explanatory power. Based on the revised parameter system, the conditions for high sustainability of integrated medical and elderly care services were again subjected to Boolean minimization operations, yielding a simplified solution and an intermediate solution. The results showed that the configurations generated after adjusting the case number cutoff value and the consistency threshold were consistent with the original configurations, indicating that the configurational analysis results are robust.

5讨论
5 Discussion

结合组态分析结果将医养结合服务高可持续性的驱动路径归纳为“长期护理保险制度引领型”（H1a、H1b、H1c）、“基本医疗保险制度引领型“（H2、H3、H4）、“供需匹配型”（H5a、H5b）。
Translate to English: Combining the configuration analysis results, the driving paths for high sustainability in integrated medical and elderly care services are summarized as "long-term care insurance system-led type" (H1a, H1b, H1c), "basic medical insurance system-led type" (H2, H3, H4), and "supply-demand matching type" (H5a, H5b).

长期护理保险制度引领型（H1a、H1b、H1c）
Long-term care insurance system-led type (H1a, H1b, H1c)

“长期护理保险制度引领型”路径以长期护理保险为资金支柱，以建立健全监管政策体系为依托，路径H1a辅以加强医养结合服务能力建设提升供给质量；路径H1b辅以加强区域老年人口医养服务需求评估、优化医养结合服务核心人力资源配置；路径H1c辅以优化医养结合服务核心人力资源配置。这类路径往往出现于老龄化程度高于全国平均水平且较早实行长期护理保险的地区，政府主导，通过将医养结合服务纳入区域国民经济和社会发展规划、加大投入，来快速拓展服务，并不断扩大长期护理保险覆盖面，但需警惕过度依赖政府可能抑制市场活力。典型案例为陕西省汉中市，其核心人力资源配置到位，每千名常住人口拥有执业（助理）医师提升至3.53人且日常监管到位，出台《汉中市医养结合机构行业标准》、《医疗卫生机构与养老机构签约合作服务指南》等文件，建立健全监管机制和服务质量评估体系，定期开展监督检查和评估工作。
The "long-term care insurance system-led type" path relies on long-term care insurance as the financial pillar and is supported by a robust regulatory policy framework. Path H1a supplements this by enhancing the capacity of integrated medical and elderly care services to improve supply quality; Path H1b supplements it by strengthening regional elderly population needs assessment for medical and elderly care services and optimizing the core human resource allocation for integrated medical and elderly care services; Path H1c supplements it by optimizing the core human resource allocation for integrated medical and elderly care services. These paths often emerge in regions with higher levels of aging and earlier implementation of long-term care insurance, where the government plays a leading role. Through inclusion in the regional national economy and social development plan and increased investment, services are rapidly expanded, and the coverage of long-term care insurance is continuously expanded. However, there is a risk of over-reliance on the government, which may suppress market vitality. A typical case is Hanzhong City, Shaanxi Province, where core human resources are adequately configured, with the number of practicing (assistant) physicians per thousand permanent residents increasing to 3.53, and daily supervision is in place. The city has issued documents such as the "Hanzhong City Standards for Integrated Medical and Elderly Care Institutions" and the "Guidelines for Collaborative Services between Medical and Health Institutions and Elderly Care Institutions," establishing a regulatory mechanism and service quality assessment system, and regularly conducting supervision and evaluation work.

基本医疗保险制度引领型（H2、H3、H4）
Basic medical insurance system-led type (H2, H3, H4)

“基本医疗保险制度引领型”以基本医疗保险制度为核心支撑，通过拓展其支付范围（如家庭病床服务、基础护理项目、康复项目等）增强老年人对于医养结合服务的获得感。
The "Basic Medical Insurance System Leading Type" centers on the basic medical insurance system as the core support, enhancing the elderly's sense of 获得感 by expanding its payment scope (such as home-based medical beds, basic nursing services, rehabilitation projects, etc.).

路径H2利用基本医疗保险制度替代长期护理保险的缺位功能。典型地区有辽宁大连市甘井子区、沈阳市浑南区等。辽宁大连市甘井子区将全区医养结合机构全部纳入医保范围，降低老年人医疗支付门槛，提高服务可及性，形成“预防、治疗、照护”全链条的医养结合服务模式；沈阳市浑南区将符合条件的养老机构内设医疗机构纳入医保定点管理，逐步扩大医保服务范围。
Path H2 leverages the basic medical insurance system to fill the gaps of long-term care insurance. Typical regions include Dalian's Ganjingzi District and Hunnan District in Shenyang, Liaoning Province. Dalian's Ganjingzi District has included all its integrated medical and elderly care institutions in the medical insurance coverage, lowering the medical payment threshold for the elderly and improving service accessibility. This has formed a full-chain medical and elderly care service model covering prevention, treatment, and care. In Shenyang's Hunnan District, eligible nursing homes with internal medical facilities have been included in the medical insurance 定点 management, gradually expanding the scope of medical insurance services.

路径H3通过优化核心人力资源配置、建立健全监管政策体系，以规范服务流程。典型代表是河北石家庄市正定县。通过建成老年人医疗报销绿色通道，解决了医养结合机构医保定点难题；通过同时发展全日托养、日间照料、上门服务等基本服务，优化基层核心人力资源配置；通过加大资金投入、拓宽投融资渠道、盘活土地资源，推进康养项目落地、落实税收优惠政策和土地支持政策。在监管政策体系建设方面，通过建立信用体系、黑名单制度和市场退出机制，以标准化建设促进医养结合服务的可持续发展。
Path H3 optimizes core human resource allocation and establishes a comprehensive regulatory policy system to standardize service procedures. A typical example is Zhengding County, Shijiazhuang City, Hebei Province. By establishing a green channel for elderly medical reimbursement, it has addressed the medical insurance 定点 issue for integrated medical and elderly care institutions; by developing full-day care, daytime care, and home-based services, it has optimized the core human resources at the grassroots level; by increasing financial investment, broadening financing channels, and revitalizing land resources, it has promoted the implementation of health and wellness projects, and has introduced tax and land support policies. In terms of regulatory policy system construction, it has established a credit system, a blacklist system, and a market exit mechanism to promote the sustainable development of integrated medical and elderly care services through standardized construction.

路径H4指针对区域老龄化程度较轻的地区，在医养结合服务监管政策缺位的情况下，辅以加强区域老年人口需求评估、完善服务能力建设工作。此类路径适用于医保覆盖率较高，但长期护理保险滞后的三四线城市或县域地区。典型地区为：江西南昌市南昌县。该地区多措施并举，模式一：将内设医务室的养老机构纳入南昌市基本医疗保险定点单位，解决养老机构内老人看病难的问题。模式二：以医疗机构为主体，在公办医院及民营医院内开设老年科。模式三：建立人才支撑机制，包括每年组织医养结合机构管理人员及医护人员参加各级政府安排的医养结合人才人力培训；畅通专业技术人才上升通道，在护理人员队伍中实行“以岗定筹、同工同酬、绩效工资”的分配制度，提升基层医护人员的专业能力与服务意愿，进而为医疗机构与居家养老站的签约合作提供合格的人力资源保障，最终实现家庭医生服务的标准化、常态化运作。模式四：整合社会服务资源，通过政府购买服务的方式，实现线上平台与线下服务结合的互联网居家医养照护模式。
Path H4 refers to regions with relatively lower levels of aging, where the regulatory policies for integrated medical and elderly care services are missing. It involves strengthening regional elderly population demand assessments and improving service capacity building. This path is suitable for cities or counties with high medical insurance coverage but lagging long-term care insurance, such as Nanchang County, Nanchang City, Jiangxi Province. The region has adopted multiple measures: Mode 1: Including nursing homes with internal medical clinics in the basic medical insurance 定点 units of Nanchang City to solve the problem of elderly patients seeking medical care in nursing homes. Mode 2: Establishing geriatric departments in public and private hospitals. Mode 3: Building a talent support mechanism, including organizing medical and elderly care personnel training for management and medical staff in integrated medical and elderly care institutions arranged by the government at various levels; establishing a professional talent promotion channel, implementing a "job-based allocation, equal pay for equal work, performance-based salary" distribution system in the nursing staff team, enhancing the professional capabilities and service willingness of grassroots medical staff, thereby providing qualified human resources for the signing and cooperation between medical institutions and home-based elderly care stations, ultimately achieving the standardized and routine operation of family doctor services. Mode 4: Integrating social service resources through government-purchased services, achieving a combined online and offline home-based medical and elderly care service model.

供需匹配型（H5a、H5b）
Supply-Demand Matching Type (H5a, H5b)

在“供需匹配型”所对应的路径中，以精准识别老年群体健康养老服务需求并充分配置人力资源、完善医养结合服务能力建设、长期护理保险资金支持为核心驱动力。此类路径的核心逻辑在于社会生态系统论视角下的最优资源配置——通过各要素的互补，构建高效、灵活的医养服务体系，继而实现服务供需的高度匹配。该方法适用于资源丰富、政策配套完善、数字化水平高的发达城市或示范区。典型地区有：上海市徐汇区、浙江省温州市瓯海区、浙江嘉兴市嘉善县等。具体而言，上海市徐汇区发挥数字化优势精准对接区域老龄人口需求；依托国家继续医学教育项目，加强医养结合人才和老年健康相关复合型人才培养；实现人力资源的长效供给。浙江省温州市瓯海区通过政府提供土地，市场化引入医养结合机构，来实现资源最优组合，形成“一个社区、一家医院”实践模式，确保供需空间匹配；浙江嘉兴市嘉善县以“健康大脑”建设项目为基础，逐步将健康管理数据和养老服务数据进行县域资源共享，实现居家移动医保支付，构建了“居民—平台—医疗机构”的闭环健康管理。
In the path corresponding to the "supply-demand matching type," the core drivers are precise identification of elderly groups' health service needs, full configuration of human resources, enhancement of the capacity for integrated medical and elderly care services, and long-term care insurance fund support. The core logic of this path lies in optimal resource allocation from the perspective of social ecosystem theory—by complementing various elements, it constructs an efficient and flexible integrated medical and elderly care service system, thereby achieving high alignment between service supply and demand. This approach is applicable in resource-rich, policy-supportive, and digitally advanced developed cities or demonstration areas. Typical regions include: Xuhui District, Shanghai; Ouhai District, Wenzhou, Zhejiang; and Jiashan County, Jiaxing, Zhejiang. Specifically, Xuhui District in Shanghai leverages its digital advantages to precisely match the needs of regional elderly populations; it strengthens the training of integrated medical and elderly care professionals and 复合型人才 through national continuing medical education projects; and ensures a long-term supply of human resources. Ouhai District in Wenzhou, Zhejiang, achieves optimal resource allocation by having the government provide land and marketizing the introduction of integrated medical and elderly care institutions, forming a "one community, one hospital" practice model to ensure spatial alignment between supply and demand. Jiashan County in Jiaxing, Zhejiang, builds on the "Healthy Brain" project to gradually share health management and elderly care service data at the county level, enabling mobile medical insurance payments at home, and establishing a closed-loop health management system involving residents, platforms, and medical institutions.

6结论与启示
6 Conclusions and Insights

医养结合服务是政府引导社会部门和私人部门有序参与，整合健康医疗资源与养老资源，满足老年人多元化个性化的健康养老需求。通过让老年人获得优质连续的服务，延缓自主生活能力衰退，从而真正实现健康老龄化，积极老龄化。对于本课题的研究问题—“如何提升医养结合服务的可持续性”，需要厘清各主体关系和运行机制，社会生态系统理论对此具有较好的适应性，能够从不同层次解释需求主体（老年人个体层面）与其所处的社会环境之间的相互作用，继而提出针对性建议。
Integrated medical and elderly care services are government-led initiatives that encourage the orderly participation of social and private sectors, integrating health and medical resources with elderly care resources to meet the diverse and personalized health and care needs of the elderly. By providing high-quality, continuous services to the elderly, these services aim to slow down the decline in their self-care abilities, thereby truly achieving healthy and active aging. For the research question of this topic—"how to enhance the sustainability of integrated medical and elderly care services"—it is necessary to clarify the relationships and operational mechanisms among various stakeholders. Social ecosystem theory is well-suited for this purpose, as it can explain the interactions between demand subjects (individual elderly) and their social environment at different levels, thereby providing targeted recommendations.

为提升医养结合服务可持续性，建议不断完善顶层设计，逐步提高政策的保障程度：（1）将家庭病床、康复护理及安宁疗护纳入基本医保，按服务类型和失能等级实施差异化报销；（2）推进长护险与基本医保衔接，建立“职工+居民”统一参保模式；（3）构建政府专项资金、社会资本和个人共担的多元投入机制，在保障可及性的同时优化资源配置。
To enhance the sustainability of integrated medical and elderly care services, it is recommended to continuously improve the top-level design and gradually increase the level of policy support: (1) include home-based medical beds, rehabilitation care, and palliative care in basic medical insurance, implementing differential reimbursement based on service type and level of disability; (2) promote the integration of long-term care insurance with basic medical insurance, establishing a unified enrollment model for "employees and residents"; (3) establish a diversified funding mechanism involving government special funds, social capital, and individual contributions, ensuring accessibility while optimizing resource allocation.

以促进基层服务能力建设为目标，应重点推广“社区卫生服务中心+养老驿站”模式，并明确分工定位：社区卫生服务中心主攻家庭医生签约和基础医疗服务，养老驿站着力提升生活照护与精神慰藉服务能力。组建“全科医生+康复师+社工”跨专业团队，为失能老人提供个性化服务包，同时通过职称评审倾斜和岗位补贴等激励措施吸引专业人才下沉。
With the goal of enhancing grassroots service capabilities, it is recommended to promote the "community health center + elderly care station" model and clarify the division of labor: community health centers will focus on family doctor 签约 and basic medical services, while elderly care stations will enhance their capabilities in daily care and emotional support. Form "general practitioners + rehabilitation specialists + social workers" interdisciplinary teams to provide personalized service packages for disabled elderly individuals, and attract professional talent through incentive measures such as preferential 职称评审 and position subsidies.

为推动医养结合服务精准供给，建议采取以下措施：（1）是建立全国统一的老年人综合能力评估体系，涵盖身体、认知、心理及社会参与等多维度指标，评估结果与长期护理保险待遇直接挂钩，实现精准需求识别；（2）是强化人才政策支持，通过薪酬激励、职称倾斜及院校学科建设扩大专业人才供给，并加强现有服务团队培训；（3）是推动区域化需求评估中心或智慧平台建设，依托医疗机构或社区中心动态收集需求数据，优化资源配置，并建立“设备共享网络”提升资源利用率，从而系统性提升供需匹配效率。
To promote the precise supply of integrated medical and elderly care services, it is recommended to take the following measures: (1) establish a nationwide unified elderly comprehensive ability assessment system, covering multiple dimensions such as physical, cognitive, psychological, and social participation, with assessment results directly linked to long-term care insurance benefits, achieving precise demand identification; (2) strengthen talent policy support, incentivizing through salary incentives, preferential 职称倾斜, and expanding professional talent supply through university and discipline development, while also enhancing the training of existing service teams; (3) promote the construction of regional demand assessment centers or smart platforms, dynamically collecting demand data through medical institutions or community centers, optimizing resource allocation, and establishing a "shared equipment network" to improve resource utilization, thereby systematically enhancing the efficiency of supply-demand matching.

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