A social work service method and system based on long-term diseases

Abstract

This application proposes a social work service method and system based on long-term diseases, the method includes: determining the patient and his case data, selecting an assessment service team; conducting pathological and psychological assessments on the patient by the assessment service team; determining the service object based on the assessment results; determining whether to include his family members in the second service object who needs social work services; determining the current social work service stage of the first service object and generating the demand for social workers; according to the needs and the schedules of each social worker and the skill tags they possess, finding one or more social workers who meet the preset conditions to provide social work services to the patient and / or family members. This application accurately analyzes the specific needs of patients and their families through an intelligent matching algorithm, and can effectively provide high-quality, personalized social work services to patients with long-term diseases and their families, ensuring that each patient and their family members can obtain a tailored service plan, which greatly improves the professionalism and pertinence of social work services.

Description

Technical Field

[0001] The present application relates to the field of role simulation, and more specifically, to a social work service method and system based on long-term illness. Background Art

[0002] With the improvement of medical technology and living standards, the survival rate and quality of life of patients with long-term diseases have been significantly improved. However, long-term diseases not only affect the physical health of patients, but also put tremendous pressure on their mental health, social function and family economic conditions. Traditional medical services often focus on medical treatment, while ignoring the psychological, social and economic support needs of patients and their families. Social work services play a vital role in this process, providing comprehensive support to help patients better cope with the challenges brought by the disease.

[0003] Currently, many medical institutions and social service agencies have begun to introduce social work services, but these services are often scattered, non-systematic, and lack effective management and coordination. In addition, due to limited social work resources, how to efficiently match the right social workers with the needs of patients has become an urgent problem to be solved. Traditional manual matching methods are not only time-consuming and labor-intensive, but also prone to inaccurate matching, resulting in uneven service quality. Summary of the invention

[0004] Based on the problems existing in the prior art, this application provides a social work service method and system based on long-term diseases. The specific scheme is as follows:

[0005] A long-term illness-based social work approach that includes:

[0006] Determine patients with long-term diseases and their case data under the preset medical institution, determine the disease range corresponding to the patient and the assessment service team corresponding to the disease range based on the case data; conduct pathological and psychological assessments on the patients through the assessment service team;

[0007] When the pathological evaluation and / or psychological evaluation results of a patient indicate that social work services are needed, the patient is included in the first service recipient and an economic evaluation is performed on the patient; based on the economic evaluation results, the degree of influence of economic factors on the pathological evaluation and / or psychological evaluation results of the first service recipient is analyzed;

[0008] Based on the degree of impact and the medical staff's assessment of the family's condition, determine whether to include the family member as the second service recipient who needs social work services, and conduct a psychological assessment of the second service recipient through the assessment service team, and obtain the family member assessment results based on the psychological assessment results;

[0009] Obtaining historical service data of past social work services provided to the first service object, determining the illness duration and treatment status of the first service object by parsing the case data, and determining skill tags of past social workers by parsing the historical service data to obtain historical tags;

[0010] Determine the current social work service stage of the first service object based on the illness time and treatment situation; generate the first demand for social workers based on the disease interval, historical label, and social work service stage, and generate the second demand for social workers based on the family assessment result;

[0011] According to the first demand, the second demand, and the schedules of each social worker stored in the database and the skill tags possessed, one or more social workers meeting the preset conditions are searched to provide social work services to the first service object and / or the second service object.

[0012] In some specific embodiments, different disease intervals and social worker service stages are pre-set with corresponding basic skill requirements for social workers; each long-term disease is pre-set with specific multiple exclusive skill requirements for social workers;

[0013] The pre-conditions include:

[0014] A social worker can only become the first social worker who meets the first requirement and provides social work services to the first service recipient if the skill tags he / she possesses meet all the basic skill requirements of the disease range and the social work service stage, and the satisfaction ratio of the exclusive skill requirements is not less than the preset ratio;

[0015] A social worker must have at least psychological counseling and guidance as his or her skill tags before he or she can become a second social worker who meets the second needs and provides social work services to the second service recipients.

[0016] In some specific embodiments, the range of the long-term disease is predetermined; the long-term disease is divided according to whether it is a psychological disease, and two disease intervals, namely a physiological disease interval and a psychological disease interval, are obtained;

[0017] Taking psychological counseling and guidance as the basic skill requirements for the psychological disease interval, screening out the skills requirements for social workers required by diseases exceeding a preset proportion in the physiological disease interval to obtain the basic skill requirements for the interval;

[0018] For each of the long-term diseases, the skill requirements for social workers required for the disease in addition to the basic skill requirements are pre-set to obtain the exclusive skill requirements for each disease.

[0019] In some specific embodiments, when the degree of influence exceeds a preset first ratio, the family members of the patient are directly included in the second service objects;

[0020] When the degree of impact is between the first ratio and the preset second ratio, the assessment service team will conduct a psychological assessment on the patient's family members, and select the corresponding family members to be included in the second service objects based on the results of the psychological assessment of the family members; when the degree of impact does not exceed the second ratio, the medical staff who provide medical services to the patient will be pre-determined, and the medical staff will conduct a preliminary assessment of the psychological state of each family member of the patient, and based on the results of the preliminary assessment, one or more family members who may need the help of social workers will be determined, and the family members will be included in the second service objects.

[0021] In some specific embodiments, it also includes:

[0022] Obtain the basic information and past medical history information of the second service object, parse the historical service data to find out whether there is any past social worker's evaluation of the family member, parse the past medical history information to determine the current health status of the second service object; conduct a psychological evaluation of the second service object through the evaluation service team; and generate a family member evaluation result by integrating the psychological evaluation results, past social worker evaluations and basic information.

[0023] In some specific embodiments, the social work service stages include diagnosis and initial adaptation stage, treatment and management stage, rehabilitation and recovery stage, maintenance and self-management stage, and late-stage care and hospice care stage.

[0024] In some specific embodiments, when the first service object is in the diagnosis and initial adaptation stage, the basic skill requirements at least include understanding relevant disease knowledge, the ability to handle acute stress reactions, follow-up planning for the disease, and psychological status assessment;

[0025] When the first service recipient is in the treatment and management stage, the basic skill requirements include at least coordination of medical services, intervention in crises such as acute complications;

[0026] When the first service recipient is in the rehabilitation and recovery stage, the basic skills requirements at least include social integration and life skills training;

[0027] When the first service recipient is in the stage of maintenance and self-management, the basic skills requirements at least include long-term supervision management, self-management education, and regular assessment;

[0028] When the first service recipient is in the advanced care and hospice stage, the basic skill requirements include at least palliative care, bereavement counseling, legal and financial planning.

[0029] In some specific embodiments, multiple social workers are selected to form a social worker group to provide social work services to the first service object and / or the second service object, and the skill labels possessed by the social workers in each social worker group are complementary to meet the first demand and / or the second demand, and the social workers in each social worker group can serve one or more first service objects or second service objects at the same time;

[0030] A service object group is constructed according to the first service object or the second service object served by each social worker in the social worker group, and the social worker services in the service object group are deployed according to the schedule of each social worker.

[0031] In some specific embodiments, while parsing the historical service data to determine the historical tags, the social worker's service evaluation of the first service object in the past is searched, and the service precautions are parsed from the service evaluation; the social work service stage of the patient during the past social work service is determined, and the skill tags associated with the social work service stage at that time in the historical tags are analyzed to obtain the first tag; the first tag in the historical tags is excluded to obtain the social work service stage requirement; the requirements corresponding to the service precautions are analyzed to obtain the precaution requirements; the basic skill requirements currently required are determined according to the disease range and the current social work service stage, and the corresponding exclusive skill requirements are determined according to the long-term disease; the first requirement is obtained by combining the social work service stage requirements, the precaution requirements, the basic skill requirements and the exclusive skill requirements.

[0032] A social work service system based on long-term illness, including:

[0033] The first evaluation unit is used to determine patients with long-term diseases in a preset medical institution and their case data, determine the disease interval corresponding to the patient and the evaluation service team corresponding to the disease interval according to the case data; and perform pathological and psychological evaluations on the patient through the evaluation service team;

[0034] The second assessment unit is used to include a patient in the first service object and conduct an economic assessment on the patient when the pathological assessment and / or psychological assessment results of the patient indicate that social work services are needed; and to analyze the influence of economic factors on the pathological assessment and / or psychological assessment results of the first service object according to the economic assessment results;

[0035] A family assessment unit is used to determine whether to include the family members into the second service object in need of social work services based on the degree of impact and the medical staff's assessment of the family members' status, and to conduct a psychological assessment on the second service object through the assessment service team, and obtain a family assessment result based on the psychological assessment result;

[0036] A historical data unit, used to obtain historical service data of the first service object regarding past social work services, determine the illness time and treatment status of the first service object by parsing the case data, and determine the skill label of the past social worker by parsing the historical service data to obtain a historical label;

[0037] A demand generation unit is used to determine the current social work service stage of the first service object based on the illness time and treatment situation; generate a first demand for social workers based on the disease interval, historical tags, and social work service stage, and generate a second demand for social workers based on the family assessment result;

[0038] The social worker matching unit is used to find one or more social workers who meet the preset conditions to provide social work services to the first service object and / or the second service object according to the first demand, the second demand and the schedules and skill tags of each social worker pre-stored in the database.

[0039] Beneficial effects: This application proposes a social work service method and system based on long-term diseases, which provides more personalized, efficient and comprehensive social work service support for patients with long-term diseases and their families through automated and intelligent methods. Through pathological evaluation, psychological evaluation and economic evaluation of patients, the specific needs of patients can be accurately identified, so as to provide more targeted services. Detailed needs are generated according to the evaluation results to ensure that each patient and their family can obtain a tailored support plan. Including the psychological state and service needs of family members in the scope of evaluation improves the family's overall ability to cope with the disease and the support strength, and enhances the depth and breadth of services. Through a series of scientific and reasonable steps and technical means, not only the quality and efficiency of social work services are improved, but also the satisfaction and quality of life of patients and their families are enhanced. This method is not only applicable to medical institutions, but can also be extended to wider fields such as community health service centers. It has important social significance and broad application prospects.

[0040] In order to make the above-mentioned objects, features and advantages of the present application more obvious and easy to understand, preferred embodiments are specifically cited below and described in detail with reference to the attached drawings. BRIEF DESCRIPTION OF THE DRAWINGS

[0041] In order to more clearly illustrate the technical solutions of the embodiments of the present application, the drawings required for use in the embodiments will be briefly introduced below. It should be understood that the following drawings only show certain embodiments of the present application and therefore should not be regarded as limiting the scope. For ordinary technicians in this field, other related drawings can be obtained based on these drawings without paying creative work.

[0042] Figure 1 It is a flowchart of the social work service method of this application;

[0043] Figure 2 It is a schematic diagram of the principle of this application;

[0044] Figure 3 It is a schematic diagram of the social work service system module of this application.

[0045] Figure numerals: 1-first assessment unit; 2-second assessment unit; 3-family assessment unit; 4-historical data unit; 5-demand generation unit; 6-social worker matching unit. DETAILED DESCRIPTION

[0046] The following will be combined with the drawings in the embodiments of the present application to clearly and completely describe the technical solutions in the embodiments of the present application. Obviously, the described embodiments are only part of the embodiments of the present application, not all of the embodiments. Based on the embodiments in the present application, all other embodiments obtained by ordinary technicians in this field without creative work are within the scope of protection of this application.

[0047] This application proposes a social work service method based on long-term diseases. Through automated and intelligent methods, it realizes the comprehensive collection and analysis of patient information, the division of social work service stages, the precise matching of social work skills, and the customized planning of service schedules, thereby providing more personalized and efficient services for patients and their families. The flow chart of the social work service method based on long-term diseases is as follows Figure 1 The principle is shown in the attached Figure 2 The specific plan is as follows:

[0048] A long-term illness-based social work approach that includes:

[0049] 101. Identify patients with long-term diseases and their case data in the preset medical institutions, determine the disease range corresponding to the patients and the assessment service team corresponding to the disease range based on the case data; conduct pathological and psychological assessments on the patients through the assessment service team;

[0050] 102. When the pathological evaluation and / or psychological evaluation results of a patient indicate that social work services are needed, the patient shall be included in the first service recipient and an economic evaluation shall be conducted on the patient; and the degree of influence of economic factors on the pathological evaluation and / or psychological evaluation results of the first service recipient shall be analyzed based on the economic evaluation results;

[0051] 103. Determine whether to include the family members in the second service recipients who need social work services based on the degree of impact and the medical staff's assessment of the family members' status, and conduct a psychological assessment of the second service recipients through the assessment service team, and obtain the family member assessment results based on the psychological assessment results;

[0052] 104. Obtain historical service data of the first service object regarding past social work services, determine the illness time and treatment status of the first service object by parsing the case data, and determine the skill label of the past social worker by parsing the historical service data to obtain a historical label;

[0053] 105. Determine the current social work service stage of the first service recipient based on the duration of illness and treatment; generate the first demand for social workers based on the disease interval, historical labels, and social work service stage, and generate the second demand for social workers based on the family assessment results;

[0054] 106. According to the first demand, the second demand, and the schedules of the social workers stored in the database and the skill tags they possess, search for one or more social workers who meet the preset conditions to provide social work services to the first service recipient and / or the second service recipient.

[0055] Through intelligent data processing and efficient resource management, this application can provide patients and their families with more personalized, accurate and high-quality social work services, effectively alleviate the multi-faceted pressures brought by long-term diseases, improve the quality of life of patients and their families and the overall well-being of the family, and provide personalized social work services for patients with long-term diseases and their families.

[0056] Step 101 involves identifying patients with long-term illnesses and their case data, and conducting preliminary assessments and classifications based on this information. The effect of this step is to provide an accurate information basis for subsequent services, ensuring that each patient can receive targeted support.

[0057] First, it is necessary to identify all patients with long-term diseases registered in a specific medical institution. Long-term diseases usually refer to those that last for a long time, may affect the quality of daily life, and are difficult to cure or fully control (such as diabetes, hypertension, chronic obstructive pulmonary disease, etc.). Case data includes patients' medical records, diagnostic reports, treatment history, etc. Through this process, a detailed patient database can be established to provide basic information for subsequent analysis and services. Disease intervals are a way to classify patients based on factors such as disease type and severity.

[0058] In some embodiments, the disease interval mainly includes two categories, namely, mental illness and physical illness. At the same time, the long-term illness, illness duration and family economic status of the first service object are comprehensively considered to evaluate the current economic status of the family members. The case data is parsed to extract the specific disease type from the diagnosis report of the first service object. According to the disease type, it is divided into the corresponding disease interval (mental disease or physical disease).

[0059] In this application, pathological assessment focuses on the patient's physical health status, including checking symptoms, monitoring treatment response, etc., while psychological assessment focuses on evaluating the patient's psychological state, such as emotional problems, stress levels, coping ability, etc. Suppose a 50-year-old male patient named Li Hua is being treated. He suffers from stage 3 chronic kidney disease (CKD). The hospital's social work department extracts all relevant information about Li Hua from the electronic health record system, including his age, gender, occupation, family situation, past medical history, current treatment plan, etc. Based on Li Hua's renal function indicators and other relevant factors, he is classified as "mid-stage chronic kidney disease." For this type of patient, the hospital has a special assessment team composed of nephrologists, nutritionists, and psychological counselors. The team conducted a comprehensive physical examination of Li Hua and found that his blood pressure was poorly controlled and he also had a certain degree of depression. These findings suggest that Li Hua not only needs medical adjustments, but may also benefit from psychological support and social resources.

[0060] Regarding data collection, the required data can be automatically obtained through interfaces with the hospital's electronic health record (EHR) system, social work service record system, and other relevant databases. Electronic health record (EHR) system: obtains the diagnosis report, treatment record, medical history and other information of the first service object from the EHR system of the hospital or clinic. Medical files: include all medical documents of the first service object, such as outpatient records, hospitalization records, surgical records, laboratory test results, etc. In some cases, manual input or uploading of data may be required, such as family registration forms, interview records, etc. Integrate the data obtained from different sources to form a unified data set.

[0061] Regarding data parsing, in some embodiments, NLP technology is used to parse text data and extract key information, such as disease types in diagnostic reports, treatment methods in treatment records, etc. Structured data processing: cleaning, standardizing and normalizing structured data (such as tabular data). Feature extraction: extracting useful features from raw data for subsequent analysis and matching. The parsed data is stored in a preset database for subsequent query and analysis. In practical applications, the basic family information form filled out by the first service object or family members includes name, age, gender, occupation, educational background, marital status, etc. The records of face-to-face or telephone interviews between social workers and the first service object and their families, including family assessment results, social function assessment, etc. In practical applications, Python's Pandas library or other data cleaning tools are used to remove missing values, outliers and duplicate data. Standardize the data to ensure that the numerical data is in the same dimension. Normalize the numerical data to make it within a specific range (such as between 0-1). Define feature extraction rules to extract keywords from text data and key fields from structured data.

[0062] The results of pathological and psychological assessments can reveal the patient's physical and mental health problems, which can help determine whether social workers are needed. When pathological or psychological assessments show that the patient has significant health or mental health problems, especially when these problems are affected by social environmental factors or require additional social support, it indicates that the patient needs the services of a social worker. The intervention of social workers can not only help solve direct health problems, but also improve the patient's quality of life from a broader perspective.

[0063] Preferably, when the pathological evaluation shows the following results, the patient can be deemed to need social work services:

[0064] Difficulty managing chronic diseases:

[0065] Example: If a diabetic patient frequently experiences poor blood sugar control and is at increased risk for complications (e.g., retinopathy, nephropathy, etc.), this may be due to the patient's lack of adequate self-management knowledge or resources. Social workers can help provide educational support, assist in connecting with relevant resources such as dietitians, exercise instructors, etc., and help patients apply for financial assistance to purchase necessary medications and equipment.

[0066] Poor compliance with treatment:

[0067] Example: A patient with high blood pressure does not take medication as prescribed, resulting in poor blood pressure control. Social workers can investigate the reasons behind this, such as whether the patient cannot afford the medication due to financial reasons or has misunderstandings about the treatment plan. Social workers can also provide motivational interviews to improve the patient's treatment compliance.

[0068] Complex health conditions:

[0069] Example: A patient with multiple long-term medical conditions (such as heart disease plus diabetes) has a complex medical condition that requires a multidisciplinary team. A social worker can serve as a bridge between different healthcare providers, ensure information flows smoothly, and help the patient understand complex medical recommendations.

[0070] Preferably, the patient may be deemed to need social work services when the psychological assessment shows the following results:

[0071] Depression symptoms:

[0072] Example: A psychological assessment reveals that a patient exhibits persistent low mood, loss of interest, etc. Social workers can provide emotional support, help patients establish social connections, and assist with referrals to professional counseling or psychiatrists for further treatment.

[0073] Anxiety disorders:

[0074] Example: The patient shows excessive worry, nervousness, and even panic attacks. Social workers can help patients learn coping strategies through methods such as cognitive behavioral therapy, reduce anxiety, and improve quality of life.

[0075] Inadequate coping mechanisms:

[0076] Example: Patients seem helpless and lack effective coping strategies when facing the disease. Social workers can teach patients and their family members how to actively cope with the challenges brought by the disease, including stress management techniques, communication skills, etc.

[0077] Suicide risk:

[0078] Example: A patient expresses suicidal thoughts or has suicidal tendencies. This situation requires immediate attention and the social worker should act quickly, working with professionals to ensure the patient's safety and provide urgent psychological support.

[0079] For example, Li Hua is a 50-year-old male with stage 3 chronic kidney disease. Pathological evaluation showed that his kidney function was gradually deteriorating, while psychological evaluation found that he had moderate depression. In addition, he also expressed extreme stress because the high medical expenses put the family in a difficult situation. In this case, social workers can not only help Li Hua and his family deal with emotional problems, but also assist them in finding financial assistance resources, such as Medicaid, help from charitable organizations, etc. At the same time, social workers can also provide education and support to help Li Hua better manage his condition and improve his quality of life.

[0080] If the patient is found to have significant physical or mental health problems in the previous assessment (step 101), and these problems may require additional social support to resolve, then the patient will be marked as a recipient of social work services, ensuring that only patients who really need additional help will enter the next economic assessment process to avoid waste of resources. Patients marked as requiring social work services will be listed as the first service recipients. Next, social workers will conduct a detailed economic status survey of these patients, including income level, family financial burden, ability to pay medical expenses, etc. Through economic assessment, it is possible to identify which patients have difficulty obtaining necessary medical services or are at risk of a decline in quality of life due to financial difficulties.

[0081] Based on the results of the economic assessment, analyze how economic pressure specifically affects the patient's physical health or mental health. For example, financial difficulties may prevent patients from purchasing necessary medicines, thereby exacerbating their condition; or long-term financial pressure may lead to worsening depression. This analysis helps to develop more precise service plans, focusing not only on medical needs but also on socioeconomic challenges. For example, the social worker learned that Li Hua's family income is low, he himself is unable to work due to illness, and the family mainly relies on his wife's meager income to make a living. In addition, the high medical expenses have brought great economic pressure to the family. Through the analysis of Li Hua's situation, it was found that financial difficulties were one of the reasons for his poor treatment compliance. At the same time, continuous economic pressure is also an important factor in his depression. Therefore, Li Hua's health condition requires not only medical intervention, but also financial assistance and social support. Based on the above analysis, the social worker can develop a comprehensive service plan for Li Hua. In addition to recommending appropriate medical plans, he can also contact relevant institutions to provide financial assistance, such as applying for medical subsidies and introducing employment opportunities. By deeply understanding the patient's economic situation and its impact on health, more targeted support can be provided to improve the patient's overall well-being.

[0082] In practical applications, the patient's family data can be obtained in advance, including family income, family members, medical insurance, etc. The first diagnosis date of the first service object can be obtained from the hospital's diagnosis report to calculate the length of time the patient has been ill. The patient's treatment plan and progress can be obtained from the treatment record. According to the treatment progress and current treatment status, the patient's social work service stage can be judged. Regarding the assessment of economic status, the family's occupation and income information can be obtained from the family data to calculate the family's total income. The medical expenses paid by the family for the patient can be obtained from the family data, and the proportion of medical expenses to the total family income can be calculated. The family's medical insurance information is obtained from the family data to evaluate the insurance coverage and reimbursement ratio. In addition, other economic pressure information of the family, such as debt, housing costs, education expenses, etc., needs to be obtained from the family data. Take these factors into consideration to assess the family's overall economic status.

[0083] In step 102, the analysis of the impact of economic factors on the pathological assessment and / or psychological assessment results of the first service object based on the economic assessment results is achieved through systematic data analysis and personalized situation review. This process aims to gain a deeper understanding of how economic conditions specifically affect the patient's health status, thereby providing a basis for formulating effective social work intervention strategies. First, a detailed economic assessment is conducted, including but not limited to family income, expenditure (especially medical expenses), debt level, social security benefits, etc. Combined with the results of the pathological assessment and psychological assessment obtained in step 101, ensure that there is enough information for comprehensive analysis. Use statistical software or spreadsheet tools to quantify the relationship between economic factors and health outcomes. For example, calculate the proportion of patients who fail to take medication on time due to economic reasons, or analyze the correlation between income level and mental health scores. Obtain a deeper understanding through interviews, observation records, etc. For example, understand whether the patient reduces the number of medical visits due to financial pressure, or dares not seek psychological help because of concerns about costs.

[0084] Determine how financial factors directly affect pathology assessment results. For example, the inability to pay for medications can lead to worsening of the condition; lack of funds to purchase special diet materials can affect nutritional status. Examine the impact of financial factors on psychological assessment results through other channels. For example, long-term financial stress can lead to increased depression or anxiety, which in turn affects overall health. Combine all collected data to form a comprehensive view of how financial factors affect the patient's health in many ways. Generate a detailed report for each patient, clearly indicating which financial factors have had a significant impact on their health and make corresponding recommendations.

[0085] Step 103 is to decide whether to include the patient's family members in social work services based on the economic status of the first service object (patient) and its impact on health, as well as the medical staff's assessment of the family members' status. If it is decided to include, the family members will be psychologically assessed by the assessment service team, and corresponding support will be provided to the family members based on the results. This ensures that not only the patient himself, but also the entire family, including his family members, receive appropriate social work support and services. This can build a more stable social work support network to help patients and their families better cope with the various challenges brought by long-term diseases.

[0086] Review the results of the economic assessment to determine how financial difficulties specifically affect the patient's treatment compliance, disease control, and mental health. Medical staff understand the family members' stress level, emotional state, and coping mechanism in the process of caring for the patient through observation, interviews, or questionnaires. Based on the above analysis, if it is found that family members are also facing significant psychological or social pressure, and these pressures may affect the quality of their care for the patient or their own health, consider including family members in the service objects. When the following symptoms appear, it can be determined that family members need social work services. Specifically, 1) Family members show obvious psychological distress (such as depression, anxiety, etc.); 2) Family members are under great pressure due to long-term care of patients, which affects their daily life or work. 3) Family members lack the necessary social support network or resources and find it difficult to cope with the current situation alone.

[0087] Once it is decided to include family members in the service, the assessment service team will conduct a more in-depth psychological assessment of the family members to fully understand their mental health status. The assessment content includes: mental health status (such as whether there are problems such as depression and anxiety), coping ability and emotional support needs, quality of life and impact on daily functions. Based on the results of the family members' psychological assessment, a detailed family assessment report is generated, and personalized service and support plans are formulated accordingly. For example, psychological counseling or treatment is provided to help family members deal with emotional problems; stress management and coping skills are taught to enhance self-efficacy; assistance is provided to contact community resources, such as support groups, volunteer services, etc., to expand the social support network; education and support on disease management are provided so that family members can better assist patients.

[0088] For example, Li Hua's family income is low. He cannot work due to illness, and the family mainly relies on his wife, Ms. Zhang's meager income to make a living. The high medical expenses have brought great financial pressure to the family, causing Li Hua to frequently interrupt treatment and further deteriorate his condition. The continuous financial pressure is also an important reason for Li Hua's worsening depression. Medical staff noticed that Ms. Zhang had to bear the financial burden of the family while taking care of Li Hua, showing obvious anxiety and fatigue. Based on the above assessment results, the social work team believed that Ms. Zhang was not only facing great psychological pressure, but her condition also indirectly affected Li Hua's recovery process. Therefore, it was decided to take Ms. Zhang as the second service object to ensure that she could also receive appropriate support. The assessment service team conducted a detailed psychological assessment of Ms. Zhang and found that she had mild anxiety disorder and felt very lonely and helpless. These assessment results showed that Ms. Zhang needed emotional support and social resources to improve her mental health. Regular psychological counseling services can be provided to Ms. Zhang to help her deal with anxiety. And assist Ms. Zhang to join a support group for families of chronic disease patients so that she can communicate with others who are experiencing similar difficulties.

[0089] Step 104 involves obtaining the historical service data of the first service object (patient) regarding past social work services, and determining the patient's illness duration, treatment status, and past social worker skill tags by parsing the relevant data. The purpose of this step is to fully understand the patient's medical history and service experience, so as to more accurately assess the current service needs and develop a personalized service plan.

[0090] Specifically, it is necessary to collect all records of social work services that the patient has received in the past, including but not limited to: the time and frequency of social work intervention, the specific service content provided (such as psychological counseling, financial assistance, resource links, etc.), and the patient's feedback and satisfaction evaluation on the services. Social work service records can be obtained from the electronic health record system within the medical institution, the database or record files of the social work service agency, and the written or oral information provided by the patient and his or her family.

[0091] Specifically, key information is extracted from case data to understand the patient's disease diagnosis time, disease progression, and treatment effects. For example, the analysis involves the date of the first diagnosis of a long-term disease, the timeline of previous treatments, treatment methods (drugs, surgery, etc.), treatment response (effective, ineffective, side effects, etc.), and whether the condition is stable, worsening, or improving over time. In actual applications, the timeline function in the electronic health record system can be used to view the course of the disease, and data analysis software can be used to count quantitative indicators such as the number of treatments and medication dosages, and finally a comprehensive judgment can be made based on the doctor's diagnosis report and examination results.

[0092] Based on the historical service data of social workers in the past, and according to the content and methods of services provided by social workers in the past, we summarize their professional skills and expertise to form skill labels. Skill labels include mental health support, financial assistance, legal consultation, etc. By reviewing the service records of social workers, we can identify the main goals and means of each service, and communicate with social workers who have participated in the service to understand their focus and challenges in handling the case. By analyzing the patient's response to different forms of service, we can find the most effective service strategy. Combining all the above information, we can evaluate the patient's current stage of social work service, that is, what kind of social work service is needed to promote rehabilitation. Through such label classification, social workers with corresponding skills can be more accurately matched to provide services to patients and their families. For example, if the patient and his family need more mental health support now, they can choose a social worker with mental health support and individual counseling labels; if he faces new financial difficulties, he can choose a social worker who is good at financial assistance. This method ensures the professionalism and pertinence of the service and improves the quality and efficiency of the service.

[0093] Step 105 is to comprehensively determine the patient's current social work service stage based on a comprehensive understanding of the patient's medical history, treatment progress, and past social work services, and generate specific social work needs based on this information. This process is designed to ensure that each patient can receive the support and services that best suit their current situation. By analyzing the patient's medical history (such as the time of first diagnosis) and treatment history (including the timeline of previous treatments, treatment methods and their effects), it is determined which stage of disease management the patient is currently in. Combined with the patient's disease type (i.e., "disease range"), professional skill labels identified in past social work services (such as mental health support, financial assistance, etc.), and the current service stage, the patient's most urgent needs are identified. For those family members who are included in the service objects, specific service needs also need to be generated based on their psychological assessment results.

[0094] Step 106 is a key link in the entire social work service method, which aims to find and assign the most suitable social worker to provide services to the first service object and / or the second service object based on the first demand (for the patient) and the second demand (for the family), as well as the schedules and skill tags of each social worker stored in the database. Based on the first and second demands generated previously (step 105), combined with the professional background, skill tags and schedules of the existing social workers, find the social worker who best meets the needs. By reviewing the specific content of the first and second demands, clarify the required professional fields and service models. Compare the needs with the social worker's skill tags to ensure that the selected social worker has the necessary professional knowledge and experience. Check the schedules of the candidate social workers and select those who have enough time and can respond in a timely manner.

[0095] When selecting social workers, give priority to those who are familiar with specific diseases (such as chronic kidney disease, mental health problems, etc.). And ensure that the selected social workers are free during the required time period to avoid service delays due to time conflicts. In practical applications, it is also necessary to consider the location of the service and select social workers who live or work in the same area or nearby areas to improve service efficiency. By referring to past service records, understand the historical performance and service quality evaluation of candidate social workers. If relevant information is available, consider the preferences or feedback of patients and their families for specific social workers to enhance service acceptance. After considering the above factors, finally determine the social workers who will provide services to patients and their families. Introduce the social workers who will provide services to patients and their families, including their background and expertise, to increase their confidence in the service. Ensure that all relevant personnel are clear about the time, location and other specific arrangements of the service, and prepare the necessary resources and support materials.

[0096] In some specific embodiments, different disease intervals and social work service stages are pre-set with corresponding basic skill requirements for social workers; each long-term disease is pre-set with specific multiple exclusive skill requirements for social workers; the preset conditions include: the skill labels possessed by a social worker meet all basic skill requirements of the disease interval and social work service stage, and the satisfaction ratio of the exclusive skill requirements is not less than the preset ratio, before he can become the first social worker who meets the first requirement and provides social work services to the first service object; the skill labels possessed by a social worker include at least psychological counseling and guidance, before he can become the second social worker who meets the second requirement and provides social work services to the second service object.

[0097] Each disease interval (such as mild, moderate, and severe) and each social work service stage (such as initial adaptation, mid-term management, and late rehabilitation) sets basic skill requirements that social workers must have. These requirements are set based on the typical problems of the disease interval and the characteristics of the service stage. For example, in the moderate stage of chronic kidney disease, more financial assistance and mental health support may be needed. At the same time, each long-term disease has its own unique challenges and requirements, so a number of exclusive skill requirements are set for each disease. For example, for cancer patients, in addition to basic psychological support, special skills such as hospice care and pain management are also required; while for diabetic patients, more emphasis may be placed on diet control and self-care education. For the first service object (i.e., the patient), the skill labels possessed by the social worker must not only meet all basic skill requirements, but also the satisfaction ratio of the exclusive skill requirements must not be lower than the preset ratio (such as 80%). This means that social workers must not only have a wide range of professional knowledge, but also have in-depth understanding and practical ability in certain specific areas. For the second service object (i.e., the family members), any social worker who provides services to them should at least have the ability of psychological counseling and counseling. This is because family members are often under great psychological pressure, and they need professional guidance and support to cope with this pressure. After screening, only those social workers who fully meet the above conditions will be selected to provide services to the first or second service recipients. This ensures the quality and pertinence of the service, so that each patient and their family can get the most personalized support for them. According to the disease type and social work service stage of the first service recipient, the system can accurately match social workers with corresponding skills to ensure that social workers can provide professional and targeted services. The setting of exclusive skill requirements enables social workers to better meet the specific needs of the first service recipient and provide personalized support and services. Through the intelligent matching algorithm, social workers who meet the requirements can be found quickly, avoiding the time and error rate of manual screening and improving the utilization efficiency of social work resources. Ensure that each social worker works in the field in which he or she is good at, reducing the decline in service quality and waste of resources caused by mismatch.

[0098] In some specific embodiments, the scope of long-term diseases is determined in advance; long-term diseases are divided according to whether they are mental illnesses, and two disease intervals are obtained, namely, a physiological disease interval and a psychological disease interval; psychological counseling and guidance are used as the basic skill requirements for the psychological disease interval, and the skill requirements for social workers required for diseases that exceed a preset proportion in the physiological disease interval are screened out to obtain the basic skill requirements for the interval; for each long-term disease, the skill requirements for social workers required for the disease in addition to the basic skill requirements are pre-set to obtain the exclusive skill requirements for each disease.

[0099] First, we need to clarify which diseases are classified as long-term diseases. Long-term diseases usually refer to diseases that last for a long time and require long-term management, including but not limited to:

[0100] Mental illness: depression, anxiety, bipolar disorder, post-traumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), schizophrenia; Physical illness: diabetes, hypertension, Parkinson's disease, Alzheimer's disease, autism spectrum disorder, spinal cord injury, cancer, chronic obstructive pulmonary disease (COPD), heart disease, rheumatoid arthritis.

[0101] For example,

[0102] Basic skills required for mental illness range:

[0103] Psychological consultation and guidance: Ability to conduct psychological assessment, provide psychological support and guidance.

[0104] Family Support: Ability to provide support and education to the family of the primary client to help them better understand and cope with the primary client’s condition.

[0105] Resource Links: Ability to connect first service recipients and families to relevant community resources and support networks.

[0106] Basic skills required for physiological disease range:

[0107] Health Education: Ability to provide health education on disease management and prevention.

[0108] Resource Links: Ability to connect primary service recipients and families to relevant medical and social resources.

[0109] Life skills training: Ability to teach the first service recipients and their families the necessary life skills to improve their quality of life.

[0110] Establishment of social support network: can help the first service recipients establish a social support network.

[0111] Mental illness can extract the same skill requirements, mainly in the field of psychological counseling. The scope of physical diseases is wider, and social workers can provide services such as health education and resource links, but some diseases are relatively rare, and social workers cannot understand their specific knowledge. Therefore, this application chooses to set it according to the proportion when customizing the basic skill requirements for the physiological disease range. For example, most physiological disease ranges require health education, but it is inevitable that some diseases cannot be achieved due to insufficient resources. At the same time, health education is necessary.

[0112] This application divides the skill requirements into two categories according to the disease, namely the basic skill requirements corresponding to the disease range and the exclusive skill requirements corresponding to the long-term disease. The basic skill requirements are generally easy to master, and there are many social workers with such skills. First, select the first social worker who meets the basic skill requirements from the database. Exclusive skill requirements require experience and specialization, and there are relatively few social workers with such skills. This can be used as a further screening criterion for the first social worker, which is equivalent to a scoring criterion. One or more social workers with higher scores are selected from the first social workers to provide services.

[0113] In some embodiments, a list of basic skill requirements is generated based on the disease interval and the social worker service stage. A list of exclusive skill requirements is generated based on the specific long-term disease of the first service object. The database contains basic information, schedules, and skill tags about the skills that each social worker is good at. Use a matching algorithm to compare the generated matching requirements with the skill tags in the database to find social workers who meet the requirements. Calculate the proportion of each social worker who meets the exclusive skill requirements, screen out social workers whose satisfaction ratio is not less than the preset ratio, and obtain the first social worker. Among them, the first social worker must meet all basic skill requirements and must meet at least 80% of the exclusive skill requirements (for example, if a long-term disease has 5 exclusive skill requirements, the social worker must meet at least 4 of them), and the social worker's schedule must be able to match the needs and service time of the first service object. In some embodiments, the first social worker can also be prioritized according to the social worker's experience, professional level, and other relevant factors.

[0114] In this application, the disease intervals are divided into mental disease intervals and physical disease intervals, and basic skill requirements and exclusive skill requirements are set in a targeted manner, which can significantly improve the quality and efficiency of social work services. This approach not only ensures that the first service recipients can obtain the support that best suits their specific circumstances, but also promotes the professional development and interdisciplinary cooperation of social workers, and ultimately improves the satisfaction and trust of the first service recipients and their families. Mental disease interval: Social workers need to have skills such as psychological counseling, crisis intervention, and family support. Physiological disease interval: Social workers need to have skills such as health education, resource linkage, and life skills training. Each disease interval has its own specific needs and challenges. Through targeted settings, social workers can better understand the specific circumstances of the first service recipients and provide personalized services.

[0115] In order to more accurately determine whether to include the patient's family members in the second service object who needs social worker services, the system introduces a grading mechanism of the degree of influence. This mechanism determines whether and how the family members are included in the service object by setting two preset ratios (the first ratio and the second ratio) according to the degree of influence of economic factors on the patient's pathological evaluation and / or psychological evaluation results. In some specific embodiments, when the degree of influence exceeds the preset first ratio, the patient's family members are directly included in the second service object; when the degree of influence is between the first ratio and the preset second ratio, the patient's family members are psychologically evaluated by the evaluation service team, and the corresponding family members are selected to be included in the second service object according to the psychological evaluation results of the family members; when the degree of influence does not exceed the preset second ratio, the medical staff who provide medical services to the patient are pre-determined, and the psychological state of each family member of the patient is preliminarily evaluated by the medical staff, and one or more family members who may need social worker help are determined according to the results of the preliminary evaluation, and the family members are included in the second service object.

[0116] If economic factors have a very significant impact on the patient's pathological or mental health (i.e., exceeding the preset first ratio), no further evaluation is required and the patient's family can be directly included in the second service object. In this case, the economic pressure may have seriously affected the family's overall quality of life and may even lead to an aggravation of the family's mental health problems. Therefore, immediate support is very necessary.

[0117] For those cases where the degree of economic impact is between the first and second proportions, the system will arrange for the assessment service team to conduct a detailed psychological assessment of the patient's family. The assessment may include emotional state, coping ability, social support network and other aspects. Based on the results of the family's psychological assessment, the corresponding family members will be selectively included in the second service object. This means that only those family members who do show psychological distress or other needs will receive additional support.

[0118] For situations where economic factors have a smaller impact (i.e., not exceeding the second ratio), the system will pre-determine the medical staff who will provide medical services to the patient, and use them to conduct a preliminary assessment of the psychological state of each family member of the patient. Medical staff may observe the emotional reactions and communication patterns of family members to quickly understand their psychological state. Based on the results of the preliminary assessment, medical staff will point out one or more family members who may need help from social workers, and these family members will then be included in the second service recipients. This approach can effectively utilize existing resources and ensure that family members who need help most can get support in a timely manner, while also avoiding unnecessary comprehensive assessments and improving efficiency.

[0119] In some embodiments, in order to implement an impact grading mechanism, data analysis and machine learning algorithms can be used to evaluate the impact of economic factors on the patient's pathological and psychological conditions, and decide whether the family members should be included in the second service object. Obtain detailed economic information (such as income, expenditure, debt), medical records (such as diagnosis results, treatment history), and psychological assessment data (such as anxiety level, depression score, etc.) from patients and their families. Clean and standardize the data, and create feature variables that are helpful for analysis, such as the proportion of monthly medical expenses to total income, the number of interruptions in treatment in the past year, etc. Select a suitable machine learning or statistical model based on the characteristics of the problem. For quantifying the impact of economic factors, a regression model (such as linear regression, logistic regression), a decision tree model (such as random forest, gradient boosting tree), or a neural network model can be selected. Use historical data to train the model, where the input is economic and medical features and the output is the target variable (such as changes in psychological assessment scores). Evaluate the performance of the model through cross-validation or other methods to ensure its accuracy and reliability. Based on domain knowledge or through model prediction results, set two thresholds as judgment criteria, and continuously adjust the thresholds according to the actual application effect to achieve the best service allocation effect. Regarding psychological assessment, validated psychological assessment tools can be used, such as the Beck Depression Inventory and the State-Trait Anxiety Questionnaire. Online assessment platforms can also be developed or integrated to allow family members to complete the assessment at home, improving convenience and responsiveness. A periodic reassessment mechanism should be set up to regularly reassess the situation of patients and their families to ensure the effectiveness and adaptability of the service. User feedback channels should be established to collect opinions and suggestions from patients and their families for improving models and service processes.

[0120] In some specific embodiments, it also includes: obtaining the basic information and past medical history information of the second service object, parsing the historical service data to find out whether there is a past social worker's evaluation of the family member, parsing the past medical history information to determine the current health status of the second service object; conducting a psychological evaluation of the second service object through the evaluation service team; and generating a family evaluation result by integrating the psychological evaluation results, the past social worker's evaluation and basic information. Not only does it take into account the specific impact of economic factors on patients and their families, but it also ensures the pertinence and effectiveness of the service through comprehensive information collection and analysis. It uses multi-dimensional data sources to improve the scientific and personalized level of decision-making, so that each family member can get the most suitable help. In order to more comprehensively understand the needs of the second service object (i.e., the patient's family member) and provide accurate support, the system will not only consider the degree of influence of economic factors, but also obtain and analyze the basic information, past medical history and historical service data of the family member. Obtain the previous health status, chronic diseases, hospitalization experience, etc. of the second service object through medical records or information provided by the family member. Retrieve from the database whether there have been past social workers who have provided services or contacted this family member, and check the evaluations and feedback left by these social workers. Summarize the types of services and service effects provided by social workers in the past, such as whether they have effectively alleviated the psychological pressure of family members or improved their quality of life. Based on the family members' past medical history information, combined with the latest physical examination report or other medical records, assess their current physical health status. Pay attention to any physical problems that may affect mental health, such as chronic pain, long-term disease management, etc. A professional assessment service team conducts a detailed psychological assessment of the family members, using standardized psychometric tools such as the Beck Depression Inventory, anxiety questionnaire, etc. In addition to questionnaires, the assessment results can also be supplemented by face-to-face interviews or observing the behavioral responses of family members. Based on the data of the psychological assessment, the current mental health status of the family members is obtained. Refer to the service records and evaluations of past social workers to understand the effects of the support received by the family members before. Consider the basic information of the family members, such as the impact of factors such as age and occupation on their needs. Based on all the above information, generate detailed assessment results for each family member, and formulate personalized service plans accordingly.

[0121] In some specific embodiments, multiple social workers are selected to form a social worker group to provide social work services for the first service object and / or the second service object. The skill labels possessed by the social workers in each social worker group are complementary to meet the first demand and / or the second demand, and the social workers in each social worker group can serve one or more first service objects or second service objects at the same time; a service object group is constructed according to the first service object or the second service object served by each social worker in the social worker group, and the social worker services in the service object group are deployed according to the schedule of each social worker. In order to more efficiently and comprehensively meet the needs of the first service object (patient) and the second service object (family), the system will select multiple social workers to form one or more social worker groups. The members of each social worker group have complementary skill labels to ensure that all necessary service needs can be covered. According to the first demand and / or the second demand, the required professional field and service model are clarified. Ensure that the members of each social worker group meet all basic skill requirements for the corresponding disease interval and social work service stage. Select social workers who have multiple exclusive skill requirements for specific long-term diseases and ensure that these skills are complementary within the group. For the second service recipient, at least one social worker must have the ability to provide psychological counseling and guidance.

[0122] Optimize the combination of social workers through algorithms so that the skill labels in each social worker group are as complementary as possible to maximize the needs of the service recipients. Construct a service recipient group based on the first or second service recipients served by each social worker in the social worker group. Based on the schedule of each social worker, rationally allocate services in the service recipient group to ensure that each social worker can provide support to the service recipient at the appropriate time. Design service processes to allow social workers in each social worker group to serve one or more first or second service recipients at the same time to improve service efficiency. Establish an effective internal communication mechanism to ensure smooth information flow between different social workers and between social workers and service recipients. Establish an effective internal communication mechanism to ensure smooth information flow between different social workers and between social workers and service recipients. Adjust the composition and service plan of the social worker group in a timely manner according to changes in the needs of the service recipients or new situations.

[0123] For example, Li Hua needs mental health support, financial assistance and disease management education; Ms. Zhang needs psychological support and stress management counseling.

[0124] Skill Matching:

[0125] Mental health support: Choose social worker A who is good at psychological counseling and support.

[0126] Financial Assistance: Choose social worker B who is familiar with Medicaid and social welfare policies.

[0127] Disease management education: Select social worker C who has knowledge of chronic kidney disease management and care.

[0128] Family support: Choose social worker D who has extensive experience in family conferences and stress management skills.

[0129] Optimize the combination: ensure that the skill labels of social workers A, B, C, and D are complementary and together form an efficient social work team.

[0130] Establish a service object group: Li Hua and Ms. Zhang will be treated as a pair of service objects, and the above-mentioned social work group will provide comprehensive services.

[0131] Consider schedules: Check the schedules of the four social workers to make sure they are available to provide the support that Li Hua and Ms. Zhang need during appropriate time periods.

[0132] Serving multiple people at the same time: Social worker A can provide psychological counseling to Li Hua and psychological support to Ms. Zhang at the same time; social worker B can help Li Hua apply for financial assistance while assisting Ms. Zhang in understanding relevant policies; social workers C and D can provide disease management and stress management guidance respectively based on their respective professional fields.

[0133] Coordination and communication mechanism: Set up weekly team meetings for social workers to exchange progress and problems encountered to ensure consistency and continuity of services.

[0134] In some specific embodiments, while determining the historical tags by parsing the historical service data, the past social worker's service evaluation of the first service object is searched, and the service precautions are parsed from the service evaluation; the social worker service stage of the patient during the past social worker service is determined, and the skill tags associated with the social worker service stage at that time in the historical tags are analyzed to obtain the first tag; the first tag in the historical tag is excluded to obtain the social worker service stage requirements; the requirements corresponding to the service precautions are analyzed to obtain the precaution requirements; the basic skill requirements currently required are determined according to the disease interval and the current social worker service stage, and the corresponding exclusive skill requirements are determined according to the long-term disease; the first requirement is obtained by integrating the social worker service stage requirements, precaution requirements, basic skill requirements and exclusive skill requirements. In order to more accurately determine the first requirement of the first service object (patient), the system will deeply parse the historical service data and extract valuable information from it, including the service evaluation and service precautions of the past social workers. The service content provided by each social worker is parsed from the past social worker service records, and skill tags are formed. The past social workers' service evaluations of the first service object are retrieved to understand their views and suggestions on service quality. Analyze the specific matters that need to be paid attention to during the service process from the service evaluation, such as the patient's special reactions, family members' feedback, etc. Convert these matters into specific needs so that they can be taken seriously in future services. Determine the social work service stage that the patient was in during the past social work service (such as initial adaptation, mid-term management, and late rehabilitation). Analyze the skill tags associated with the social work service stage at that time in the historical tags to obtain the first tag. Exclude the first tags that have been met from the historical tags, and the remaining part is the needs of the current social work service stage. According to the service matters, further refine and clarify the aspects that need special attention in future services to form the matters needing attention. Determine the basic skill requirements based on the disease range and the current social work service stage. Based on the characteristics of long-term diseases, determine the corresponding multiple exclusive skill requirements to ensure that social workers have the ability to deal with specific problems. Combine the social work service stage requirements, matters needing attention requirements, basic skill requirements, and exclusive skill requirements to form the final first requirement. According to the first requirement, tailor a detailed service plan for each first service recipient to ensure that they receive the most suitable support. This method not only improves the pertinence and effectiveness of the service, but also ensures the continuity and improvement of the service through in-depth analysis of historical data.

[0135] In some embodiments, the rule engine is used to divide disease intervals, determine social work service stages, and evaluate economic status according to defined rules. The system automatically parses case data and family data, extracts the required key information, and automatically divides disease intervals, determines social work service stages, and evaluates economic status according to defined rules. It automatically generates an evaluation report that summarizes the patient's disease interval, social work service stage, and family economic status. The rules that need to be defined are as follows:

[0136] Disease interval division rules: define the mapping relationship between disease types and disease intervals.

[0137] Social work service stage judgment rules: define the mapping relationship between illness duration, treatment progress and social work service stages.

[0138] Economic status assessment rules: Define the mapping relationship between income level, medical expense burden, insurance status and other economic pressures and economic status.

[0139] In some embodiments, the social work service stages include, in sequence, the diagnosis and initial adaptation stage, the treatment and management stage, the rehabilitation and recovery stage, the maintenance and self-management stage, and the advanced care and hospice stage. Diagnosis and initial adaptation stage: The first service recipient has just been diagnosed and needs psychological support and preliminary planning. Treatment and management stage: The first service recipient is undergoing active treatment and requires case management and resource linkage. Rehabilitation and recovery stage: The first service recipient has completed the main treatment, with an emphasis on rehabilitation and restoration of normal life functions. Maintenance and self-management stage: The first service recipient has learned how to manage his or her condition and needs continued support and supervision. Advanced care and hospice stage: For incurable diseases, the first service recipient enters the end of life and needs palliative care and support.

[0140] By dividing social work services into different stages, more targeted support and services can be provided to meet the needs of the first service recipients and their families at different stages. Each stage has its own specific tasks and goals, and social workers play an important role in these stages to help the first service recipients better cope with the disease and improve their quality of life. In some embodiments, basic skill requirements are preset for the social work service stages. Specifically:

[0141] When the first service recipient is in the diagnosis and initial adaptation stage, the basic skills required include at least understanding the relevant disease knowledge, the ability to deal with acute stress reactions, follow-up planning for the disease, and psychological status assessment. The diagnosis and initial adaptation stage is generally 0-3 months after diagnosis. It is just the beginning of initial treatment and diagnosis. It is necessary to help the first service recipient and his family understand and accept the diagnosis results and start initial psychological and social adaptation. Exemplary services that social workers can provide include: providing emotional support to help the first service recipient and his family cope with the shock of the diagnosis. Providing basic information about the disease to the first service recipient and his family, including the cause, symptoms, and treatment methods. Connecting the first service recipient and his family to relevant medical resources and social support networks. Developing a preliminary treatment and support plan to help the first service recipient and his family prepare. For the first service recipient with depression, social workers can help the first service recipient and his family understand the symptoms, possible causes, and common treatment methods (such as medication and psychological counseling) of depression. At the same time, provide psychological support to help them cope with the anxiety and confusion caused by the diagnosis. For the first service recipients with diabetes, social workers can provide basic knowledge about diabetes, introduce methods of blood sugar monitoring, and the importance of diet and lifestyle adjustments, help the first service recipients to diabetes education classes and community support groups, and link them to the necessary medical and social resources.

[0142] When the first service recipient is in the treatment and management stage, the basic skill requirements at least include coordinating medical services, acute complications and other crisis interventions; social workers are required to support the first service recipient in active treatment, manage the condition and improve the quality of life. Exemplary services that social workers can provide include: coordinating multidisciplinary teams (doctors, nurses, nutritionists, etc.) to ensure the effective implementation of the treatment plan. Teach the first service recipient and his family the necessary life skills to better manage the disease. Continue to provide psychological support to help the first service recipient cope with the treatment process. For the first service recipient with cancer, social workers can assist the first service recipient and his family to work with oncologists, nutritionists and psychological counselors to develop a comprehensive treatment plan. Teach the first service recipient how to manage the side effects of chemotherapy and provide psychological support to help them cope with the stress during treatment. For the first service recipient with Parkinson's disease, social workers can coordinate neurologists, physical therapists and occupational therapists to develop a personalized rehabilitation plan. Teach the first service recipient and his family how to assist in daily activities and provide psychological support to help them cope with the challenges brought by the progression of the disease.

[0143] When the first service object is in the rehabilitation and recovery stage, the basic skill requirements include at least social integration, life skills training, and multidisciplinary collaboration; through social workers, the first service object is helped to restore function, resume normal life, and improve independence and quality of life. The first service object can be assisted in rehabilitation training, including physical therapy, occupational therapy, etc. Continue to teach the first service object and his family the necessary life skills to improve independence. Help the first service object reintegrate into society and participate in community activities. Provide psychological support to help the first service object cope with emotional problems during the rehabilitation process. For the first service object with spinal cord injury, social workers can assist the first service object with physical therapy and occupational therapy, teach them how to use assistive devices, and improve their self-care ability. At the same time, help the first service object participate in community activities, rebuild social networks, and provide psychological support to help them cope with frustration during the rehabilitation process. For the first service object with heart disease, social workers can assist the first service object with cardiac rehabilitation training and teach them how to do proper exercise and diet management. Help the first service object reintegrate into work and community life, provide psychological support, and help them cope with anxiety and depression during the rehabilitation process.

[0144] When the first service recipient is in maintenance and self-management, the basic skill requirements include at least long-term supervision management, self-management education, and regular evaluation; social workers need to help the first service recipient learn self-management, maintain stable condition, and improve quality of life. The first service recipient and his family can be taught how to conduct self-management, including drug management, symptom monitoring, etc. Provide continuous health education to help the first service recipient maintain good living habits. Continue to provide psychological support to help the first service recipient cope with emotional problems in long-term management. For the first service recipient with hypertension, social workers can teach the first service recipient how to correctly measure blood pressure, record data, and adjust lifestyle according to the doctor's advice. Provide health education to help the first service recipient maintain healthy eating and exercise habits. Follow up regularly and provide psychological support to help the first service recipient cope with the pressure of long-term management. For the first service recipient with bipolar disorder, social workers can teach the first service recipient and his family how to recognize early signs of mood swings and take timely measures. Provide health education to help the first service recipient establish regular living habits. Follow up regularly and provide psychological support to help the first service recipient cope with emotional swings in long-term management.

[0145] When the primary client is in the advanced care and hospice stage, the basic skills required include at least palliative care, bereavement counseling, and legal and financial planning. Social workers can provide palliative care for primary clients with incurable diseases to improve the quality of life at the end of life. Assist the medical team with pain management and symptom control. Provide psychological support to help the primary client and family cope with the pain of the impending loss of a loved one. Provide support and education to family members to help them cope with the role of caregiver. Connect the primary client and their family to relevant social support networks, such as hospice agencies. For primary clients with advanced cancer, social workers can assist the medical team with pain management and symptom control to ensure that the primary client is as comfortable as possible in the last stage of life. Provide psychological support to help the primary client and family cope with the impending separation. Connect the primary client and their family to hospice agencies to provide comprehensive support. For primary clients with Alzheimer's disease, social workers can assist the medical team with symptom management and provide psychological support to help the primary client and family cope with the challenges of cognitive decline. Connect the primary client and their family to relevant support networks, such as memory care centers, to provide comprehensive support.

[0146] This application also provides a social work service system based on long-term diseases. The module diagram of the system is shown in the attached Figure 3 As shown, the system includes:

[0147] The first evaluation unit 1 is used to determine the patients with long-term diseases in the preset medical institution and their case data, determine the disease interval corresponding to the patient and the evaluation service team corresponding to the disease interval according to the case data; and perform pathological and psychological evaluations on the patients through the evaluation service team;

[0148] The second evaluation unit 2 is used to include a patient in the first service object and conduct an economic evaluation on the patient when the pathological evaluation and / or psychological evaluation results of the patient indicate that social work services are needed; and to analyze the influence of economic factors on the pathological evaluation and / or psychological evaluation results of the first service object according to the economic evaluation results;

[0149] The family assessment unit 3 is used to determine whether to include the family members into the second service object requiring social work services based on the degree of impact and the medical staff's assessment of the family members' status, and to conduct a psychological assessment on the second service object through the assessment service team, and obtain the family assessment result based on the psychological assessment result;

[0150] The historical data unit 4 is used to obtain the historical service data of the first service object regarding the past social work services, determine the illness time and treatment status of the first service object by analyzing the case data, and determine the skill label of the past social worker by analyzing the historical service data to obtain the historical label;

[0151] Demand generation unit 5 is used to determine the current social work service stage of the first service object based on the duration of illness and treatment; generate the first demand for social workers according to the disease interval, historical label, and social work service stage, and generate the second demand for social workers according to the family assessment result;

[0152] The social worker matching unit 6 is used to find one or more social workers who meet the preset conditions to provide social work services to the first service object and / or the second service object according to the first demand, the second demand and the schedules and skill tags of each social worker pre-stored in the database.

[0153] The present application provides a computer program product, which includes computer instructions, which are stored in a computer-readable storage medium. A processor of a computer device reads the computer instructions from the computer-readable storage medium, and the processor executes the computer instructions, so that the computer device executes a social work service method based on a long-term disease. A social work service method based on a long-term disease is applied to a computer program product for easy execution.

[0154] The present application also provides a computer-readable storage medium having a computer program stored thereon, which, when executed by a processor, implements the steps of a social work service method based on long-term illness as described above.

[0155] The computer storage medium of the present application may adopt any combination of one or more computer-readable media. The computer-readable medium may be a computer-readable signal medium or a computer-readable storage medium. The computer-readable storage medium may be, for example, but not limited to: an electrical, magnetic, optical, electromagnetic, infrared, or semiconductor system, device or device, or any combination of the above. More specific examples (non-exhaustive list) of computer-readable storage media include: an electrical connection with one or more wires, a portable computer disk, a hard disk, a random access memory (RAM), a read-only memory (ROM), an erasable programmable read-only memory (EPROM or flash memory), an optical fiber, a portable compact disk read-only memory (CD-ROM), an optical storage device, a magnetic storage device, or any suitable combination of the above. In this document, a computer-readable storage medium may be any tangible medium containing or storing a program, which may be used by or in combination with an instruction execution system, device or device. The present application applies a social work service method based on long-term illness to a computer-readable storage medium, on which a computer program is stored, and when the program is executed by a processor, the method steps provided in the present application are implemented, which is simple and fast, easy to store, and not easy to lose.

[0156] This application proposes a social work service method and system based on long-term diseases, which provides more personalized, efficient and comprehensive social work service support for patients with long-term diseases and their families through automated and intelligent methods. Through pathological evaluation, psychological evaluation and economic evaluation of patients, the specific needs of patients can be accurately identified, so as to provide more targeted services. Detailed needs are generated according to the evaluation results to ensure that each patient and their family can obtain a tailored support plan. Including the psychological state and service needs of family members in the scope of evaluation improves the family's overall ability to cope with the disease and support, and enhances the depth and breadth of services. Through a series of scientific and reasonable steps and technical means, not only the quality and efficiency of social work services are improved, but also the satisfaction and quality of life of patients and their families are enhanced. This method is not only applicable to medical institutions, but can also be extended to wider fields such as community health service centers, which has important social significance and broad application prospects.

[0157] Those skilled in the art should understand that the modules of the present application described above can be implemented by a general-purpose computing system, they can be concentrated on a single computing system, or distributed on a network composed of multiple computing systems, and optionally, they can be implemented by program codes executable by a computer system, so that they can be stored in a storage system and executed by the computing system, or they can be made into individual integrated circuit modules, or multiple modules or steps therein can be made into a single integrated circuit module for implementation. Thus, the present application is not limited to any specific combination of hardware and software.

[0158] Note that the above are only preferred embodiments of the present application and the technical principles used. Those skilled in the art will understand that the present application is not limited to the specific embodiments herein, and that various obvious changes, readjustments and substitutions can be made by those skilled in the art without departing from the scope of protection of the present application. Therefore, although the present application is described in more detail through the above embodiments, the present application is not limited to the above embodiments, and may include more other equivalent embodiments without departing from the concept of the present application, and the scope of the present application is determined by the scope of the appended claims.

[0159] The above disclosure only discloses several specific implementation scenarios of the present application. However, the present application is not limited thereto, and any changes that can be conceived by technicians in this field should fall within the scope of protection of the present application.

Claims

1. A social work service method based on long-term illness, characterized in that: include: Determine patients with long-term diseases and their case data under the preset medical institution, determine the disease range corresponding to the patient and the assessment service team corresponding to the disease range based on the case data; conduct pathological and psychological assessments on the patients through the assessment service team; When the pathological evaluation and / or psychological evaluation results of a patient indicate that social work services are needed, the patient is included in the first service recipient and an economic evaluation is performed on the patient; based on the economic evaluation results, the degree of influence of economic factors on the pathological evaluation and / or psychological evaluation results of the first service recipient is analyzed; Based on the degree of impact and the medical staff's assessment of the family's condition, determine whether to include the family member as the second service recipient who needs social work services, and conduct a psychological assessment of the second service recipient through the assessment service team, and obtain the family member assessment results based on the psychological assessment results; Obtain historical service data of the first service object served by a past social worker, determine the illness time and treatment status of the first service object by parsing the case data, and determine the skill label of the past social worker by parsing the historical service data to obtain a historical label; The social work service stage currently in which the first service object is located is determined by comprehensively considering the illness time and treatment situation, and the social work service stages include diagnosis and initial adaptation stage, treatment and management stage, rehabilitation and recovery stage, maintenance and self-management stage, and late-stage care and hospice care stage in sequence; the first demand for social workers is generated according to the disease interval, historical label, and social work service stage, and the second demand for social workers is generated according to the family assessment result; According to the first demand, the second demand, and the schedules of each social worker stored in the database and the skill tags possessed, one or more social workers meeting the preset conditions are searched to provide social work services to the first service object and / or the second service object.

2. The social work service method according to claim 1, characterized in that: Different disease intervals and social worker service stages are pre-set with corresponding basic skills requirements for social workers; each long-term disease is pre-set with specific and multiple exclusive skills requirements for social workers; The pre-conditions include: A social worker can only become the first social worker who meets the first requirement and provides social work services to the first service recipient if the skill tags he / she possesses meet all the basic skill requirements of the disease range and the social work service stage, and the satisfaction ratio of the exclusive skill requirements is not less than the preset ratio; A social worker must have at least psychological counseling and guidance as his or her skill tags before he or she can become a second social worker who meets the second needs and provides social work services to the second service recipients.

3. The social work service method according to claim 2, characterized in that: Predetermine the range of the long-term disease; divide the long-term disease into two disease intervals, namely, a physiological disease interval and a psychological disease interval, according to whether the long-term disease is a psychological disease; Taking psychological counseling and guidance as the basic skill requirements for the psychological disease interval, screening out the skills requirements for social workers required by diseases exceeding a preset proportion in the physiological disease interval to obtain the basic skill requirements for the interval; For each of the long-term diseases, the skill requirements for social workers required by the disease in addition to the basic skill requirements are pre-set to obtain the exclusive skill requirements for each disease.

4. The social work service method according to claim 1, characterized in that: When the degree of influence exceeds the preset first ratio, the family members of the patient are directly included in the second service objects; When the degree of impact is between the first ratio and the preset second ratio, the assessment service team will conduct a psychological assessment on the patient's family members, and select the corresponding family members to be included in the second service objects based on the results of the psychological assessment of the family members; when the degree of impact does not exceed the second ratio, the medical staff who provide medical services to the patient will be pre-determined, and the medical staff will conduct a preliminary assessment of the psychological state of each family member of the patient, and based on the results of the preliminary assessment, one or more family members who may need the help of social workers will be determined, and the family members will be included in the second service objects.

5. The social work service method according to claim 1, characterized in that: Also includes: Obtaining basic information and past medical history information of the second service object, parsing the historical service data to find out whether there is a past social worker's evaluation of the family member, and parsing the past medical history information to determine the current health status of the second service object; Conducting a psychological assessment on the second service recipient by the assessment service team; The family assessment results are generated by integrating the psychological assessment results, previous social workers' evaluations and basic information.

6. The social work service method according to claim 2, characterized in that: When the first service recipient is in the diagnosis and initial adaptation stage, the basic skill requirements at least include understanding relevant disease knowledge, the ability to handle acute stress reactions, follow-up planning for the disease, and psychological status assessment; When the first service recipient is in the treatment and management stage, the basic skill requirements include at least coordination of medical services and intervention in acute complication crises; When the first service recipient is in the rehabilitation and recovery stage, the basic skills requirements at least include social integration and life skills training; When the first service recipient is in the maintenance and self-management stage, the basic skills requirements at least include long-term supervision management, self-management education, and regular assessment; When the first service recipient is in the advanced care and hospice stage, the basic skill requirements include at least palliative care, bereavement counseling, legal and financial planning.

7. The social work service method according to claim 1, characterized in that: Select multiple social workers to form a social worker group to provide social work services to the first service object and / or the second service object, the skill labels of the social workers in each social worker group are complementary to meet the first demand and / or the second demand, and the social workers in each social worker group can serve one or more first service objects or second service objects at the same time; A service object group is constructed according to the first service object or the second service object served by each social worker in the social worker group, and the social worker services in the service object group are deployed according to the schedule of each social worker.

8. The social work service method according to claim 2, characterized in that: By analyzing the historical service data to determine the historical tags, the social worker's past service evaluation of the first service object is searched, and the service precautions are parsed from the service evaluation; the social worker service stage of the patient during the past social worker service is determined, and the skill tags associated with the social worker service stage at that time in the historical tags are analyzed to obtain the first tag; the first tag in the historical tags is excluded to obtain the social worker service stage requirements; the requirements corresponding to the service precautions are analyzed to obtain the precaution requirements; the basic skill requirements currently required are determined according to the disease interval and the current social worker service stage, and the corresponding exclusive skill requirements are determined according to the long-term disease; The first requirement is obtained by comprehensively considering the social work service stage requirements, the precaution requirements, the basic skill requirements and the exclusive skill requirements.

9. A social work service system based on long-term diseases, characterized in that: include: The first evaluation unit is used to determine patients with long-term diseases in a preset medical institution and their case data, determine the disease interval corresponding to the patient and the evaluation service team corresponding to the disease interval according to the case data; and perform pathological and psychological evaluations on the patient through the evaluation service team; The second assessment unit is used to include a patient in the first service object and conduct an economic assessment on the patient when the pathological assessment and / or psychological assessment results of the patient indicate that social work services are needed; and to analyze the influence of economic factors on the pathological assessment and / or psychological assessment results of the first service object according to the economic assessment results; A family assessment unit is used to determine whether to include the family members into the second service object in need of social work services based on the degree of impact and the medical staff's assessment of the family members' status, and to conduct a psychological assessment on the second service object through the assessment service team, and obtain a family assessment result based on the psychological assessment result; A historical data unit, used to obtain historical service data of the first service object served by past social workers, determine the illness time and treatment status of the first service object by parsing the case data, and determine the skill label of the past social worker by parsing the historical service data to obtain a historical label; A demand generation unit is used to determine the current social work service stage of the first service object based on the illness time and treatment situation, wherein the social work service stages include diagnosis and initial adaptation stage, treatment and management stage, rehabilitation and recovery stage, maintenance and self-management stage, and late-stage care and hospice care stage; generate a first demand for social workers based on the disease interval, historical label, and social work service stage, and generate a second demand for social workers based on the family assessment result; The social worker matching unit is used to find one or more social workers who meet the preset conditions to provide social work services to the first service object and / or the second service object according to the first demand, the second demand and the schedules and skill tags of each social worker pre-stored in the database.

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