随着社会工作的发展和人们对医疗服务的需求逐渐扩大，医务社会工作作为一门新兴职业走进了大众的视野。作为社会工作的发源地，英美等西方国家的医务社会工作已形成了一套成熟的发展模式，而对于医务社会工作还处于探索阶段的我国，研究其在英美的服务模式在实践层面具有十分重要的意义。 本文以医务社工如何利用以个案管理服务的方法介入终末期肾脏病患者为研究主题，以美国加州洛杉矶R市R透析中心为例，通过半结构访谈和参与式观察收集资料，描述笔者作为医务社工实习生的身份接触到的实际案例，进行质性研究。本文首先对R机构以及医务社工的服务进行概况介绍，描述终末期肾脏病患者面临的具体困境及需求，接着通过医务社会工作的工作方法的描述，利用案例呈现了医务社工如何从“生理-心理-社会”三个方面对患者进行介入，展现了医务社工是如何评估患者需求，根据患者的具体问题提供相应的干预措施并解决患者的具体问题达到提升其生活质量的目的的，以医务社工实习生的视角提供了个案管理服务模式的全景图。 通过总结经验，结合评估结果的变化以及观察感受到患者的状态，以及患者干预前后的对比，本研究得出了利用个案管理服务的医务社会工作能够对终末期肾脏病患者的生理、心理、社会三方面的状态起到积极作用，提升其生活质量的结论，即医务社会工作在对改善患者对疾病的认知以及增强其改变的动机，从而维持生理状态的稳定方面起到了积极的作用；在心理方面帮助患者缓解了陌生与不适应感的同时减缓了孤独与无助感；为患者提供了其与所需资源之间的链接，从而拓展了其社会支持网络。最后，结合我国实际，讨论了我国现阶段医务社工发展现状，并从不同层面为我国的医务社会工作提出相关建议，展望未来。

With the development of social work and the increasing demand for medical services, medical social work has entered the public's field of vision as an emerging profession. As the birthplace of social work, the medical social work in the western countries, such as America, has developed a mature model. For the country where the medical social work is still in the developmental stage like us, it is very important to study its service model at the practical level. This article examines how medical social workers use the method of case management services to intervene in patients with end-stage renal disease. Taking the R dialysis center in the United States as an example, qualitative research methods are used to describe the author's identity as a medical social worker intern through case study. This paper first gives an overview of the services of the R center and the job contents of medical social workers, then presents the specific problems and needs faced by patients with end-stage renal disease through the case, followed by the description of the working methods of medical social work, from the "Biological-Psychological-Social" aspect. This aspect presents how the medical social workers achieve the purpose of improving their quality of life by assessing their needs, providing appropriate interventions based on the specific problems. Through comparing the conditions before and after the intervention, it is concluded that the medical social work with case management service can play a positive role in improving ESRD patients’ quality of life. Finally, combined with the reality of China, author put forward relevant suggestions for developing medical social work in China from different levels.