Abstract
<jats:p>The population ageing trend in the Russian Federation, as in all developed countries worldwide, is accompanied by an increasing prevalence of chronic non-communicable diseases. This creates a sustained need for long-term medical and medico-social support and requires organizational adaptation of the primary health care system. One of the promising directions is the development of integrated organizational models that ensure multidisciplinary support for patients at social risk. Purpose of the study was to scientifically substantiate and develop of an organizational and functional model of a medico-social care department operating within a medical organization providing primary health care. Materials and methods. The study employed organizational modeling focused on the needs of older age groups and patients at social risk in the context of population ageing. The methodological framework was based on systemic and structural-functional approaches to the analysis of primary health care organization. Results. An organizational and functional model of a medico-social care department operating within a medical organization providing primary health care was developed. The model includes a regulated management system (strategic, tactical, and operational levels), a target structure of specialized functional areas and a multidisciplinary team, as well as a mechanism for establishing a medico-social service area based on stratification of the attached population by levels of medico-social risk. This approach ensures a legally defined, targeted, and intensity-differentiated organization of medical follow-up for patients belonging to social risk groups. Findings. The proposed medico-social care department model serves as a tool for adapting primary health care to population ageing by integrating medical and social components of care for patients at social risk. The model aligns with strategic priorities of health system development and may be recommended for wider implementation provided that adequate infrastructure and human resources are available and intersectoral cooperation is well developed. Application of results. The study results may be used by executive authorities in the field of health protection and by medical organizations when implementing management decisions aimed at organizing medical and medico-social support for older age groups and patients at social risk.</jats:p>