Yilan residents with chronic disease/HTN-DM-HL risks
Partner primary care clinics & community hospitals
Community-site participants and caregivers
Lotung Poh-Ai Hospital leads a regional-to-primary tiered co-care network in Yilan, linking partner clinics and community sites through a patient-centered model. With a bidirectional referral information platform, quarterly symposiums, and a real-time LINE consultation group, the program streamlines referrals, introduces a ‘green channel’ for key tests, and supports risk-stratified chronic care. Performance is monitored via KPI dashboards and PDCA cycles to deliver a replicable, scalable model for continuity of care and healthy aging.
146-clinic alliance covering all 12 townships
100% adoption of a bidirectional referral platform
Green channel, co-attending model, and PDCA-driven KPI management
146 partner clinics (78% coverage)
18 community service sites
2024: 285 activities / 12,709 visits
2024 referral-out rate >50% (national avg 11%)
2024 return-referral rate 52.7%
2018→2024 referrals-out +420%
Monthly performance reports reviewed by leadership
Abnormal-case reporting & complaint RCA tracking
Digitalized workflow reduces referral omissions
Patients: 88% / 89.4% / 88.67% (2022–2024)
Community: 99% / 91% / 95%
Partner clinics: 94.9% / 95% / 96.4%
Primarily disseminated as a national benchmark
No formal international certification/guideline inclusion yet
Ongoing evidence generation and dissemination
Improves continuity of chronic care and access
Enables hospitals to focus on complex care while clinics follow stable cases
Establishes a replicable benchmark for tiered co-care
