Greater Cishan rural residents and patients referred from partner health centers/clinics needing cancer screening follow-ups, chronic liver disease, GI, or other specialist care.
This program was established through collaboration between E-Da Hospital, community clinics, and public health centers in the Greater Cishan rural region of southern Taiwan. A patient-centered bidirectional referral model was developed to improve healthcare accessibility, continuity of care, and coordination between primary care providers and specialists. Key strategies include streamlined referral pathways, shared-care mechanisms, teleconsultation support, and transportation assistance for rural residents. The program serves patients requiring follow-up after positive cancer screening results, management of chronic liver diseases, gastrointestinal disorders, and other specialty care needs. Through close collaboration between the medical center and community-based healthcare providers, patients can access timely specialist services while stable cases are referred back to primary care for long-term follow-up and health management. Since its implementation, the referral network has expanded to multiple collaborating clinics and public health centers. The program has improved referral efficiency, reduced waiting times for specialist services, strengthened follow-up of screening-positive individuals, and promoted appropriate allocation of healthcare resources. This integrated care model demonstrates how hospital-community partnerships can bridge healthcare gaps and improve health equity in rural and underserved populations.
Established a bidirectional referral network linking a medical center, public health centers, and primary care clinics.
Integrated a transportation support system (“Community Shuttle Taxi”) to improve healthcare accessibility in rural areas.
Developed a One-Visit Colonoscopy Pathway to reduce waiting time and improve follow-up after positive FIT results.
Integrated cancer screening follow-up, chronic liver disease management, and specialist shared-care services into a scalable community-based healthcare model.
From 2020 to 2025, the program established a bidirectional referral network involving 7 public health centers and 17 primary care clinics. Through a shared-care model between the medical center and community providers, the number of patients referred back to collaborating clinics for follow-up care increased from 9 to 445, while the number of FIT-positive individuals referred for colonoscopy increased from 13 to 186. The model was also applied to a hepatitis C micro-elimination program in Liouguei District, where 1,879 residents were screened, 70 individuals were successfully referred, 35 received antiviral therapy, and 4 cases of hepatocellular carcinoma were identified. These results demonstrate the effectiveness of the bidirectional referral model in improving healthcare accessibility, continuity of care, and healthcare resource integration.
The program improved healthcare accessibility and quality of care in rural communities through a bidirectional referral and shared-care model. The number of FIT-positive individuals undergoing colonoscopy increased from 13 to 186. The one-visit colonoscopy pathway reduced waiting time (19vs.29 days) and improved the 30-day colonoscopy completion rate (71.0% vs. 53.3%). In addition, the colonoscopy follow-up rate among FIT-positive individuals increased from 0% at program initiation to 87.5% in 2025, demonstrating substantial improvement in the quality of cancer screening follow-up. For hepatitis C micro-elimination, 1,879 residents were screened, and screening coverage increased from 40% to 69.4%. Among individuals requiring referral, the referral success rate reached 88.6%, and the treatment uptake rate was 92.1%. A total of 35 patients received antiviral therapy, achieving a treatment success rate of 100%, and four cases of hepatocellular carcinoma were identified. Regarding bidirectional referral outcomes, the number of patients referred back to collaborating primary care clinics by the Division of Gastroenterology and Hepatology increased from 9 to 445. More than 95% of eligible patients were successfully referred back to community providers, establishing an effective shared-care model between the medical center and primary care clinics. This model enhanced continuity of care, improved healthcare accessibility, and promoted appropriate allocation of healthcare resources.
To ensure that referral outcomes are not lost to follow-up, several measures were implemented:
The referral-back form includes relevant examination and test reports, and patients are instructed to bring the form back to their primary care physician for follow-up.
Referral outcomes, particularly for complex or high-priority cases, are communicated through the referral network communication group to ensure timely information sharing among healthcare providers.
Participating primary care physicians regularly review referral-back information and clinical outcomes through Taiwan’s National Health Insurance Virtual Private Network (NHI VPN) system.
Collaborating healthcare institutions may apply for access to the E-Da Healthcare System Referral Information Platform, which allows authorized providers to track the medical status and healthcare utilization of patients referred to E-Da Healthcare System facilities.
When a critical result is identified (e.g., a malignant pathology report), the E-Da physician who receives the critical value notification proactively contacts the referring physician and confirms the patient’s subsequent management plan, including specialist appointments and follow-up arrangements.
96.6% of patients were willing to use the referral model again.
Patients expressed their appreciation and satisfaction with the program through the Hospital Superintendent’s mailbox.
Tai CM, Bair MJ, Chen TH, Tseng CH, Chen CC, Lam H, Yu ML. Collaborative Referral Model for Hepatitis C Screening and Treatment in a Remote Mountainous Region of Taiwan during the COVID-19 Pandemic..Viruses. 2023 Mar 24;15(4):827.
Association of a one-visit colonoscopy pathway with access to confirmatory colonoscopy after positive fecal immunochemical testing in a primary care–hospital referral network. Chen CC, Lam H, Tseng CH, Che TH, Tsa TC, Tai CM Archives of Public Health (revised)
Aligned with Taiwan’s national strategies for hepatitis C elimination and cancer screening follow-up.
Improved follow-up completion among FIT-positive individuals through a proactive patient-tracking model.
Reduced transportation and healthcare access barriers for residents in rural and underserved communities.
Strengthened the capacity of primary care physicians to participate in cancer screening follow-up and chronic liver disease management.
Established a bidirectional referral and shared-care model between a medical center and community-based healthcare providers.
Developed a scalable and replicable model for integrated healthcare delivery in rural areas.
Provides a framework for future expansion to hepatitis B management, colorectal polyp surveillance, and other chronic disease care programs.
