• 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