The divisions of Administrative Affairs, Information Technology, Education and Training, and Care Coordination of RMC work together to execute eight strategies of NTUH healthcare networks. The eight strategies include: launching P-STARs conferences seasonally, monitoring the quality indicators of medical referrals, building an integrated platform for P-STARs healthcare network organizations on the website, communicating among physicians and teams, establishing case management for those at the end of life and those had high medical utilization, Setting up integrated care clinic for patients with multiple co-morbidities, creating mobile APP for referring or seeing doctors, promoting “Choosing Wisely” Campaign to patients and professionals. We aim to improve the quality of transition care and integrated care in the P-STARs program.