Table 5 CMOc of core members
1. Community residents | |
 Context | Established women’s association. Anxiety regarding community health for aged people. Anxiety regarding weakening of human relations in the community. |
 Mechanism (intervention/resources) | Set up a community health study group creating a guidebook for community healthcare. Made a place to stay and communicate for community members. |
 Mechanism (reasoning)(Purpose) | Good timing due to the establishment of women’s association and working on solving local issues. Anxiety about super-aging society, from worry to practice. Anxiety stimulated efforts to deepen and spread connections with people. |
 Outcome | Many activities began: Communication among residents, recognition of community health, recognition of residents' role in community-integrated care, and helping with community medicine. Active interactions with people. |
2. Community nurses | |
 Context | Head nurse responsible for home care. Need quality improvement of home care. Participated in community-integrated care system. |
 Mechanism (intervention/resources) | Set up a study group. Made a vision and quality improvement for community nurses. |
 Mechanism (reasoning)(Purpose) | Occupational love by head nurse for colleagues and community members. Good opportunities for education. Community nursed received a good evaluation. |
 Outcome | Increase the number of nurses and home care patients. Became top-level home care nurse station in the prefecture. Improvement of the quality of care for patients. |
3. Doctor (program deputy manager) | |
 Context | Anxiety as a head doctor in a hospital due to a decreasing number of doctors. Community health challenges for patients and hospital stuffs. |
 Mechanism (intervention/resources) | Started a residency programme for GPs in the community hospital. Helping home care nurses. Participated in community-integrated care. |
 Mechanism (reasoning)(Purpose) | This programme began during a difficult time for the hospitals. Good motivation for the programme and efforts to improve the hospital’s quality of care and academic level. |
 Outcome | Increase in the number of doctors and nurses at the hospital. Improved quality of care for home care and community-integrated care. |
4. Administrative officers | |
 Context | Needed solutions for community issues. |
 Mechanism (intervention/resources) | Support from programme for public relations, reports, and distribution. |
 Mechanism (reasoning)(Purpose) | Support from programmes and mutual understanding among community members and medical professionals. |
 Outcome | Established horizontal connections among city hall departments. |