Objective To analyze the key issues of county⁃level medical communities reform in the real world, and to explore the corresponding solutions. Methods (1) Quantitative research: a typical sampling method was adopted to select one county⁃level medical community from each of the cities of Nanning, Guilin, and Liuzhou in Guangxi Zhuang Autonomous Region. A self⁃developed questionnaire was employed to investigate the construction status of county⁃level medical communities in 2023. (2) Qualitative research: a stratified purposive sampling method was used to select a total of 57 participants, including health administration managers from the autonomous region and various counties, heads of leading hospitals and member hospitals of county⁃level medical communities, and medical personnel from leading hospitals. Focus group interviews were conducted, and the interview content was evaluated using the grounded theory analysis. (3) Identification of key issues: a mixed method combined with relevant literature and typical survey data was adopted to identify the key issues of county⁃level medical communities reform. Results (1) Quantitative research results: in terms of resource investment, the average number of general practitioners per 10 000 population in the county⁃level medical communities of Shanglin County, Pingle County, and Luzhai County was 3.33. In terms of hierarchical diagnosis system, the average proportion of patients transferred downward by the leading hospitals was 0.09%. In terms of service capacity, the average county⁃level medical attendance rate was 83.43%. (2) Qualitative research results: a total of 101 open codes were generated from the interview content, which were then consolidated into 15 axial codes and 4 core categories (hierarchical diagnosis system, service capacity, management mode, and resource investment). (3) Mixed⁃method research results: 4 key issues were ultimately identified, namely how to improve internal governance, how to identify support for primary healthcare personnel and information technology, how to improve two⁃way referral mechanism, and how to improve primary medical technology level. Conclusion The effect of county⁃level medical communities reform is affected by hierarchical diagnosis, service capacity, management mode, and resource investment. In order to ensure substantial progress on county⁃level medical communities reform, county⁃level medical communities should further promote the reform practice in building a benefit sharing mechanism, optimizing pharmaceutical management, two⁃way referral supervision mechanism, information integration and talent integration in the future.

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