The unbalanced and inadequate conflicts in the field of health care are prominent, and the dilemma of the mismatch between supply and demand of health services needs to be broken through from the system design. An analytical framework for an integrated health care service system is constructed to systematically respond to the shortcomings of the existing system based on the panoramic evolution of residents’ health demand in the aspects of subject, content and mode in the new era. Combining the characteristics of the evolution of health needs, it proposes a strategy for system optimization: clarifying the service chain and constructing a content integration path that combines “point, line, surface and body”; creating a horizontal multi-participant governance model based on the triple direction of “subject-structure-function”; bringing into play the driving force of governance elements and promoting the deeper development of the service approach, providing internal impetus and external force to promote the optimization of an integrated healthcare service system.