The elderly population account for 10.65% of the total population in Taiwan (Ministry of the Interior in Taiwan, 2009). The increasing number of older people could be seen as a triumph for modern living standards, but this can cause new problems which will become a focal point for both the public sector and non-profit welfare agencies. Also, some of the organizations are not able to commit themselves to community care services and can not coordinate with others. Therefore, collaboration in the provision of community care services in Taiwan has become an important issue. This case study took one welfare agency in a rural mountain area where most of the clients are indigenous older people. Three major home outreach services for the elderly are provided, including homecare service, meals-on-wheels and emergency notifyication service, as an example to explore the perspectives on care services from different professionals and members of staff and the situations of working together. The opinions on improving the current situations these service providers face in the delivery of care services for older people and the essential elements for working together are the important section to research. This research found that some factors influenced the understanding and interation among members of staff positivly, including workspace arrangement, support by joint meetings and supervision, informal interaction, and acquiring skills and knoweldge by training. However, heavy job load and conflicts among some staff impacted on their coordination and service delivery. The service providers also paid attention on the needs of older people casued by the limitations of geography and transportation.Thus, when addressing community care policy and understanding that professions from different fields are all important for older people, the essential implication is to educate these related professionals together so that they understand each other as early as possible in their professional training. It is essential to consider cultural issues and the geography of communities that served. 台灣老年人口已佔總人口數的百分之十點六五（內政部，2009）。日益增加的老年人口可視為現代生活的傲人成果，但老年人口帶來的新問題則成為政府部門和非營利組織共同關心的焦點，而這些服務提供者亦難以承擔社區照顧服務之責或與其他相關組織協調合作，故協調合作成為台灣社區照顧的一個重要議題。本文以某一位於提供外展居家支持服務、位於台灣東部且多數個案為原住民長者（包括居家服務、老人送餐、緊急救援系統）之社福機構為個案研究對象，探討此機構內不同專業的工作人員、機構與外部社區相關組織之間協調合作之狀況，研究重點亦包含工作人員對於改善當前所面臨的問題之建議與增強合作協調的基本要素。 透過個案研討、聯繫會報、與非正式的互動關係，團隊成員於服務輸送時可更深入瞭解並運用各專業領域的角色與功能，服務輸送亦需考慮到地理環境的限制，以及因為限制導致長者的特殊需求。在重視老人社區照顧政策與認同不同專業領域的服務提供者的重要性時，宜儘早讓來自不同專業領域的服務提供者共同接受專業訓練課程以瞭解在社區服務輸送時彼此的角色與功能。
