由於長期照護資源管理示範中心的積極推動，致使許多處於社會陰暗角落的弱勢族群之問題開始獲得關注。本個案管理對象為一問題複雜且多元，包括失能、失智且缺乏家庭支持系統，加上主要照顧者的心智功能障礙，導致許多照顧技巧無法提昇及溝通上的困難，亦由於缺乏一技之長，而無主要經濟來源，因此使得個案管理顯得格外艱辛。在個案照顧相關方面呈現疾病未獲適當照護、營養攝取少於身體所需之問題需求；在案女能力相關方面出現生活照顧需求缺損、持家能力障礙、缺乏應付能力及基本就業能力不足等問題需求；案家問題相關方面呈現經濟能力無法支持基本生活所需及永續性照顧障礙。同時，在個案管理期間也面臨政府政策的挑戰，包括醫療、社會、經濟等層面，須仰賴專業團隊及各種資源的介入服務，因此，透過個案管理人員的連結資源，介入專業團隊的外展服務，使長期照護的各相關專業人員得以發揮所長，使案主得到多元化的服務，順利取得相關的福利資源，達到個案管理的目標。

　　　　　In recent years, social welfare has been provided in the community and ongoing long-term care service has been advocated. As a result, more attention has been focused on disadvantaged groups in society. In this study, the problems of interaction between the subject and the major caregiver were complex. For example, one of the problems was that the psycho-mental functional disabilities of the major caregiver resulted in difficulty in the application of care skills and communication. Another problem was that the major caregiver was unemployed, which increased the difficulty of case management. At the same time, it was challenged by government policy and by medical ethics and social and economic factors. It was more important to provide interaction of the disciplinary team and various resources. That is, by way of case manager interaction, related disciplines can provide valuable knowledge and service in long-term care. Otherwise, the case may get multiple professional services and the qualification of related benefit for his needs. Furthermore, the life quality ofthe case will be improved in the future.