本社區創立於2004 年，是國內第一家核定及最大的老人住宅，整體規劃以高齡者為中心的全人照護為理念，以達到「活的好、老的慢、病的輕、平安終」的晚年生活為服務目標。然而隨著人口高齡化，長照需求與負擔也隨之遽增，近年我國政府推展多元的長期照顧服務資源，但經現況分析發現本老人住宅中因老化退化有長期照顧服務需求者有103 人佔14.5%，但是申請政府長期照顧資源使用率卻為0%，主因為社區內的長期照顧資源轉介制度不完整、健康管理師轉介長期照顧資源執行率低、及社區老人不知道政府長期照顧資源的內容等。因此，本專案旨在提升社區老人長期照顧資源使用率由0% 增進到33%。依據現況分析及文獻查證，擬定解決辦法：修訂長期照顧資源轉介作業、建置長期照顧資源運用指引本、舉辦長照資源教育訓練及多元宣導策略。經由實施改善對策後社區老人長期照顧資源使用率由0% 提升至37.6%。本專案透過社區轉介制度的建立與政府長照資源連結，提升健康管理師對長照資源認知，並主動提供轉介服務，有效的提升社區老人對長期照顧資源使用，確保其獲得適切的持續性照顧服務，亦可提供長照政策規劃與服務推動之參考。

Established in 2004, this community was the first approved and largest residential building for elderly in Taiwan. Our philosophy of overall design and plan is based on the holistic and person-centered care for the elderly in order to achieve the service goal of sunset years of the elderly with "living well, slowing down aging, and reducing sick level". However as population is aging, the long-term care needs and burdens also increase. We found that 103 residents (14.5%) of this elderly residence needed long-term care service due to age-related degeneration. However, the utilization rate of government-funded long-term care resources in this community was 0%. The main causes were the incomplete long-term care referral system, inadequate referral among health managers, and unaware of the long-term care resources among elderly residents. Therefore, the purpose of the project aimed to increase the long-term care resource utilization rate of the elderly in the community from 0% to 33%. Based on current status analysis and literature review, we created strategies, including revising the long-term care referral practice, establishing an instruction booklet for long-term care resources application, holding a training program to introduce long-term care resource, and introducing a multiple propaganda. The utilization rate increased from 0% to 37.6% after implementing these improving strategies. This project enhanced the health managers’ knowledge about long-term care resources, actively provided referral service, effectively enhanced the utilization rate of long-term care resources in this community. Further efforts also ensured continued care services. The article provides a reference for policy planning, recommending service promotion through linkage between the community referral system and the government-funded long-term care service program.