Objectives: The purpose of this action research was to design, implement, and evaluate preliminary outcomes of a community-based care management model for long-term care. Methods: Chia-Yi City and San-Shia /Ing-Ger area of Taipei county were selected as a samples of the urban and rural community respectively. Care managers were recruited and trained while the experimental community centers were established in these two communities. The first outcome indicator was the number of suggested services and the number of actual services that care managers linked indicating implementation of care management. The second indicator was the major topics discussed in interdisciplinary case conferences indicating the extent of congruence between the focus of training and the expected role of care managers. Results: The services of care management were successfully delivered. A total of 1511 community-based services were suggested to the potential users by the care managers with only 482 service suggestions being accepted. The service utilization rate was 31.9%. The 2 most discussed topics during case conferences were the assessment and coordination, and the linkage of services that were consistent with the role of care managers. Conclusions: For this action research, a care management model that integrated health and social services was established. The low acceptance of community-based services needs to be further explored.