This paper presents an approach to inclusive community care system with institutional welfare services and in-home welfare services based on variety of field work in community social work. It also discusses concerned topics in the area especially focusing on elderly care. In addition，the paper presents a context and an idea regarding multi-dimensional in-home welfare service in this transitional era，characterized with social welfare based on measures and welfare society based on decentralization. This is done by the context of long-term insurance and social welfare law.

It is necessary to reconstruct weakened family function，neighborhood network，and relative connection as supply resources in order to seek solutions for modernized welfare and elderly care. The local government and Japan National Council of Social Work are now responsible to promote program to strengthen informal support network such as family，neighbors，and community. Furthermore，this paper points out a condition to achieve in-home care and institutional care for elderly and people with disability. As a key to construct community care system with formal and informal supports through long-term insurance service and preventive welfare service，it is essential to train community social workers.