This document describes services for the elderly provided by the Spokane Community Mental Health Center (CMHC) in Spokane, Washington. It begins by stating several reasons that the elderly are often unserved or underserved by health and social service agencies and by noting the need for community efforts to identify and locate the subpopulation of isolated, resistant, high-risk elderly persons who are living in their own homes and who do not self-refer for community services. Characteristics of the 538 elderly persons served by the Spokane CMHC multidisciplinary in-home evaluation, treatment, and case management program in 1986 are presented; demographic and clinical data on the chronically mentally ill elderly served are included. Other sections describe program structure and funding; telephone information and referral services; the multidisciplinary in-home evaluation, treatment, and case management program; location of high-risk elderly; in-home assessment and evaluation; treatment and service plans; the program's relationship with other agencies; and program results. Thirteen references and five data tables are included. (NB)