Many Persons with Disability (PWD) living in the community eagerly tackle challenges raised from the postmorbid impairment in health and functioning, and thus to enhance the quality of life. The YANG Memorial Methodist Social Service Kownloon (1) Regional Home Care Service (KHCS) builds on the clinical wisdom from the implementation of International Classification of Functioning, Disability, and Health (ICF) in enhancing rehabilitation progress and facilitating PWD’s participation. By adopting an evidence-based approach, the project aligned with experts and scholars to formulate a localized ICF core set for community living stroke people. The goal is to improve the quality of life for PWD and promote participatory community living. The project's achievements have also attracted friendly invitations from social service, academia, and the technology sector for exchanges, which contribute continuously to the development of rehabilitation services.