Health problems for which individuals, families, and communities are at risk are exacerbated in sparsely populated, geographically remote, rural areas. Vast distances limit access to essential health services. The University of North Dakota Nursing Center's paradigm of population-specific, family-focused, community- based services directed toward primary prevention and care during chronic illness is proposed as an effective perspective for rural health care delivery. Based fundamentally on an agricultural metaphor, the center is grounded in an ecologic understanding of the health and illness experiences of vulnerable rural populations, with a primary emphasis on nursing case management for improved care in a system of managed cooperation. Sources of reimbursement for services are varied, including grants, contracts, and fees. Evaluation focuses on outcomes of individuals, families, and communities to ensure that services are responsive to meeting health needs of vulnerable rural populations.