This paper describes a systematic, coordinated approach to the delivery of health and social services to the rural elderly of Maine provided by the Kennebec Valley Regional Health Agency. Four points of the model are described which distinguish it from other models of coordination: (1) a strong medical orientation in the assessment process; (2) involvement of rural, primary health care centers as part of a service team; (3) location of rural coordinators in medically underserved areas; and (4) the provision of client, consumer and provider education. These four points illustrate how the provision of services to the rural elderly can be enhanced through primary care centers. The implementation of the model is also described, and the role of the agency in preventing or delaying unnecessary institutionalization is discussed both as a measure of cost effectiveness and as improving the quality of life and emotional well being of the rural elderly. (JAC)