The article reports the process, contents and strategies in the development of community based-heath care management program for high-risk infants and family, which was based on literature review, empirical needs assessment from pilot study. The program was divided into two emphasis areas: (1) identification and home visiting nursing care program, and (2) the construction of self-supporting group. The contents of home visiting nursing care were developed from the pilot study of the direct home visiting to premature infants after discharge. The documentation form for home care was standardized, including the demographic data, birth history, home care services, education and counsels, and visiting schedules. The integrated education protocol was elaborated to enhance the body of knowledge as well as clinical competency in caring high-risk infants and family by the supports of neonatologists, nursing scholar, and clinical specialists. In addition, the process and strategies in developing self-supporting group, consisting the high-risk infants and family, and any significant others were addressed. Emphases were given to the role of public health center and the recycling health care referral system to maximize the growth and development of high-risk infants on the community-base, which in turn, contributing to decrease the postneonatal mortality rate.