tals, Medicare-dependent hospitals, and, in 1997, critical access hospitals. More recently, the Medicare Prescription Drug Improvement and Modernization Act of 2003 introduced a more favorable financial climate for rural hospitals.

Partly in response to these changes, there has been a renaissance in rural health care in a number of rural communities. Some rural hospitals are replacing aging facilities (Gregg et al., 2002; Howe and Bavery, 1999; Rees, 2002). There are also examples of hospitals, physicians, and other health care providers building regional networks that are giving rural residents greater access to state-of-the art health care (Gregg and Moscovice, 2003; Minyard et al., 2003; Nebraska Office of Rural Health, 2002; Novack, 2003; Rosenthal et al., 1997; User Liaison Program, 1997). In addition, some rural health care providers and communities are embarking on significant quality improvement initiatives in response to the national quality movement (see Chapter 3). But these changes have not been enough. They are not widespread, and they are occurring too slowly. Many rural communities continue to struggle to sustain viable health care delivery systems (see Appendix C). In recent years, it has also become apparent that rural communities confront serious quality of care challenges as well.

In the above context and given the increased interest in the quality of health care in rural America, the Health Resources and Services Administration (HRSA), the Agency for Healthcare Research and Quality (AHRQ), and the Substance Abuse and Mental Health Services Administration (SAMHSA) of the Department of Health and Human Services (DHHS), together with the W. K. Kellogg Foundation, requested that the Institute of Medicine (IOM) undertake an independent, unbiased assessment of the condition of health and health care in rural America, and formulate an action plan for quality-focused rural community health systems. The charge to the committee included the following specific tasks:

• Assess the quality of health care in rural areas;

• Develop a conceptual framework for a core set of services and the essential infrastructure necessary to deliver those services to rural communities;

• Recommend priority objectives, and identify the changes in policies and programs needed to accomplish those objectives, including, but not