This IOM committee concurs with earlier IOM committees that fundamental change in the health care delivery system is needed to improve the quality of care and ultimately the health status of the population. But this will not be enough. Although access to high-quality personal health care services (e.g., preventive, acute, chronic, and end-of-life care) increases health and reduces pain and suffering, there are other determinants of health status in a community. Health outcomes are determined to a great extent by genetic predispositions, health behaviors, environmental exposures or threats, and social circumstances (e.g., educational levels, socioeconomic status) (LaLonde, 1975; McGinnis et al., 2002).

Moreover, a growing body of research demonstrates the importance of considering these factors within a community context (Hillemeier et al., 2003). There is much variability across communities in terms of population health needs. Communities also have different strengths and resources to bring to bear in addressing population health needs. Lastly, addressing population health needs often requires strong local leadership and collaboration across different sectors and multiple stakeholders within a community.

This chapter presents an integrated approach to addressing both personal health care and population health needs that builds on the six quality aims of the Quality Chasm report. The approach is intended to be most useful at the community level in facilitating prioritization of a community’s health needs and identification of the most promising interventions. The first section reviews the rather limited amount of literature that is available on the quality of rural health care. The second section addresses population health priorities in rural areas, with emphasis on the unique aspects of rural communities that should be considered in shaping a reform strategy. The third section proposes an integrated framework for addressing both personal health care and population health needs in rural communities, providing examples of interventions at both the community and individual levels that might contribute to improved population health. The fourth and final section summarizes the IOM committee’s conclusions and recommendations for moving forward.


As noted above, there is a large body of evidence documenting serious shortcomings in the American health care system for each of the six quality aims identified in the Quality Chasm report. In 2000, the IOM published the report To Err Is Human: Building a Safer Health System, calling national

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