This policy brief shares insights gained from site visits in 2013 to four Accountable Care Organizations (ACOs) serving rural Medicare beneficiaries. Initial strategic decisions made and challenges faced as the ACOs were being developed can inform development of other rural ACOs. Key Findings. (1) The rural ACOs we studied were formed as a step toward a value-driven rural delivery system, recognizing that ACO participation may or may not have a short term return on investment. (2) Common rural ACO strategies to increase health care value include care management, post-acute care redesign, medication management, and end-of-life care planning. (3) Access to data is an important enabler of population health management, care management, and provider participation.