This document discusses options for rural hospitals and providers to transition to accountable care models. It outlines the challenges rural providers face in existing Medicare Shared Savings Program (MSSP) ACO models due to their reliance on fee-for-service reimbursement and complex attribution models. As an alternative, the document proposes a Rural Clinically Integrated Network (RCIN) model that would allow independent rural providers to clinically integrate and collectively negotiate with payers while maintaining local decision making. Key functions of a RCIN would include promoting evidence-based medicine, facilitating care coordination across settings, and negotiating and managing value-based payer contracts.