Primary care provided in rural areas is different from primary care provided in urban locations. Different approaches are needed to build and sustain a high performance rural health care system. The high performance rural primary care system uses a coordinated, person-centered, and team-based approach that integrates behavioral, social, and community services, including inpatient services when indicated, and is supported by value-based payments and care coordination. To build and sustain a high performance rural primary care system, an adequate supply of primary care health professionals that serve distinctive, multifaceted roles is needed. To achieve this high performance system, unique policy choices and opportunities must be considered that support the transition to a high performance rural primary care system and workforce. This paper reviews the essential elements of a robust rural primary care system, including development and maintenance of a high performance rural primary care system and workforce, as well as policy considerations and opportunities that address the sustainability of rural primary care.