Long-term services and supports (LTSS) include both medical and social support services provided to enable individuals to live as independently as possible. Focusing on the population of older LTSS users (i.e., age 65+), this paper reviews the fundamentals of the rural LTSS system, examines rural access to and use of LTSS, and discusses opportunities and limitations of current Federal and State LTSS policy for advancing rural health system transformation toward a high-performing rural health delivery system. Ideally, primary care, acute care, post-acute care, and LTSS form a continuum of coordinated services designed to meet individuals' needs based on their level of clinical, social, behavioral, or other chronic care needs and preferences. In reality, these services tend to be fragmented, with only weak coordinating connections. The effects of fragmentation are exacerbated in rural areas, where the availability of, and access to, LTSS is more limited. The growing population of older adults in rural areas, combined with the more limited capacity of rural LTSS systems, suggests the need for targeted initiatives, including expanded community-based service options, enhanced workforce capacity, and improved care coordination.