This qualitative comparative case study identified factors that distinguish between high and low-performance on reading achievement in elementary rural Appalachian schools. This study determined the most effective instructional reading strategies, as well as other influential factors, implemented by school districts in the rural Appalachia area with similar student demographics and economic disadvantages. Data were collected through interview questions to assess the staffs' perceptions of their school's instructional program, leadership strategies, and teaching methods. Observations of classrooms during reading instruction also were conducted to identify instructional strategies being used. Results indicate high teacher morale, teacher efficacy, supportive leadership, meaningful professional development, and instructional strategies such as: explicit small group instruction, uninterrupted time spent on reading instruction, and inclusion of literacy centers are all variables that discriminate between these high and low performing schools.