Accountable Care Organizations (ACOs) are a promising new model for payment reform in the complex and fragmented health care system in the United States. Nursing vision and leadership are essential for the success of an organization participating in an ACO. By understanding the political, financial, and cultural facilitators and barriers to change, as well as models for helping organizations transition toward change (e.g., Kotter Model of Change Management), nurses have the potential to be leaders in health care change.