Question: Comment 1: Prior to the passing of the Patient Protection and Affordable Care Act (PPACA) of 2010, the health care system was fragmented. There was no one single entity responsible for the overall coordination and quality of a patient's care. The PPACA provides many provisions that seek to connect the quality of care with the cost of care. It creates incentives for integrated care delivery models and pays for coordination and quality of care. One innovative care delivery model addressed in the PPACA is the accountable care organization (American Nurses Association [ANA], 2010).

An Accountable Care Organization (ACO) is a collaboration of primary care providers, a hospital, specialists, and other health care professionals that accept joint responsibility for the quality and cost of patient care. While ACOs are not new, the PPACA brought them to the forefront of new delivery models and provides the ACO with more leeway regarding who can lead them. This permits greater nursing leadership and participation. In fact, a key term in the PPACA is "ACO professional." The law defines the ACO professional as a physician "and" a nurse practitioner, clinical nurse specialist, or a physician assistant (ANA, 2010).

Comment 2: In the PCMH, the team would know and care for the patient in their home. This would require a consistent and timely team work between team members. The use of electronic medical records increase the teams timely response and care. Also included with electronic care systems is the ability to request a consult from another team member. The progress, charting, labs and other pertinent information would be made available to each team member at all times. It is also imperative that nurses and physicians be able to contact a specialty physician. Getting to know who is on your team and being able to contact the specialty is important. Relationships need to be built or reinforced in order to provide quality care. In the PCMH, the care is focused on medical care given in the home (Haas, S., 2010). Patient-Centered Primary Care Collaborative (PCPCC) published an Annual Review of Evidence 2014-2015, in which it examined the cost measures and utilization of services. It was reported that PCMH care costs were lower and the health care quality had improved (Gross, A., 2016). The report continued to state that "The evidence continues to build that a high performing, patient-centered medical home - especially when supported by multiple, committed and aligned payers - is the foundation for a better performing health care system". "...it [PCMH] can control costs and promote the right care" (Gross, A., 2016). The report continued to show evidence of improved health care, improved health for the client, decreased hospital admissions and emergency room visits. Overall, the quality of care was increased and costs decreased (Gross, A., 2016). Using a telehealth with the RN as the point of contact increases the clients confidence at being heard. Some places call this form as a telehealth buddy, where the RN can triage, educate and counsel the patient (Haas, S., 2010). Telehealth systems are in place to compliment the home visits by the RN and helps the client to feel as though the health care team is always available to them without the traveling or long waits for doctor's appointments.