care provided by the pcmhs and ensure and incentivize communications between teams of providers that operate in various settings. acos can facilitate transitions and align the resources needed to meet the clinical and coordinated care needs of the population. they can develop and support systems for the coordination of care of patients in non-ambulatory care settings. furthermore, they can monitor health information systems and the timeliness and completeness of information transactions between primary care physicians and specialists. the tracking of this information can be used to incentivize higher levels of responsiveness and collaborations.