Students identified with disabilities are increasingly being educated with the assistance of support services within heterogeneous (i.e., general education) classrooms (United States Department of Education, 2011). Yet, in this era of high stakes accountability, students are labeled, sorted, and differentially treated according to their academic achievement as reflected on standardized tests. We engaged in a project to better understand how educators grapple with these externally imposed pressures as they work to change the organizational structure of their schools to be able to implement greater inclusion of their students served by special education. We spent four years in two elementary schools engaged in inclusive school reform (shifting from exclusionary model to an inclusive one) specifically as a response to the pressures of test-based accountability mandates. Our work was guided by the following questions. In this era of high-stakes testing accountability: (1) What does school-wide inclusive reform for students with disabilities involve?; (2) What kinds of changes can result from inclusive reform?; and (3) What role does leadership play in inclusive reform? The chapter focuses on what inclusive reform involved, the resulting changes, and the role distributed leadership played in moving toward more inclusive service in the age of high-stakes accountability.