The Impact of Barriers on the Continuum of Care

::written circa. Fall 2013.

Spanning the course of a lifetime, the continuum of care, in the United States, has evolved into a strategic and organized system that strives to deliver high quality care.  Barton, illustrates the continuum of health care services as a timeline, which begins with prenatal care and ends with palliative care.  Prenatal care attempts to use the knowledge of contemporary medicine, to aid in the development of a healthy and safe childbirth (Barton, 2010).  On the other side of the spectrum, palliative care stresses efforts in comforting the pain and suffering of those in end-to-life situations (Barton, 2010).

Throughout the course of care, major emphasis is placed on primary, secondary, and tertiary disease prevention.  However, all points on the continuum of care timeline share equal importance.  Primary prevention focuses on averting the possibility of initially acquiring a disease or injury in completely healthy individuals.  Simple examples of primary prevention would include (1) implementing the practice of frequent hand washing techniques to avoid contamination and (2) up-to-date administration of vaccination shots.  Secondary prevention concentrates on “detecting” and “controlling” diseases as early as possible (Barton, 2010).  The utilization of medical equipment such as sphygmomanometers, mammograms, and magnetic resonance imaging machines (MRIs) are all examples of technological resources used in the detection of diseases.  Lastly, by using a course of therapeutic aids such as antibiotics or chemotactic medications, tertiary prevention centers on mediating the escalation of pre-diagnosed conditions.

According to the Patient Centered Medical Home (PCMH) model, primary healthcare services function as the “first-to-contact,” gateway to the continuum of care (Fisher, Rittenhouse, & Shortell, 2009).  These primary care facilities are described as community-outpatient clinics or “relay powerhouses”, which aid in determining the cause of disease and course of care (Barton, 2010).  In general, for asymptomatic, adult patients prone Type II diabetes, the course of care typically begins with an initial visit to a primary care facility.  Upon entry, patients interact with administrative staff members to determine how health services will be delivered.  It is highly suggestive that the abundant number of parties involved in the payment transaction for healthcare services has caused the delivery system to become very complex (Barton, 2010).  After this initial step into the continuum of care, a medical assistant normally leads the patient to obtain miscellaneous measurements and recordings, which follow the procedure for secondary disease prevention.  According to the American Diabetes Association (2013), body mass index (BMI), blood & urine samples, and hemoglobin A1C readings are all essential tools in the diagnosis of Type II diabetes.  In closing of the visit, the physician comprehensively intervenes with a suggested course of action.  Depending on the severity of the disease, the physician may suggest preventative diet and exercise regiments to mediate the course of symptoms, prescribe indirect care from pharmaceuticals, or refer the patient to a more specialized physician.  Unfortunately, however, many factors can impede this initial primary care procedure.  Thus, inhibiting the accessibility to the continuum of care.

Among the many different factors, relative geographical location and cultural barriers can both serve to hinder the quality of care, throughout the course of the continuum.  According to Guagliardo (2004), the 1967 Report of the National Advisory Commission on Health Manpower noted a bias in the geographical distribution of healthcare professionals and facilities, due to “pre-existing preferences.”  And as a result, showing a significant demand and hindrance on the accessibility of healthcare in rural areas.  Ambulatory care is emphasized as a significant indicator of the quality of care, attributing to the differences in travel time.  Furthermore, studies in U.S. metropolitan areas shown to have an inverse relationship between the high physician supply and mortality rates (Guagliardo, 2004).  Similarly, cultural differences also place a substantial barrier on the quality of delivery in the continuum of care.  According to Clarridge et al. (2003) discrepancies can be made between the patient and physician within “quality domains”, throughout the basis of the communicative relationship.  Quality domains relate to the expressive needs of patients in association with (1) beliefs & practices, (2) interpretations & perceptions, (3) availability of social support services, (4) information & education and (5) continuity & transition (Clarridge et al., 2003).  All of which raise essential questions relating to the continuum of care.  Do patient’s beliefs and values contradict the course of care?  Will the directions for medications need to be in a native language? How should follow-up referrals be organized?




Barton, P.L. (2010). Understanding the u.s. health services system (4th Ed.) Chicago, IL. Health Administrative Press

Fisher, E.S., Rittenhouse, D.R., & Shortell, S. (2009). Primary care and accountable care- two essential elements of delivery-reform. The New England Journal of Medicine. 361(24) 2301-2303

American Diabetes Association. (2013). Standards of medical care in diabetes- 2013. Diabetes Care. 11, 11-65 

Guagliardo, M.F. (2004). Spatial accessibility of primary care: concepts, methods, and challenges. International Journal of Health Geographics. 3(3)

Clarridge, B.R., Davis, R.B., Iezzoni, L.I., Manocchia, M., Massagli, M., Ngo-Metzger, Q., & Phillips, R. (2003). Linguistics and cultural barriers to care: perspectives of chinese and ietnamese immigrants. Journal of General Internal Medicine. 18 (44-52).

Author: nursesarereal

My nursing professor once said that keeping a journal, over time, will allow me to see growth. In myself? I’m not sure yet. I’m hoping. I like to believe that nursing school saved my life. Maybe I’ll have some fun doing this. Cheers.

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