Identifying social determinants and mapping organisational and personal networks to enhance community support for people living with multimorbidity

Socially and economically deprived populations experience greater risk and earlier onset of multimorbidity. Healthcare services are one part of complex networks supporting people with chronic conditions. but knowledge of people’s social networks has not been used to inform and tailor chronic disease policy and programmes. Intersectoral links between primary care and non-clinical community services (CSS) which can support chronic disease management are not always well-developed. Onward referral to these types of services, needs to begin with identification of vulnerable patients using social risk (SR) screening. However, it is unclear how to optimally implement SR screening in general practice. 

The proposed project will develop actionable evidence to enhance support for people with multimorbidity living in disadvantaged communities using a case study approach focused on two Community Health Networks (CHNs) in Ireland. Social network studies will: explore the role played by networks in self-management among people with multimorbidity eligible to attend the Chronic Disease Management (CDM) Programme in general practices, and; understand networks between general practices and non-clinical community support services. A mixed method evaluation will determine the acceptability and feasibility of implementing SR screening in general practice during CDM consultations. Study findings will be synthesised to inform a stakeholder consensus process to develop recommendations to enhance community support for people living with multimorbidity. 

The findings will have immediate, local impact, by guiding network-building activities between CSS and general practices and informing how providers within CHNs work with people with multimorbidity.  Recommendations will be informed by the experiences of multiple stakeholders (people with multimorbidity, healthcare professionals and managers, voluntary/community sector representatives) and guided by an interdisciplinary and inter-sectoral research team. This project will address national priorities to build health and social care services at a community level and meet the needs of local populations, targeting those most in need of support. 

Award Date
22 September 2023
Award Value
Principal Investigator
Dr Fiona Riordan
Host Institution
University College Cork
HRB Postdoctoral Fellowships: ARPP 2023