Transforming access, relational care, and primary health care in an urban Aboriginal and Torres Strait Islander population through patient-centred medical homes: a prospective cohort study using mixed methods

The intervention is the Institute for Urban Indigenous Health System of Care version 2 (ISoC2), a reformed model of primary health care implemented within Aboriginal and Torres Strait Islander community-controlled health services. ISoC2 represents a system-level redesign of care delivery grounded in Aboriginal ways of Respect (for clients’ stories), Connection (with clients and their families), and Kinship (ways of working together). It shifts care from episodic, provider-driven interactions to continuous, relationship-based, team-delivered care that is proactive, coordinated, and responsive to client and community needs. The intervention has been implemented at two community-controlled primary health care clinics in Southeast Queensland, Moreton Aboriginal and Torres Strait Islander Community Health Service (MATSICHS) and Kalwun Coomera Integrated Health and Wellbeing Hub. Care is delivered in clinic settings and, where appropriate, in community and home-based contexts by multidisciplinary primary health care teams as part of routine service delivery. Participants are not randomised; allocation is based on clinic of attendance, with matched comparison groups from non-intervention clinics. A core feature of ISoC2 is client enrolment (empanelment) into a multidisciplinary care team (“Pod”), a structural change designed to enhance continuity, accountability, and coordination of care. Enrolment is voluntary and occurs when clients engage with the service (e.g. self-presentation, referral, or existing clients). Each Pod includes a Reception/Admin staff member, an Aboriginal Health Worker (AHW), nurse, and general practitioner. Clients are empanelled within a Pod for the duration of their engagement with the service, with flexibility to move between Pods if requested. Initial and ongoing care includes the standard wholistic assessment of physical health, wellbeing (including social, emotional, cultural, and practical dimensions) and identification of client priorities, including acute and chronic care needs, preventive health, and client identified goals. Care pathways are dynamic and individualised, responding to each client’s clinical needs, goals, priorities and context rather than fixed or provider driven protocols. Care is delivered through team-based, multidisciplinary practice. ISoC2 transforms care delivery through shared responsibility across Pod members, supported by daily team “huddles,” shared electronic health records including care plans where appropriate, and data-driven quality improvement processes to support proactive care management of empanelled clients. Strengthened relational care is embedded within the Pod model and involves sustained, culturally safe relationships between clients and their care team, with all team members sharing responsibility for connection, trust, and continuity of care, supported by consistent engagement, proactive follow-up, and flexible communication. Pod members routinely support goal setting and client-led decision-making using tools such as the Australian Therapy Outcome Measure for Indigenous Clients (ATOMIC). ISoC2 offers clients flexible and responsive access to services, enabling care delivery via face-to-face consultations, telephone contact, and home or community visits, including extended hours where required. This supports improved accessibility, responsiveness, and continuity of care. Workforce transformation is supported through expanded and intersecting scopes of practice across Pod members, particularly non-GP providers. This is complemented by training and ongoing professional development delivered in-house or externally, both prior to and during implementation. Staff undergo a series of training modules, including a one-day workshop in the preceding 1-2 months prior to implementation, provided by trained facilitators from the service development team. Ongoing training and support provided by the service development team on a weekly and ad hoc basis. Quarterly workshop will be convened throughout to the intervention period for participating sites and staff to share learnings and reinforce concepts of the model. Healthcare resources are allocated using a data-driven, wholistic assessment of client needs. Intervention fidelity is monitored through routinely collected clinical and administrative data (e.g. electronic medical records, care plans, follow-up activities), alongside service-level quality improvement processes and audits of Pod functioning, including data dashboards providing information of empanelment, continuity of Pod team and distribution of care between Pod team members. The intervention is delivered continuously as part of routine care, with participants exposed to the model for the duration of their engagement with the service during the study period, rather than for a fixed number of sessions or time-limited program.