Overview
Initiative type
Model of Care
Status
Deliver
Published
June 2026
Summary
Sustainably funded primary care for asylum seekers improves prevention, early diagnosis and ongoing management, benefiting patients and health systems.
Dates: July 2024 - June 2025
Implementation sites: Mater Hospital Brisbane
Partnerships: Mater Refugee and Multicultural Health, Refugee Health Network Queensland
This project was presented as a Poster at CEQ Showcase 2026 (PDF, 1.1MB).
Aim
To improve healthcare for people seeking asylum by funding and redesigning a sustainable, interdisciplinary primary care model that addresses system gaps and reduces pressure on secondary and tertiary services through comprehensive, culturally responsive, trauma-informed care.
Outcomes
- In the first 12 months, Mater Refugee CCC delivered 2593 appointments, supported 476 patients receiving ongoing care, and enabled 179 new patients to access services.
- Comprehensive care and screening revealed a substantial burden of conditions aligned with state and national priorities, including mental health, cardiovascular disease, cancer risk, syphilis, hepatitis B, women's and children's health issues, and gender-based violence, with quantitative outcomes to be presented.
- A sustainably funded, interdisciplinary model enabled earlier diagnosis, treatment, preventive care and reduced impact on hospital services demonstrating the personal, organisational and systemic impact of investing in an integrated and sustainable model of primary care for patients facing barriers to healthcare access.
Background
For over 20 years, people seeking protection in Brisbane have accessed primary healthcare, including medical and nursing care, through MRCCC at Mater's South Brisbane campus. The clinic provided compassionate, trauma-informed, high-quality care through a largely volunteer-led and philanthropically funded model. While clinically effective, reliance on volunteers limited appointment availability, workforce stability, and continuity of care. Demand regularly exceeded capacity, resulting in delays in accessing essential services.
These limitations became especially evident in 2022, when the service responded simultaneously to the COVID-19 pandemic, the evacuation of Afghanistan, the war in Ukraine, and severe flooding in Brisbane. Volunteer general practitioners faced unprecedented pressure at a time of heightened patient need, exposing the fragility of a refugee health model dependent on volunteer workforce capacity.
This project was guided by the question of whether transitioning to a sustainably funded, interdisciplinary model could address persistent gaps in primary care access for people from refugee backgrounds seeking asylum in Queensland. The aim was to improve access to acute and chronic disease management, preventive care, and health promotion, while strengthening system sustainability and reducing pressure on secondary and tertiary services.
In July 2024, the clinic secured its first four-year grant from Queensland Health, supplemented by philanthropic contributions. This funding enabled structural redesign and embedded strengthened governance, equity, continuity, and sustainability into care delivery.
Key objectives included increasing timely access to appointments; improving early identification and management of acute and chronic conditions; and optimising preventive healthcare, including recommended screening, immunisation, and health promotion.1,2, 3 The culturally responsive, whole-of-person primary care model delivered by MRCCC, is inherently longitudinal, meaning patients cannot readily be discharged. This characteristic informed service capacity planning and evaluation, as the clinic sought to maintain continuity for existing patients while enabling access for new referrals.
The first evaluation cycle (July 2024 - June 2025) examined the impact of the funded model on service capacity, patient access, and detection and management of priority health conditions. Early findings indicate that funding integrated primary care models such as this can address significant gaps in healthcare access, improve health outcomes, and promote equity, while generating benefits for patients, staff, organisations, and the broader health and social system.
Methods
This project was guided by the Model for Improvement and represents the implementation (Do) and evaluation (Study) phases of a Plan-Do-Study-Act (PDSA) cycle, developed through several years of prior planning and service reflection.4
From July 2024, funded medical officer (general practitioner), nursing (clinical nurse), and senior administrative roles were embedded within the clinic's trauma-informed, culturally responsive framework. Philanthropic contributions complemented government funding, ensuring access to recommended pathology, radiology, and pharmaceuticals.
Key implementation strategies included:
- Expanding clinic sessions and appointment availability
- Strengthening clinical governance systems
- Supporting interdisciplinary collaboration
- Stabilising workforce capacity and professional development to sustain ongoing care
- Embedding evaluation and quality improvement initiatives
- Balancing comprehensive, patient-centred longitudinal care for existing patients with enabling access for newly referred patients
Evaluation drew on clinical records and service activity data over the first 12 months of the funded period. Metrics included total appointments delivered, number of patients receiving ongoing care, number of new patients, waiting times, and outcomes from screening and patient presentations, aligned with state and Commonwealth health priorities. Screening focused on mental health, cardiovascular disease, cancer risk, communicable diseases, chronic disease management, nutritional deficiencies, and women's and children's health.
Findings from this first cycle will continue to inform service refinement, capacity planning, and workforce allocation in preparation for the next PDSA cycle.
Discussion
The first funded year demonstrates that strategic investment in multidisciplinary primary care, including experienced medical officers, nursing, and administrative staff, strengthens health outcomes and system sustainability. Workforce stabilisation enhanced continuity of care, governance, interdisciplinary collaboration, and staff support and development. Patients benefitted from earlier diagnosis, timely intervention, ongoing management, and improved access to screening, immunisations, preventive care, and health promotion. The service effectively addressed many priority health needs, including mental health and suicide prevention, cardiovascular health, chronic disease management, women's and children's health, domestic and family violence, cancer screening, immunisation, and management of communicable diseases.
Key strengths of the model include longstanding community trust built over twenty years, experienced clinicians, robust cross-sector partnerships, active engagement with refugee communities, and alignment with state and national health priorities. Limitations of this evaluation include a short timeframe and the absence of formal economic analysis at this stage.
The principles underpinning this redesign, sustainable funding to support proven models, interdisciplinary collaboration, evidence-based, culturally responsive, whole-of-person, trauma-informed practice, and longitudinal access, are transferable across Queensland Health. They are particularly relevant to refugee health services, regional centres, and community health settings serving populations experiencing barriers to existing care models.
Next steps include refining and further reporting outcome measurements, optimising capacity, and exploring opportunities for scale and adaptation across other Hospital and Health Services.
This project demonstrates that when structural gaps in the healthcare system are intentionally addressed, access is improved, emerging health needs are identified early, and appropriate intervention and management are offered. Preventive care and health promotion are strengthened, staff support is enhanced, and more equitable and sustainable care is achievable. Sustainable investment in comprehensive frontline primary care for populations experiencing systematic barriers to healthcare access is both feasible and essential.
References
1. Australian Refugee Health Practice Guide. Melbourne (VIC): Foundation House; 2018. Available from: https://refugeehealthguide.org.au/ [cited 2026 Mar].
2. Australasian Society for Infectious Diseases; Refugee Health Network of Australia. Recommendations for a comprehensive post-arrival health assessment for people from refugee-like backgrounds. 2nd ed. Surry Hills (NSW): ASID; 2016. Available from: https://www.rch.org.au/uploadedFiles/Main/Content/immigranthealth/ASID%20RHeaNA%20screening%20guidelines.pdf [cited 2026 Mar].
3. Royal Australian College of General Practitioners. Guidelines for preventive activities in general practice. 10th ed. East Melbourne (VIC): RACGP; 2025. Available from: https://www.racgp.org.au/getattachment/3eddf0a7-7cec-4064-a44b-5bde6c2515a5/Guidelines-for-preventive-activities-in-general-practice.aspx [cited 2026 Mar].
4. Langley GL, Moen R, Nolan KM, Nolan TW, Norman CL, Provost LP. The improvement guide: a practical approach to enhancing organizational performance. 2nd ed. San Francisco (CA): Jossey-Bass; 2009.