Introduction
Derbarl Yerrigan Health Service (Derbarl) is the largest and oldest Aboriginal Community Controlled Health Service in Western Australia, servicing over 20,000 patients across four clinics on Whadjuk Noongar Boodja. Our model is unique in being set within a primary health care setting, allowing holistic care for Aboriginal and Torres Strait Islander families across the Perth metro area and beyond. Housing is an often-forgotten social determinant of health[1]: in 2021, 27% First Nations people aged 15 and over experienced rental stress[2], and poor home environments drive infections that lead to ARF and RHD.
At 31 December 2024, 7,500 people were recorded as having RHD on registers in QLD, WA, SA and NT, 78% First Nations people[3]. In WA, 1,761 patients are on the ARF/RHD Register; 87% of cases occur in Aboriginal people[4], and Indigenous ARF/RHD incidence rose 1.9% per year from 1996 to 2022, with children aged 5-14 most affected[5]. Communicare reflects 400 Derbarl clients with ARF/RHD; 98 are current regular clients.
The model and what makes it unique
Our model, commenced late 2025, integrates a clinical nurse, dedicated GP, Aboriginal Health Practitioner support and an Environmental Health Officer. Patients face challenges maintaining penicillin prophylaxis due to transience and complex social needs. The GP can refer a client for environmental health assessment, offered whenever children present with skin sores or sore throats. What makes the model distinctive is this linkage between environmental health and clinical care: activated not only for patients on RHD treatment, but through prevention, including opportunistic skin checks and clinic-to-home referrals.
Wins
Since implementation, 143 home visits have been completed, approximately 25% of homes requiring more than one visit, some as many as four. The officer's flexible, culturally safe approach builds trust and engagement. Interventions addressing waste and pest management reduced environmental risk factors for Strep A infection. The model pairs education with practical support: a Healthy Living Bag (around $165) per family, pest control, waste management, Department of Housing liaison and basic repairs.
Case Study
At a Derbarl "Family Fun Day", a family attended for opportunistic skin checks. The GP diagnosed and treated scabies and identified previously undiagnosed heart murmurs in two children. The Environmental Health team then found 15 people living in a one-bedroom Community housing unit, supplying new mattresses, skip bins, pest control, shade cloth, hygiene education and a Healthy Living Bag.
Challenges
The environmental health service consists of one officer covering the entire Perth metropolitan area, with short-term, limited funding. Prevention does not begin in the clinic alone; it begins in homes and community environments. Planned steps include expanding the team, embedding environmental health in the initial health assessment, and adding GP home visits to streamline referrals.
Take home message
This model demonstrates the value of investing in prevention alongside primary and secondary treatment. Scaling this approach can strengthen culturally secure, holistic care and address the social and environmental determinants of inequitable health outcomes, requiring sustained government commitment and recognition of ACCHOs as essential leaders in lasting change.