BACKGROUND:
Urban Indigenous families in Canada face significant health inequities rooted in colonial legacies, systemic racism, and persistent barriers to culturally safe care. In response, Under One Sky Friendship Centre (UOS) in Fredericton, New Brunswick, in collaboration with a nurse scientist at the University of New Brunswick, created a comprehensive, Indigenous-led primary care model that integrates nursing, case management, and wellness services within a culturally grounded framework. The program has expanded into a multi-faceted model that includes two Registered Nurses, a Research and Program Facilitator, an Outreach Programs Lead, Mental Health Counsellors, and a Nurse Practitioner. The team provides primary care, counselling services, crisis intervention, case management, health, and community wellness initiatives.

METHODS:
An assessment of program effectiveness was conducted, using a community-based mixed methods participatory action research approach. Data were collected through a cross-sectional survey, interviews, and administrative data. Descriptive analysis of quantitative data and qualitative content analysis were conducted.

RESULTS:
The program promoted holistic wellbeing, enhanced adherence to care, and addressed systemic and cultural barriers. In the 2021/2022 fiscal year, the program offered 544 support services; in 2022/2023, this rose to 886 services; and in 2023/2024, the program delivered 1283 services. Results have driven an iterative quality improvement and service expansion process.

CONCLUSIONS:
The program is set to continue expand with the opening of UOS’s new primary health centre in 2026, which will host expanded primary care and birthing services. This trajectory reflects a sustainable model of Indigenous-led, community-based nursing that integrates cultural knowledge, family-oriented care, and collaborative evaluation.