The Paper will present a DVD presentation of a multidiscipline and ‘community spirit' approach to chronic disease. The Mallee Track Health & Community Service (MTH&CS) in Ouyen embarked upon a major project to identify and track people with Diabetes and those at possible risk of Diabetes across the region. The project, known as “Diabetes Management Along the Mallee Track” was funded under a Rural Chronic Disease Initiative (RCDI) program grant from the Commonwealth Department Health & Ageing, Canberra. Diabetes is recognised as a national health priority. The project is modelled on the Centre for Rural & Regional Health Education and MTH&CS Early Intervention Risk Assessment for Cardiovascular Disease Program.

Two major objectives of the project were:

• To improve the delivery of care for people with diabetes in the small rural communities along the Mallee Track through the establishment of a sustainable, integrated, multidisciplinary approach to diabetes management, and,
• To identify people at risk of diabetes and raise the level of awareness about diabetes in the general.

These objectives were achieved through the following strategies:

• A co-ordinated approach to the clinical care and management of people with diabetes, integrating the use of best practice guidelines and clinical pathways, access to the general practitioner with Point of Care (POC) testing equipment for the immediate on-site measurement of key markers of Diabetes control during the patient visit.
• Capacity building for the local diabetes workforce through the delivery of a range of staff education and resources developed and presented for the MTH&CS by Flinders University South Australia Community POC Services.
• The promotion of self-management strategies for diabetes and the development and introduction of community healthy lifestyle programs through exercise for all age groups.

Conclusion: This program is transportable and being piloted in other remote communities. The reported result based on the research of Flinders University of 51 Diabetics and 323 community participants (as of June 2004) clearly indicates the value of this intervention to reduce and identify risk through a multidiscipline and community spirit approach.

Policy recommendation: That Point of Care Technology and accompanying lifestyle practices should be adopted and adapted across rural Australia to reduce and help maintain the chronic disease Diabetes and associated health risks.