1-Year Diabetes Treatment Plan

Itechnocrat Health – Integrated Smart Care Program**

Program Overview

A structured 12-month program focused on:

• Glycemic control
• Weight reduction
• Medication optimization
• Diet modernization (microbiome-friendly, low-carb/Keto-friendly options)
• Remote patient monitoring (RPM)
• Smart device integration (glucose, BP, HRV, steps, sleep)
• Mobile nurse visits + PSW support
• Monthly physician follow-ups
• AI-powered insights from Itechnocrat EHR platform

🔷 Key Components of the Program

1. Daily glucose monitoring (smart glucometer or CGM)
2. Remote device management via the Itechnocrat Health EHR AI platform
3. Personalized nutrition & meal planning using microbiome and food-compatibility AI
4. Weight management coaching
5. Exercise and activity prescriptions
6. Medication adherence monitoring
7. Mobile nursing visits (weekly–monthly)
8. PSW support for vulnerable or elderly patients
9. Monthly labs (HbA1c, lipids, kidney function)
10. Quarterly physician review and risk-score update
11. Insurance health-risk monitoring and reporting

📍 YEARLY PLAN BREAKDOWN (12 MONTHS)

📘 Month 1 — Baseline Assessment & Personalized Plan

Assessments

• Full clinical intake (medical history, T2D status, comorbidities, medications)
• Anthropometrics: weight, BMI, waist circumference
• Baseline labs:
  • HbA1c
  • Lipid panel
  • Kidney function
  • Liver enzymes
  • Insulin level & HOMA-IR (optional)
  • Microbiome kit ordered (optional research component)

Device Setup

• Connect glucometer or CGM to Itechnocrat EHR AI
• Connect Garmin device (sleep, HRV, steps, calories, stress)
• Configure RPM alerts:
  • High glucose: >220 mg/dL
  • Low glucose: <70 mg/dL
  • BP abnormal triggers

Mobile Nurse Visit

• Onboarding
• Medication reconciliation
• Device training
• Diet education

Diet Plan (Month 1)

• Moderate-low carbohydrate (80–120g/day)
• No sugar or refined flour
• 3 meals + 1 optional snack
• Hydration goal: 2–3 L/day

PSW Support

• For elderly / limited mobility
• Meal prep assistance
• Medication reminders

Activity Plan

• Daily steps baseline
• Gentle walking 20–30 min/day
• Sleep hygiene initiation

📘 Months 2–3 — Glycemic Control & Weight Stabilization

Remote Monitoring (Daily)

• Glucose tracking
• Step count
• HRV recovery
• Sleep patterns
• AI alert for high/low sugar

Mobile Nurse (Weekly)

• Foot check
• Vitals
• Medication adherence review

Diet Plan (Months 2–3)

Transition to Keto-friendly, low-glycemic meals:

• Carbs: 50–80g/day
• Proteins: 20–30%
• Healthy fats: olive oil, nuts, avocado
• Include:
  • Keto bread
  • Keto mixes & sauces from KFS Rx Meals
  • Anti-inflammatory foods
  • High-fiber vegetables

Meal Plans Examples:

• Breakfast: Keto pancakes with sugar-free syrup, eggs
• Lunch: Green salad + grilled salmon + avocado
• Dinner: Chicken + broccoli + olive oil
• Snack: Almonds or sugar-free yogurt

Activity Plan

• 6,000 steps/day goal
• Strength training: 2× weekly
• AI-suggested workouts from device metrics

Medical Review (End of Month 3)

• Repeat HbA1c
• Adjust medications (consider GLP-1, SGLT2 inhibitors)
• Evaluate weight progress

📘 Months 4–6 — Weight Loss & Metabolic Reset

Remote Monitoring

• RPM metrics analyzed weekly by AI
• Monthly summary sent to physician & insurer

Mobile Nurses (Biweekly)

• BP, glucose logs
• Medication titration support
• Address side effects (e.g., GLP-1 nausea)

Diet Plan (Months 4–6)

• Continue low-carb therapeutics
• Introduce microbiome foods:
  • Fermented foods
  • Prebiotic fiber
  • Resistant starch (small amounts)

Weight Management

• Target: 5–7% body weight reduction
• AI-calculated calorie targets
• Telehealth appointment with dietitian monthly

Activity Plan

• 8,000 steps/day
• Resistance exercises 3× weekly
• Garmin HRV monitoring to avoid overtraining

Medical Review (End of Month 6)

• HbA1c
• Lipids
• Weight progress
• Update treatment plan

📘 Months 7–9 — Optimization & Complications Prevention

Remote Monitoring

• Daily glucose
• Sleep/HRV analytics
• Early detection:
  • neuropathy
  • silent hypoglycemia
  • poor medication adherence

Mobile Nurse (Monthly)

• Foot exam
• Vitals
• Device update & data syncing

Diet Plan

Shift to long-term sustainable diabetic diet:

• 70–100g carbs/day
• Balanced meals
• 12-hour intermittent fasting optional
• Weekly meal packs from KFS Rx Meals recommended

Activity Plan

• 10,000 steps/day target
• Cardio: 3× weekly 30–40 min
• Strength: 3× weekly

PSW Services (As Needed)

• Home support for meal prep
• Transportation to labs

📘 Months 10–12 — Maintenance & Long-Term Prevention

Monitoring

• Continue remote device data flow
• Year-end metabolic health scoring by Itechnocrat AI
• Early warning system for risk of:
  • neuropathy
  • retinopathy
  • kidney disease

Mobile Nurse (Monthly)

• Check vitals
• Perform retinal photo exam if supported
• Fall-risk assessment for seniors

Diet Plan

• Long-term maintenance plan
• Avoid sugar and refined carbs
• Encourage weekly meal shipment subscription

Activity Plan

• Maintain 8–10k steps/day
• Continue structured exercise
• Sleep optimization

Final Medical Review

• HbA1c target: <6.5–7%
• Evaluate kidney & heart health
• Adjust long-term medications
• Provide annual diabetes report for insurance or employer wellness programs

🔷 YEAR-LONG SERVICE SCHEDULE SUMMARY