Itechnocrat Health – 1-Year Comprehensive Diabetes Management Plan

***(Some parts of the program are covered by provincial insurance-talk to Itechnocrat Health for details)***

Fully Integrated, Team-Based, Technology-Enhanced Chronic Disease Care Program

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🔷 PROGRAM OBJECTIVES

Clinical

• Reduce HbA1c to <7% (or individualized)
• Decrease risk of complications (kidney, retina, heart, neuropathy)
• Increase glucose time-in-range
• Stabilize or reduce weight (5–10% year 1 goal)
• Improve blood pressure and lipids

Lifestyle

• Teach long-term diabetic-friendly meal preparation
• Improve physical fitness and mobility
• Build stress management & emotional health habits
• Maintain sleep quality and activity levels

Technology Integration

• Daily glucose monitoring via CGM/glucometer
• Garmin wearables for HRV, steps, sleep, stress
• AI-generated insights for early warning detection
• All caregivers connected via Itechnocrat EHR

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📅 THE 12-MONTH PLAN (BY PHASE)

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📘 Month 1 — Intake, Diagnosis Confirmation, Mobile Labs & The Foundation

Family Physician / Diabetes Physician

• Full medical history, diabetes staging, comorbidity screening
• Orders mobile lab baseline tests:
  • HbA1c
  • Lipids
  • Kidney function
  • Liver panel
  • Insulin/HOMA-IR (optional)
  • CBC
  • Urine microalbumin
• Sets glucose & BP targets
• Starts or adjusts diabetes medications
• Creates medical care plan in Itechnocrat EHR

Mobile Lab Services

• At-home blood draw
• Specimen processing
• Upload results automatically into EHR

Mobile Nurse

• Vitals baseline, medication reconciliation
• Sets up devices (Glucometer/CGM, Garmin, BP monitor)
• Education on diabetes self-management

Dietitian

• Full nutrition assessment
• Start diabetic-friendly low-carb meal plan
• Introduce KFS Rx Meals products
• Enroll patient into Community Kitchen Program

Community Kitchen Program (NEW)

• Orientation:
  • Low-carb cooking
  • Portion control
  • Meal prepping for diabetics
  • Sugar substitutes
  • How to use KFS Rx mixes/sauces
• Family members encouraged to attend

Kinesiologist

• Functional assessment
• Balance, mobility, strength baseline
• Create Phase 1 exercise plan

Mental Health Therapist

• Screen for:
  • Diabetes distress
  • Depression
  • Anxiety
  • Emotional eating
• Start CBT-based support plan

Social Worker

• Assess:
  • Food insecurity
  • Transportation
  • Disability/insurance benefits
  • Community support options

Footcare Nurse

• Baseline diabetic foot exam
• Neuropathy screening

Patient Care Coordinator (PCC)

• Builds full 12-month appointment schedule
• Books community kitchen classes
• Arranges mobile lab visits every 3 months
• Coordinates all team communication

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📘 Months 2–3 — Stabilization Phase (Glycemic Control + Skills Training)

Physician

• Reviews progress from RPM
• Adjusts medications
• Reviews mobile lab results for high-risk patients
• Ensures early complications are addressed

Mobile Nurse

• Weekly visits
• Vitals + glucose pattern review
• Medication adherence

Dietitian

• Strengthens low-carb plan
• Creates weekly meal plan templates
• Monitors food logs
• Community kitchen menu development
• Teaches label reading & carb counting

Community Kitchen Program

Weekly or biweekly hands-on cooking sessions:

• Meal prep for the week
• Cooking low-carb, diabetic-friendly meals
• Budget-friendly meal planning
• Using KFS Rx Meals mixes/sauces

Kinesiologist

• Progressive walking program
• Steps goal: 5,000 → 6,000
• Light strength training

Mental Health Therapist

• Weekly or biweekly CBT
• Emotional eating management
• Stress management techniques

Social Worker

• Assistance with food access
• Support with social barriers
• Connection to community fitness programs

Footcare Nurse

• Monthly assessment
• Footwear and ulcer prevention guidance

PCC

• Ensures attendance at all programs
• Troubleshoots technology
• Tracks completion of cooking classes

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📘 Months 4–6 — Weight Loss + Metabolic Reset

Physician

• Reviews Month 3 labs
• Medication optimization
  • GLP-1, SGLT2, basal insulin adjustments
• Evaluate kidney, liver, lipids

Mobile Lab

• Month 3 or Month 6 full panel

Dietitian

• Low-carb or ketogenic plan
• Introduce anti-inflammatory foods
• Higher protein focus
• Meal prep plans for:
  • Breakfast
  • Lunch
  • Dinner
  • Snacks

Community Kitchen Program

Advanced cooking modules:

• Global low-carb meals
• Keto baking with KFS Rx mixes
• High-protein cooking
• Family meal preparation
• Meal prepping for shift workers

Kinesiologist

• Steps: 7,000 → 8,000/day
• Strength training 2–3x weekly
• Cardio intro
• HRV & stress tracking via Garmin

Mental Health Therapist

• Coping skills
• Craving control
• Motivation building

Social Worker

• Address workplace, home stressors
• Connect patient to benefits (pharmacy, transport)

Footcare Nurse

• Increased monitoring as activity increases

PCC

• Adjust schedule based on progress
• Coordinates mid-year case conference

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📘 Months 7–9 — Optimization: Preventing Complications & Sustaining Gains

Physician

• Reviews RPM trends & AI risk scores
• Update medications
• Send referrals (retina, nephrology, cardiology)

Mobile Lab

• Month 9 follow-up panel

Dietitian

• Break plateaus:
  • Carb cycling
  • Protein optimization
  • Intermittent fasting (if appropriate)

Community Kitchen Program

• Specialized workshops:
  • Air fryer diabetic meals
  • Easy lunches for work
  • Meal prep for family of 4
  • Low-carb comfort foods

Kinesiologist

• Steps: 9,000 → 10,000 daily
• Strength 3x weekly
• Cardio 3x weekly
• Body composition improvements

Mental Health Therapist

• Long-term behavior change
• Burnout prevention
• Sleep therapy

Social Worker

• Reevaluates social and environmental needs

Footcare Nurse

• Monthly or bimonthly checks
• Address neuropathy early signs

PCC

• Ensures exam referrals complete
• Syncs reports to EHR and insurer portals

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📘 Months 10–12 — Maintenance + Annual Review

Physician

• Orders and reviews annual labs via mobile lab
• Full complications screening:
  • Retina
  • Kidney
  • Neuropathy
  • Cardiovascular risk
• Long-term medication plan
• Year 1 summary + Year 2 plan

Mobile Lab

• Complete metabolic profile
• Upload results to EHR

Dietitian

• Final sustainable eating plan
• “Real-life” eating strategy
• Holiday meal survival plan

Community Kitchen

Graduation modules:

• Mastering diabetic cooking
• Hosting healthy family meals
• Affordable diabetic meal planning
• Restaurant menu interpretation

Kinesiologist

• 12-month fitness maintenance plan
• Strength: 3–4× per week
• Cardio: 150–200 min weekly

Mental Health Therapist

• Monthly maintenance
• Relapse prevention

Social Worker

• Annual benefits review
• Long-term support plan

Footcare Nurse

• Annual comprehensive diabetic foot exam

PCC

• Final annual report
• Setup of Year 2 diabetes management plan