Quick summary: Growing numbers of older people are managing multiple chronic conditions such as diabetes, heart failure and kidney disease, which drives repeat hospital admissions and unsustainable costs for healthcare systems worldwide. The Clalit Guided Care and Support programme uses artificial intelligence to identify high risk patients early and pairs them with dedicated nurses and physicians for personalised plans, achieving a 46% reduction in unplanned hospitalisations, a 56% drop in total hospital days and a 69% fall in 30 day readmissions. This model improves patient well-being by preventing crises through proactive support and points the way for healthcare practices and public policy to adopt scalable, efficient approaches that ease system pressures while delivering better outcomes.
As people live longer, growing numbers are coping simultaneously with diabetes, heart failure, chronic lung disease, kidney disease and hypertension. For healthcare systems around the world, this has become one of the greatest and most expensive challenges, driving rising rates of repeat hospitalisations, increasing pressure on hospitals and soaring healthcare costs.
Now, a new study by Israel’s Clalit Health Services, the country’s largest healthcare organisation, serving more than half of Israel’s population through a network of 14 hospitals and 1,600 community clinics, and published in Nature Communications, offers a potential solution that could help reshape how healthcare systems worldwide care for patients with multiple chronic conditions.
The study, led by Professor Ran Balicer, chief innovation officer and deputy director general at Clalit, and Professor Efrat Shadmi of the University of Haifa, found that Clalit’s Guided Care and Support programme reduced unplanned hospitalisations by 46%, total hospital days by 56%-, and 30-day readmissions by 69% among the healthcare system’s most vulnerable patients.
The programme combines artificial intelligence, medical data analytics and personalised human support. AI-based algorithms analyze Clalit’s extensive medical databases to identify patients at high risk of clinical deterioration and hospitalisation. Once identified, each patient is paired with a dedicated nurse and family physician who together create a personalised care plan tailored to the patient’s medical condition, capabilities and everyday needs.
Since its launch in 2013, the programme has been implemented in more than 40 clinics across Israel, with approximately 10,000 patients participating to date. The study included nearly 1,800 patients and found that the programme’s effectiveness was maintained even after increasing the number of patients managed by each nurse by approximately 50%, highlighting its significant potential for expansion to healthcare systems worldwide.
Professor Ran Balicer, chief innovation officer and deputy director general at Clalit said: “Healthcare systems across the globe are searching for solutions to the dramatic rise in the number of people living with multiple chronic conditions. Instead of waiting for deterioration and hospitalisation, we use artificial intelligence and big data to identify patients early, intervene proactively and prevent many of the complications and hospital admissions. This represents a shift from healthcare that reacts to crises to healthcare that prevents them.”
Sefy Subol Roytblat, head of nursing at Clalit Health Services’ community division, said: “Technology identifies the risk, but nurses are the ones who translate the data into life changing action. They build personal relationships with patients, identify deterioration at an early stage and help them navigate an increasingly complex healthcare system.”
Miriam, 76, who lives with diabetes, heart failure and kidney disease, said: “Before joining the programme, I kept returning to the emergency room. Today, I have someone who knows me, calls me and takes care of me. I haven’t been hospitalised in more than a year.”
Yosef, 69, who lives with four chronic conditions, added: “I felt lost between different doctors and medications. The programme gave me one address and a sense of security. It changed my life.”
