Israel: AI-Powered Program Cuts Hospitalization Days by 56% for the Most Vulnerable Patients

Sefy Subol Roytblat, Head of Nursing, Community Division, Clalit Health Services. @Liorit Studio.

As populations continue to age, the number of people living with multiple chronic conditions is steadily increasing. Diabetes, heart failure, hypertension, chronic lung disease, and kidney disease often occur simultaneously in older adults, making their care one of the greatest challenges facing healthcare systems today. These patients are at particularly high risk of complications, repeated hospital admissions, and readmissions, creating a significant human and financial burden.

A new study conducted by Clalit Health Services, Israel's largest healthcare organization, offers a promising solution to this growing challenge. Published in the prestigious scientific journal Nature Communications, the research demonstrates that an innovative program combining artificial intelligence with personalized care can significantly reduce hospitalizations among the most vulnerable patients.

The study, led by Prof. Ran Balicer, Chief Innovation Officer and Deputy Director General at Clalit, in collaboration with Prof. Efrat Shadmi of the University of Haifa, followed nearly 1,800 patients living with multiple chronic illnesses. The results were striking: unplanned hospitalizations decreased by 46%, total hospitalization days were reduced by 56%, and 30-day hospital readmissions dropped by 69%.

At the heart of this success is Guided Care and Support, a program launched by Clalit in 2013. It is based on a predictive healthcare model that uses artificial intelligence to analyze Clalit's extensive medical databases and identify patients at high risk of health deterioration or hospitalization before serious complications occur.

Once identified, each patient is assigned a dedicated nurse working closely with the family physician to develop a personalized care plan tailored not only to the patient's medical condition but also to their abilities, daily routine, and individual needs.

This proactive approach enables healthcare professionals to intervene long before hospitalization becomes necessary. Medical teams can adjust treatments, monitor patients more closely, and respond quickly to early signs of deterioration.

Today, the program operates in more than 40 clinics across Israel and has already benefited approximately 10,000 patients. One of the study's most significant findings is that its effectiveness remained unchanged even after each nurse's caseload increased by around 50%, demonstrating that the model is scalable and could be implemented in healthcare systems worldwide.

According to Prof. Ran Balicer, the program represents a fundamental shift in the way healthcare is delivered.

"Healthcare systems around the world are searching for solutions to the growing number of people living with multiple chronic conditions. Instead of waiting for patients to deteriorate and require hospitalization, we use artificial intelligence and medical data to identify those at risk, intervene proactively, and prevent many complications. This marks a transition from reactive healthcare to predictive and preventive care."

While artificial intelligence plays a crucial role in identifying high-risk patients, Clalit emphasizes that technology is designed to support—not replace—healthcare professionals.

"Technology identifies the risk, but nurses are the ones who transform data into meaningful action. They build trusted relationships with patients, detect deterioration at an early stage, and help them navigate an increasingly complex healthcare system," explains Sefy Subol Roytblat, Head of Nursing at Clalit's Community Division.

The impact of the program is perhaps best illustrated through the experiences of its participants. Miriam, 76, who lives with diabetes, heart failure, and kidney disease, says that before joining the program she frequently found herself in the emergency room.

"Today, someone knows me, calls me regularly, and takes care of me. I haven't been hospitalized in more than a year," she says.

Yosef, 69, who suffers from four chronic conditions, recalls feeling overwhelmed by multiple specialists and medications.

"The program gave me one point of contact and a real sense of security. It changed my life," he says.

This groundbreaking initiative further reinforces Israel's position as one of the world's leading innovators in healthcare. By combining artificial intelligence with personalized human care, Clalit has demonstrated how technology can improve patient outcomes, reduce healthcare costs, and help reshape the future of chronic disease management.

Caroline Haïat