Chronic Disease and Care Management- Innovative Tools for Community Care Addressing Doctor Nurse and Patient

As the burden of chronic disease increases and the healthcare services need to cope with large populations of comorbid patients the care management approach is moving towards integrated care involving doctors, nurses and the patient as active partner in management of their health and disease. This change in care delivery creates needs to provide all stakeholders with tools that will present the relevant information and advice how to provide personalized treatment to each patient. For the patient, educational tools and personalized recommendation considering their preferences are crucial for patient empowerment and engagement to the care process.

Clalit Research Institute, as part of Clalit strategic decision to develop and implements innovation in care, is collaborating with academia and industry in developing and implementing innovative tools that are connected to the EMR and support healthcare providers and patients. CRI innovation center activity as well as some tools developed within this framework will be presented. Among these tools a platform that is designed to provide seamless solution for the physician, facilitating Integrated Care of multi-morbidity, provides clinical decision support and personalization of care and promote quality of care. The second tool is a tablet based tool for the nurse that provides information on patients’ condition and decision support tool for required procedures. The third tool is designed for the patient. A stroke risk calculator for the patient will enable him understand his relative risk, the main risk factors and what can he change his health behavior to reduce his\her risk