As the U.S health care system grapples with a burgeoning chronic disease crisis, a recent webinar hosted by HLTH highlights how major healthcare providers are leveraging strategic investments and artificial intelligence (AI) to forge a new path forward.

A leader in comprehensive kidney care, DaVita, is working with others in this movement, using its venture arm, DaVita Venture Group, and its 25 years of deep clinical experience to scale innovative solutions aimed at preventing disease progression and transforming the patient experience.

The challenge is immense: A staggering six in 10 Americans live with at least one chronic disease — many of whom are unaware of their condition until it has significantly progressed. This is especially true for chronic kidney disease (CKD), where an estimated 90% of individuals remain undiagnosed until it progresses to late-stage CKD. DaVita recognizes the urgent need to intervene earlier, identifying risks and providing timely interventions to help prevent disease progression.

This strategy of external investment is designed to complement a robust foundation of technology developed at DaVita. This foundation includes Center Without Walls™ (CWOW™), a cloud-based platform that gives care teams a 360-degree view of individual patients and manage care effectively, across centers, as well as OneView, a rounding platform with a 94% physician opt-in rate that streamlines workflows for nephrologists. By building this internal ecosystem that leverages AI, DaVita can strategically work with external innovators to target specific challenges outside of kidney care to rapidly integrate a more connected care experience.

Shifting the Model: Comprehensive, Coordinated and Preventive Care

DaVita’s strategy, as detailed by its leaders, centers on using technology as a powerful enabler for clinical teams, not a replacement. The vision is a future where data flows seamlessly across care settings, empowering clinicians with precise, actionable insights while helping patients engage more confidently in their own care.

The HLTH webinar, which was moderated by Francesca Tentori, MD, vice president of DaVita® outcomes research and patient empowerment, explored how a proactive approach to care — one that looks at a patient’s total care needs rather than siloed condition-specific factors — is already yielding significant results through collaboration. The conversation included Steve Phillips, group vice president of DaVita Venture Group,  as well as Rishi Madhok, MD, CEO of Linea; and Neil Patel, head of ventures at Redesign Health.

Linea, an AI-backed care platform for congestive heart failure (CHF), provides a powerful case study. The technology addresses a complex and costly challenge: the frequent co-occurrence or heart and kidney diseases. Nearly half of patients living with kidney disease also face heart failure, which can result in increased hospitalizations and readmissions.

By connecting cardiology and kidney care earlier, Linea’s program is already helping drive remarkable outcomes, with early results showing:

• 50% reduction in hospital readmissions
• <25% rate of 90-day hospital readmissions
• 80% of patients engaged with program before hospital discharge
• 12+ supportive calls to patients within first 30 days post-hospitalization

“Our goal is to engage the patient and keep them healthy, keep them out of the hospital,” Rishi Madhok, CEO for Linea, explained during the webinar. Later he shared: “We can use generative AI to … elevate the quality of data interpretation and really task our clinical teams … to intervene at the right point in time.”

A Blueprint for Broader Change

The lessons from the Linea pilot can extend beyond a single disease state, recognizing that solutions are needed to address fragmentation in healthcare. The kidney care provider views this model as a framework for delivering whole-person care at scale:

“CHF falls into the bucket of comorbidities that many of our patients are navigating,” Phillips said during the HLTH webinar. “And it’s one where there are protocols that we have a high degree of confidence that we can move the needle and bend the trend for our patients. And there’s a high degree of fragmentation. So for us, it was, ‘Is there a solution that exists that could create some standardization at scale?’”

Empowering Care Teams and Engaging Patients

Delivering personalized, high-touch care consistently across thousands of interactions is a monumental challenge — one that AI is well-positioned to help solve.

By using AI to streamline clinical workflows and provide predictive insights, care teams are able to focus on what matters most: direct patient interaction.

 “One thing that we’ve seen is that when you apply artificial intelligence to be able to automate certain workflows, to be able to really optimize your resources, you’re able to decrease the cost of providing really, really high quality care, and then you can also apply it to the care interaction as well,” Patel said during the HLTH webinar.

When deployed across large patient populations, it helps reinforce best practices across systems rather than confining them to single clinical settings.

“That’s where I’d say technology can engage to really do two things. One, increase access that can happen more quickly as you think about where agents can play a role in lower acuity events,” Phillips said during the webinar. “And then two … if your tools and capabilities can really get at a clinical next best action that informs a base level of care that all patients can experience, you can just envision a world where there is a rising tide that lifts. “

You can watch the webinar, “Breaking the Readmission Cycle: AI-Driven Solutions for Chronic Care Management,” on demand here.