PruittHealth reduces rehospitalization rates and improves fall prevention with AI-powered clinical risk insights

PruittHealth faced growing challenges managing patient acuity and preventing unnecessary hospitalizations, especially amid ongoing staffing shortages. Staff relied heavily on manual methods to identify which residents were at highest risk, making it difficult to intervene proactively. Pulling together the right data at the right time was time-consuming and drained frontline resources.

PruittHealth deployed MatrixCare's Clinical Advanced Insights (CAI), an AI-driven tool embedded in their existing EHR platform. CAI surfaces real-time clinical risk patterns — including fall risk, rehospitalization risk, and changes in activities of daily living — into a single acuity-level report highlighting the top 10 residents most at risk. Senior nurse consultants drove adoption by integrating CAI into weekly clinical risk meetings, shift huddles, and discharge planning workflows.

The organization achieved a measurable reduction in its rehospitalization rate, reflecting fewer care disruptions and stronger continuity of care. Earlier identification of ADL declines enabled faster therapy engagement and involvement of restorative aides, reducing further deterioration. Fall prevention efforts are also trending in the right direction, with CAI helping identify contributing risk factors earlier and prompting earlier therapy collaboration. A related JAMDA study of CAI-enabled sites found a 59% greater reduction in residents with depressive symptoms, 22% greater reduction in residents needing help with daily activities, and 9% greater reduction in major falls.

• Embed AI into clinical culture, not just workflow — frontline staff need to understand why the data matters, not just how to run reports.
• Senior nurse consultants as champions were critical to driving adoption and building cross-disciplinary buy-in across administrators, directors of health services, and CNAs.
• Tying AI insights to existing rituals (shift huddles, top-10 rounds, discharge planning) accelerates integration without adding burden to already-stretched staff.