Transforming Long-Term Condition Management Through Digital and AI-Enabled Recall: A Practical Framework for Global Primary Care
Sian KNIGHT, Tom RATCLIFFE, Belinda ROELOFS, Mina GUPTA, Nina JHITA and Vincent SAI
Long-term conditions (LTCs) are the largest driver of primary care workload globally. As populations age and multimorbidity rises, traditional manual recall systems can no longer keep pace. Many health systems face the same structural pressures: rising demand, increasing emergency presentations, and limited workforce capacity. AI-enabled recall offers a practical, scalable and evidence-based way to modernise LTC management by shifting care from reactive to proactive. Worldwide, LTCs account for a substantial proportion of primary care appointments, outpatient activity and hospital admissions. When recalls rely on manual phone calls, letters or opportunistic reviews, patients fall through gaps, clinical risk rises, and emergency demand increases. Digital and AI-supported recall pathways can automate invitations, identify non-responders, and help prioritise patients most at risk of deterioration. These models support planned care over emergency care, enabling clinicians to intervene earlier and more effectively. The workshop focuses on implementation principles that work in low-, middle- and high-resource settings, emphasising safety, inclusion and sustainable workflow redesign.Participants will be able to: 1. Understand the components of an AI-enabled LTC recall pathway and how these complement existing systems. Redesign workflows to support proactive, population-level LTC management. Apply governance, clinical safety and risk-stratification principles. Build digital and non-digital pathways to ensure inclusion. Introduce and scale recall models with strong staff and patient engagement.Focused presentations on proactive care models and workflow redesign. Mentimeter exercise: participants vote on their biggest LTC system barriers (e.g., demand spikes, workforce limits, missed recalls). Small-group reflection on transferable implementation strategies. Facilitator examples showing successful adaptation across varied settings. Schedule 0–10 min: Introduction & global LTC burden 10–20 min: Model overview 20–30 min: Mentimeter interactive polling 30–45 min: Group reflection in triads 45–55 min: Implementation stories 55–60 min: Q&A, takeaways .Participants gain a clear, adaptable framework for modernising LTC recall and shifting systems toward proactive, preventative care. They leave with practical steps to evaluate readiness, engage teams, and build hybrid recall pathways suited to their own health system.This workshop provides a scalable, internationally relevant model for strengthening LTC management using digital and AI-enabled tools—supporting safer care, earlier intervention and more sustainable primary care systems.
