A system and method for determining patient hospitalization risk and treating patients is disclosed. The system and method may include extracting patient data from one or databases corresponding to a pool of patients having end stage renal disease; using a predictive model with the extracted patient data to generate, for each of the patients, a respective expected probability for hospitalization within a predetermined time period; identifying a subset of patients having respective expected probabilities that are higher than other patients in the pool of patients; identifying, for each patient, at least one factor from the patient data that increased the expected probability of hospitalization; and based on the identified factors, determining and executing clinical interventions to lower the probability of hospitalization within the subset of the pool of patients.