Predicting hospitalisation in home care: Lessons from international providers

As Australia’s aged care sector navigates the challenges of an ageing population and increasing demand for home care services, understanding and mitigating hospitalisation risks for older adults is critical.

A recent international study published in Geriatric Nursing (Volume 64, July–August 2025) provides valuable insights into predicting hospitalisation among adult home care clients.

Conducted across the US, Canada, several European countries, and New Zealand, this study introduces the HospRisk-HC scale, a predictive tool designed to identify older adults at risk of hospitalisation.

For Australian aged care leaders, this research offers actionable lessons to enhance home care delivery, optimise resource allocation, and improve client outcomes.

Key findings from the study

The study, led by John N. Morris and colleagues, analysed data from nearly 2.93 million baseline assessments and 1.83 million follow-up assessments using the interRAI Home Care (HC) tool. This tool, widely used in multiple countries, captures clinical and functional data to assess older adults receiving home care.

Key findings include:

• High Hospitalisation Rates: In the 90 days prior to baseline assessments, 40.5% of home care clients had been hospitalised. At follow-up (approximately 9–11 months later), 29% were hospitalised within the preceding 90 days.
  
• HospRisk-HC Scale: The study developed a nine-category risk scale, HospRisk-HC, to predict future hospitalisations based on clinical data and prior hospital stays. Categories 1–5 (no baseline hospitalisation) showed hospitalisation rates ranging from 8.9% to 33.5% at follow-up, while categories 6–9 (prior hospitalisation) had rates from 50.9% to 71.5%. The scale’s predictive strength (eta value of 0.432) underscores its reliability in identifying at-risk clients.
  
• Client Profile: The cohort, with an average age of 76.9 years, was predominantly female (57.8%) and included individuals with varying levels of functional independence. About 34.9% were independent in activities of daily living, while 16% required only supervision. However, many exhibited mild cognitive impairment or dependence in instrumental activities, highlighting the complexity of their care needs.
  
• International Applicability: The study’s findings are generalisable to developed nations, including Australia, where similar healthcare systems and ageing populations exist.

Implications for Australian aged care

Australia’s aged care sector is under pressure to deliver efficient, client-centred home care services amidst rising costs and workforce shortages.

The HospRisk-HC scale offers a framework to proactively manage hospitalisation risks, which is particularly relevant given Australia’s high hospitalisation rates among older adults.

According to the Australian Institute of Health and Welfare (AIHW), in 2022–23, adults aged 65 and over accounted for 41% of hospitalisations despite being only 16% of the population. This aligns with the study’s finding that older adults with complex chronic conditions are frequent hospital users.

The HospRisk-HC scale can assist Australian home care providers in several ways:

• Early Identification of At-Risk Clients: By integrating the HospRisk-HC scale into routine assessments, providers can identify clients at higher risk of hospitalisation. This enables targeted interventions, such as enhanced monitoring, medication management, or increased support for chronic conditions like heart disease or diabetes, which are common drivers of hospital admissions.
  
• Resource Allocation: The scale’s ability to stratify clients into risk categories allows providers to allocate resources efficiently. For example, clients in higher-risk categories (6–9) may benefit from intensive case management or telehealth services, while those in lower-risk categories (1–5) may require less frequent interventions.
  
• Reducing Hospital Readmissions: The study highlights that prior hospitalisation is a strong predictor of future admissions. In Australia, the AIHW reports that 15% of hospitalisations for older adults are potentially preventable. By addressing modifiable factors—such as falls risk, medication adherence, or social isolation—home care providers can reduce readmissions and ease pressure on hospitals.

Lessons from international data

The international scope of the study provides valuable lessons for Australia. For instance, countries like the Netherlands and New Zealand, which have robust community care systems, demonstrate lower hospitalisation rates for home care clients compared to the US.

This suggests that investment in preventive care, such as multidisciplinary teams and early intervention programs, can reduce hospital reliance. Australia’s Home Care Packages (HCP) program, which supports over 200,000 older adults, could adopt similar strategies by:

• Enhancing Assessment Tools: Incorporating the HospRisk-HC scale into Australia’s home care assessment processes, such as the My Aged Care platform, could improve risk stratification. This aligns with the interRAI HC tool’s comprehensive approach, which evaluates functional, cognitive, and clinical factors.
  
• Strengthening Care Coordination: The study underscores the importance of addressing complex chronic conditions. Australian providers could emulate models from Canada, where integrated care teams (including nurses, allied health professionals, and social workers) collaborate to manage high-risk clients, reducing hospitalisations.
  
• Leveraging Technology: The rise of telehealth and remote monitoring, as seen in European countries, offers a scalable solution to monitor high-risk clients. For example, wearable devices or regular virtual check-ins could detect early signs of deterioration, preventing hospital admissions.

Additional insights from recent research

Beyond the study, recent data from X posts and web sources highlight global trends in aged care that resonate with Australian challenges.

A 2024 report from the World Health Organization (WHO) notes that integrated care models, combining health and social services, reduce hospitalisations by up to 20% in older populations.

In Australia, initiatives like the Comprehensive Geriatric Assessment (CGA) could be expanded to align with such models, ensuring holistic care that addresses both medical and social determinants of health.

Moreover, a 2025 X post from an Australian aged care provider highlighted the success of a pilot program using predictive analytics to prioritise home care visits.

Clients identified as high-risk received tailored interventions, resulting in a 12% reduction in hospital admissions over six months. This real-world example underscores the potential of tools like HospRisk-HC to drive measurable outcomes.

Challenges and considerations

Implementing the HospRisk-HC scale in Australia requires addressing several challenges:

• Workforce Capacity: Australia’s aged care workforce is stretched, with a 2024 Royal Commission report noting a shortage of 35,000 workers. Training staff to use predictive tools effectively will require investment in education and technology.
  
• Data Integration: The interRAI HC tool is not universally adopted in Australia. Aligning it with existing systems like My Aged Care will demand collaboration between government, providers, and technology partners.
  
• Equity of Access: Rural and remote communities, where 30% of older Australians live, face barriers to home care services. Ensuring predictive tools are accessible in these areas is critical to avoid exacerbating health inequities.

ConclusionThe HospRisk-HC scale offers Australian aged care leaders a powerful tool to predict and manage hospitalisation risks among home care clients. By identifying at-risk individuals early, providers can deliver targeted interventions, optimise resources, and reduce the burden on hospitals.

Lessons from international peers – such as integrated care models and technology-driven monitoring – can further enhance Australia’s home care system. As the sector prepares for a projected 1.5 million older adults accessing home care by 2030, adopting evidence-based tools like HospRisk-HC will be essential to deliver sustainable, high-quality care.