A Tool for Predicting the Risk of Escalation in Hospital at Home

Importance Hospital at Home (HaH) is an emerging model of acute care delivery that provides hospital-level care in the home. The risk factors for escalation of care from HaH to the brick-and-mortar (BAM) hospital are incompletely understood. Being able to predict a patient’s risk of escalation could help HaH programs achieve their target escalation rate and inform patient consent. Objective The aim of this study was to identify independent risk factors for escalation, with the goal of creating an escalation risk prediction tool. Design We performed a retrospective chart review of 1000 consecutive cases over approximately one year in an HaH program for 11 hypothesized clinical and demographic risk factors. A logistic regression analysis was used to identify which factors were independent risk factors for escalation. The linear regression model was used to generate a percentage risk of escalation for each combination of risk factors. We also used the model to create a Web-based tool that provides a patient’s risk of escalation based on their risk factors. Setting The HaH Program in Victoria, British Columbia, Canada, which operates as an adult inpatient medical unit, and provides a mixture of in-person and virtual nursing and physician care to acutely ill adults referred from the BAM hospital. The Program uses remote patient monitoring and provides 24/7 support. Outcomes Clinical and demographic risk factors for escalation, and the risk of escalation for each combination of risk factors. Results Advanced cirrhosis, severe heart failure, frailty, metastatic cancer and male gender were identified as independent risk factors for escalation. The risk of escalation increased as the number of risk factors increased, from 4.1% (no risk factors) to 95.0% (all risk factors). Advanced cirrhosis was associated with a very high risk of escalation. The following factors were not identified as escalation risk factors: advanced age, end stage lung disease, severe renal failure, transplant status, being on chemotherapy and living alone. Conclusion Some, but not all, end stage comorbidities and male gender appear to be escalation risk factors in a Canadian adult medical HaH program, and a patient’s risk of escalation may be predictable based upon their risk factor profile. Advanced age and living alone did not increase the risk of escalation. These findings require validation by other HaH programs.