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Background: About 30% of home health care patients are hospitalized or visit an emergency department (ED) during a home health care (HHC) episode. Novel data science methods are increasingly used to improve identification of patients at risk for negative outcomes. Objectives:To identify patients at heightened risk hospitalization or ED visits using HHC narrative data (clinical notes).Methods: This study used a large database of HHC visit notes (n = 727,676) documented for 112,237 HHC episodes (89,459 unique patients) by clinicians of the largest nonprofit home health care agency in the United States. Text mining and machine learning algorithms (Naïve Bayes, decision tree, random forest) were implemented to predict patient hospitalization or ED visits using the content of clinical notes. Risk factors associated with hospitalization or ED visits were identified using a feature selection technique (gain ratio attribute evaluation). Results:Best performing text mining method (random forest) achieved good predictive performance. Seven risk factors categories were identified, with clinical factors, coordination/ communication, and service use being the most frequent categories.Discussion: This study was the first to explore the potential contribution of HHC clinical notes to identifying patients at risk for hospitalization or an ED visit. Our results suggest that HHC visit notes are highly informative and can contribute significantly to identification of patients at risk. Further studies are needed to explore ways to improve risk prediction by adding more data elements from additional data sources. Keywordshome health care; natural language processing; nursing informatics; risk prediction; text mining Every year, more than 11,000 home health care (HHC) agencies across the United States provide care to more than 5 million older adults (MedPac, 2014). Currently, about one in three HHC patients are hospitalized or visit an emergency department (ED) during the 30-