Emplify Health has transitioned its first 12 patients to supportive housing and care through its partnership with Homecare Hub, marking a significant step in addressing a critical gap in care that occurs after hospital discharge. The collaboration, announced in 2025, involves Emplify Health's post-acute care team and its innovation investment team, Edge, which also participated in leading Homecare Hub's investment to enhance patient outcomes through integrated technology.
The partnership centers on an innovative model called Transitional Placement Services (TPS), conceptualized within Edge and vetted through operational data review. TPS is designed for patients with complex needs who face barriers to hospital discharge, offering an intermediate option before returning home or moving to long-term care. This model is particularly crucial for patients with multiple chronic conditions, those requiring specialized medical equipment, or individuals needing ongoing therapy and monitoring.
"As a hospitalist, I'm thrilled we can provide a new post-acute option that offers the personalized environment of small homes, which is often exactly what is needed for patients post-discharge," said Homecare Hub CEO Vipan Nikore, MD. "Rarely in healthcare do solutions benefit all stakeholders, but here we are pleased that the solution is a win for patients, health systems, providers and payers."
Emplify Health by Gundersen's initial residential Homecare Hub site is an existing Adult Family Home in Tomah, operated by Blackberry Hill, making it the first TPS site in Western Wisconsin. Emplify Health by Bellin is working to establish a TPS site in Green Bay, which would be the first in the state's Northeast Region. "This innovative partnership represents a significant leap forward in coordinated patient care," said Emplify Health CEO Scott Rathgaber, MD. "By implementing TPS, we are addressing a critical gap that has long plagued healthcare, especially as we face the challenges of the so-called 'silver tsunami' — a major demographic shift marked by the aging of the baby boom generation."
The TPS model works through Homecare Hub's technology platform, which streamlines care coordination by connecting patients with a network of vetted care and housing options while providing wraparound support services. The process begins with an interdisciplinary evaluation of hospitalized patients ready for discharge but unable to leave due to care needs exceeding their current living environment's capacity. If appropriate, a referral is sent to Homecare Hub to match the patient to a transitional small home in their curated network. Homecare Hub then collaborates with the patient and community supports to identify the next suitable care setting, whether another small home, traditional care environment, or returning home with in-home care supports, while identifying and removing discharge barriers.
The initial implementation in Tomah provides seamless transitions for patients requiring clinical care or having psychosocial needs that their previous living environment cannot support. Emplify Health and Homecare Hub plan to expand and create more homes in La Crosse and throughout the region based on demand and patient outcomes. "Our patients have a wide variety of clinical and social needs, and it is our job to find them the safest, healthiest placement possible," said Mandi Pericak, Emplify Health by Gundersen Clinical Operations Director for Post-Acute Care. "Whether it's dementia, a history of substance abuse or difficulty with daily basic tasks, the TPS model gives us another avenue for safe and effective placement when these patients are ready."
In its first week, the TPS home surpassed its one-month milestones and began providing an immediate return on investment for the health system. By leveraging Homecare Hub's network of nearly 100 small homes across multiple regions, along with their wraparound support services and Emplify Health's clinical expertise, the partnership delivers enhanced patient care with smoother transitions and reduced readmissions. The TPS model reduces the burden on hospital staff, allowing them to focus on acute care while optimizing resources and improving discharge efficiency. The initial implementation is expected to help Emplify Health prevent hundreds of hours in avoidable patient days and result in significant savings. Despite caring for a complex population with many Medicaid patients, the Homecare Hub TPS home has had only one readmission, putting its readmission rate in the single digits, well below the national average.
The "silver tsunami" demographic shift has created a surge in older adults requiring healthcare services, compounded by decreasing availability of long-term care beds and unique patient care needs that current post-acute care landscapes struggle to manage. This shortage has placed immense burden on hospitals, contributing to poor patient experiences and financial losses. Homecare Hub has already achieved success with its partnership with the Froedtert ThedaCare Health System in Milwaukee, with positive outcomes data recently presented at the Wisconsin Hospital Association's Post Acute Seminar. Homecare Hub also recently was awarded a nationwide SBIR grant from the National Institute of Health / National Institute for Aging to research small home outcomes across the country.
"Our partnership with Homecare Hub represents a new era in post-acute patient care, offering a practical solution to one of healthcare's most pressing challenges," Rathgaber said. For more information on Homecare Hub, visit homecarehub.com.
