Emplify Health has transitioned its first 12 patients to supportive housing and care through its partnership with Homecare Hub, marking a major milestone in efforts to address a critical gap in care that can occur once patients leave the hospital. The partnership, announced in 2025, centers around an innovative model called Transitional Placement Services (TPS), which was concepted within Emplify Health's innovation investment team, Edge, and vetted through operations after review of data. TPS targets a critical gap in patient care while supporting a growing aging population.
The TPS model is a comprehensive approach designed to ensure patients with complex needs who face barriers to hospital discharge have an additional intermediate option to receive appropriate care before returning home or transitioning to a long-term care environment. This model is particularly crucial for patients with multiple chronic conditions, requiring specialized medical equipment, or needing ongoing therapy and monitoring. Homecare Hub's technology platform streamlines care coordination by connecting patients with a network of vetted care and housing options, and they also support with wraparound care services, ensuring high-quality, consistent care.
Emplify Health by Gundersen's initial residential Homecare Hub site is an existing Adult Family Home in Tomah, run by Blackberry Hill, making it the first TPS site in Western Wisconsin. Emplify Health by Bellin is working on standing up a TPS site in Green Bay, which would be the first in the Northeast Region of the state. The partnership's initial implementation in Tomah provides a seamless transition for patients who still require clinical care, have psychosocial needs, and whose previous living environment cannot meet those requirements for a safe transition.
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 close to 100 small homes across multiple regions, 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 a large number of 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 require a care transition outside of what the current post-acute care landscape can 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 help research the outcomes of small homes across the country.
“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 CEO Scott Rathgaber, MD, added, “This innovative partnership represents a significant leap forward in coordinated patient care. 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.'”
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. For more information on Homecare Hub, visit homecarehub.com. For more on Emplify Health, see emplifyhealth.org.
