Emplify Health has transitioned its first 12 patients to supportive housing and care through its partnership with Homecare Hub, marking a significant milestone in addressing a critical gap in care that occurs once patients leave the hospital. The partnership, announced in 2025, centers on an innovative model called Transitional Placement Services (TPS), which was developed within Emplify Health's innovation team, Edge, and vetted through operations after data review. TPS targets a critical gap in patient care while supporting a growing aging population.
The TPS model is a comprehensive approach designed to ensure that 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, those requiring specialized medical equipment, or those 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, run by Blackberry Hill, making it the first TPS site in Western Wisconsin. Emplify Health by Bellin is working on establishing 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.
Homecare Hub's technology platform streamlines care coordination by connecting patients with a network of vetted care and housing options, and they also support wraparound care services, ensuring high-quality, consistent care. The TPS process begins with a thorough interdisciplinary evaluation of a hospitalized patient who is ready for discharge but unable to be discharged due to care needs that have exceeded available support. If appropriate, a referral is sent to Homecare Hub to match the patient to the most appropriate transitional small home. Next, Homecare Hub collaborates with the patient and community supports to identify the next most suitable care setting.
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 care transitions outside of the current post-acute care landscape. 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.
“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,” said Emplify Health CEO Scott Rathgaber, MD. “We are proud to mark this milestone and we look forward to continued growth.”
