Emplify Health has transitioned its first 12 patients to supportive housing and care through its partnership with Homecare Hub, marking a milestone in addressing a critical gap in care that occurs after hospital discharge. The partnership, announced in 2025, centers on an innovative model called Transitional Placement Services (TPS), which was developed within Emplify Health's innovation investment team, Edge, to provide an intermediate care option for patients with complex needs who face barriers to leaving the hospital.
The TPS model is designed for patients with multiple chronic conditions, those requiring specialized medical equipment, or individuals needing ongoing therapy and monitoring who cannot be discharged directly home. It offers a comprehensive approach to ensure these patients receive appropriate care before returning home or moving to long-term care. Homecare Hub's technology platform, accessible at https://homecarehub.com, streamlines care coordination by connecting patients with vetted care and housing options while providing wraparound support services.
"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. He emphasized that the solution benefits patients, health systems, providers, and payers alike. The initial residential site is an existing Adult Family Home in Tomah, Wisconsin, run by Blackberry Hill, making it the first TPS site in Western Wisconsin. Emplify Health by Bellin is working to establish another site in Green Bay, which would be the first in the state's Northeast Region.
The TPS 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 support. 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, a traditional care environment, or a return home with in-home care supports. The model creatively removes discharge barriers to ensure timely transitions.
In its first week, the TPS home surpassed one-month milestones and provided an immediate return on investment for the health system. By leveraging Homecare Hub's network of nearly 100 small homes across multiple regions and Emplify Health's clinical expertise, the partnership has enhanced patient care with smoother transitions and reduced readmissions. Despite caring for a complex population with many Medicaid patients, the Homecare Hub TPS home has had only one readmission, placing its readmission rate well below the national average. This efficiency helps prevent hundreds of hours in avoidable patient days and yields significant savings.
The model addresses the growing challenges posed by the "silver tsunami," a demographic shift marked by the aging baby boom generation, which has increased demand for healthcare services while long-term care bed availability decreases. This shortage burdens hospitals, contributing to poor patient experiences and financial losses. Emplify Health CEO Scott Rathgaber, MD, stated, "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.'"
Homecare Hub has demonstrated success in other partnerships, such as with the Froedtert ThedaCare Health System in Milwaukee, where positive outcomes data were presented at the Wisconsin Hospital Association's Post Acute Seminar. Additionally, Homecare Hub recently received a nationwide SBIR grant from the National Institutes of Health and National Institute on Aging to research small home outcomes across the country. Emplify Health and Homecare Hub plan to expand the TPS model to La Crosse and other regions based on demand and patient outcomes, aiming to optimize hospital resources and improve discharge efficiency for complex patient populations.
