Emplify Health has transitioned its first 12 patients to supportive housing through its partnership with Homecare Hub, marking a significant milestone in efforts to improve hospital throughput and patient experience for complex patients facing discharge barriers. The partnership, announced in 2025, centers on an innovative model called Transitional Placement Services (TPS), which provides an intermediate care option for patients who are medically ready for discharge but cannot return home due to care needs that exceed available support.
The TPS model was developed within Edge, Emplify Health's innovation investment team, and operationalized to target a critical gap in patient care, particularly for a growing aging population. The initial site in Tomah, Wisconsin, run by Blackberry Hill, has already surpassed its one-month milestones within the first week, providing immediate return on investment. The partnership plans to expand to La Crosse and Green Bay, with Emplify Health by Bellin working on a TPS site in Green Bay, the first in the Northeast Region of the state.
“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.”
The TPS process begins with an interdisciplinary evaluation of hospitalized patients ready for discharge but unable to leave due to care needs that exceed their current living environment. A referral is sent to Homecare Hub, which matches the patient to a transitional small home in its curated network of nearly 100 small homes across multiple regions. Homecare Hub then collaborates with the patient and community supports to identify the next most suitable care setting, whether that be another small home, a traditional care environment, or back home with in-home care supports.
“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. It also helps us ensure our hospital beds are available for those who truly need them.”
The impact has been notable: 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 partnership is expected to help Emplify Health prevent hundreds of hours in avoidable patient days and result in significant savings. 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.
“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 “silver tsunami” 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 exceed 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. The TPS model offers a practical solution by providing an additional intermediate option for patients with complex needs, including those with multiple chronic conditions, requiring specialized medical equipment, or needing ongoing therapy and monitoring.
“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. “We are proud to mark this milestone and we look forward to continued growth.”
