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 Edge, the health system's innovation investment team, and vetted through operations after review of data.
The TPS model targets patients with complex needs who face barriers to hospital discharge, providing an intermediate option before returning home or transitioning to long-term care. This is particularly crucial for patients with multiple chronic conditions, those requiring specialized medical equipment, or those needing ongoing therapy and monitoring. Emplify Health'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.
“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 exceeding their current living environment. A referral is sent to Homecare Hub, which matches the patient to a transitional small home in its 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, or home with in-home supports.
In its first week, the TPS home surpassed its one-month milestones and began providing an immediate return on investment. By leveraging Homecare Hub's network of close to 100 small homes and wraparound support services, the partnership delivers 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, putting its readmission rate in the single digits, well below the national average.
“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.
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.
“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.”
