Emplify Health has transitioned its first 12 patients to supportive housing and care through its Homecare Hub partnership, marking a major milestone in efforts to address a critical gap in care that can occur once patients leave the hospital. The initiative, rooted in an innovative model called Transitional Placement Services (TPS), aims to improve hospital throughput and patient experience by providing an intermediate care option for complex patients who face barriers to discharge.
In 2025, Emplify Health announced its partnership with Homecare Hub, a home care and housing coordination platform focused on creating high-quality small-care homes. Emplify Health’s post-acute care team and Edge, the health system’s innovation investment team, both partnered with and led Homecare Hub’s investment to improve patient care and outcomes through an integrated technology portfolio. The TPS model was concepted within Edge, vetted through operations after review of data, and targets a critical gap in patient care while supporting a growing aging population.
“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 model is designed for patients with multiple chronic conditions, specialized medical equipment needs, or ongoing therapy and monitoring who cannot safely return home or transition to long-term care immediately. The process begins with an interdisciplinary evaluation, followed by a referral to Homecare Hub to match the patient with an appropriate transitional small home. 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.
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. The partnership plans to expand to La Crosse and throughout the region based on demand and patient outcomes.
“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.”
In its first week, the TPS home surpassed its one-month milestones and began providing an immediate return on investment for the health system. The partnership has achieved a readmission rate in the single digits, well below the national average, despite caring for a complex population with a large number of Medicaid patients. The model reduces the burden on hospital staff, optimizes resources, and improves discharge efficiency, with the initial implementation expected to prevent hundreds of hours in avoidable patient days and result in significant savings.
“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.”
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. More information about Emplify Health is available at emplifyhealth.org, about Homecare Hub at homecarehub.com, and about Edge at ghsedge.com.
