Emplify Health has transitioned its first 12 patients to supportive housing and care through its partnership with Homecare Hub, a milestone in addressing a critical gap in post-discharge care. The collaboration, announced in 2025, centers on Transitional Placement Services (TPS), a model designed to provide an intermediate care option for patients with complex needs who face barriers to hospital discharge.
The TPS model, concepted within Emplify Health's innovation investment team Edge, targets patients with multiple chronic conditions, specialized medical equipment needs, or ongoing therapy requirements. According to Homecare Hub CEO Vipan Nikore, MD, the program offers a personalized environment in small homes, which is often exactly what patients need post-discharge. “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,” Nikore said.
The initial TPS site is an Adult Family Home in Tomah, Wisconsin, run by Blackberry Hill, making it the first such site in Western Wisconsin. Emplify Health by Bellin is working on establishing a TPS site in Green Bay. Emplify Health CEO Scott Rathgaber, MD, emphasized the importance of the model amid the “silver tsunami” demographic shift. “By implementing TPS, we are addressing a critical gap that has long plagued healthcare,” Rathgaber said.
The TPS process begins with an interdisciplinary evaluation of hospitalized patients ready for discharge but unable to return home due to care needs. A referral is sent to Homecare Hub, which matches patients to transitional small homes in its network. Homecare Hub then collaborates with patients and community supports to identify the next suitable care setting, whether another small home, a traditional care facility, or home with in-home care.
In its first week, the TPS home surpassed one-month milestones, providing immediate return on investment. The model has achieved a readmission rate in the single digits, well below the national average, despite caring for a complex population with many Medicaid patients. “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.
The partnership is expected to prevent hundreds of hours in avoidable patient days and result in significant savings. Homecare Hub has already succeeded with a partnership with Froedtert ThedaCare Health System in Milwaukee, with positive outcomes data presented at the Wisconsin Hospital Association’s Post Acute Seminar. Homecare Hub also received an SBIR grant from the National Institute of Health to research small home outcomes nationwide.
Emplify Health and Homecare Hub plan to expand TPS to La Crosse and throughout the region based on demand and patient outcomes. “This partnership represents a significant leap forward in coordinated patient care,” Rathgaber said.
