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 partnership, announced in 2025, centers on an innovative model called Transitional Placement Services (TPS), which was concepted within Edge, Emplify Health's innovation investment team.
TPS is a comprehensive approach designed to ensure that patients with complex needs who face barriers to hospital discharge have an additional intermediate option to receive appropriate care before returning home or transitioning to a long-term care environment. This model is particularly crucial for patients with multiple chronic conditions, requiring specialized medical equipment or 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.
“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 a thorough interdisciplinary evaluation of a hospitalized patient who is ready for discharge but unable to be discharged due to care needs that have exceeded available support in their current living environment. A referral is sent to Homecare Hub to match the patient to the most appropriate transitional small home. Homecare Hub then collaborates with the patient and community supports to identify the next suitable care setting, whether that be another small home, a traditional care environment, or back home with in-home care supports.
In its first week, the TPS home surpassed its one-month milestones and began providing an immediate return on investment for the health system. 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 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.
“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 partnership addresses the “silver tsunami” demographic shift, which has created a surge in older adults requiring healthcare services, compounded by decreasing availability of long-term care beds. This shortage has placed immense burden on hospitals, contributing to poor patient experiences and financial losses. Emplify Health and Homecare Hub plan to expand and create more homes in La Crosse and throughout the region based on demand and patient outcomes.
