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.

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 partnership centers around an innovative model called Transitional Placement Services (TPS), which 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. 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 the appropriate care necessary before returning home or transitioning to a long-term care environment. This model is particularly crucial for patients who have multiple chronic conditions, require specialized medical equipment or need ongoing therapy and monitoring.

“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. The program is not just about discharging patients to any open bed, but rather a bed that will allow individuals to heal and receive outstanding care with enhanced support,” 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.”

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, which would be the first in the Northeast Region of the state.

“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. This innovative model ensures patients receive the high-quality care they need in a timely manner, and it provides our staff with tools and support to manage increasingly complex patient needs.”

Homecare Hub's technology platform streamlines care coordination by connecting patients with a network of vetted care and housing options, and they also support with wraparound care services, ensuring high-quality, consistent care. With deep clinical expertise, Homecare Hub has a particular focus on serving complex patients.

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 the available care and support in their current living environment. This evaluation helps determine the most appropriate care setting for each patient, and if appropriate, a referral is sent to Homecare Hub to match the patient to the most appropriate transitional small home in their curated network. Next, Homecare Hub collaborates with the patient and community supports to identify the next most suitable care setting — whether that be another small home, a traditional care and housing environment, or back home with in-home care supports. Homecare Hub identifies barriers to discharge and creatively removes them to allow patients to be discharged from the transitional space in a timely manner.

The partnership's initial implementation in Tomah provides a seamless transition for patients who still require clinical care, have psychosocial needs, and whose previous living environment cannot meet those requirements for a safe transition. 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.

“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, allowing us to provide the right care in the right setting at the right time.”

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 across multiple regions, Homecare Hub’s wraparound support services, and Emplify Health's clinical expertise, the partnership delivers enhanced patient care with smoother transitions and reduced readmissions. The TPS model reduces the burden on hospital staff, allowing them to focus on acute care, while optimizing resources and improving discharge efficiency. The initial implementation is expected to help Emplify Health prevent hundreds of hours in avoidable patient days and result in significant savings. 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 “silver tsunami” demographic shift has created a surge in older adults requiring healthcare services. This is compounded by decreasing availability of long-term care beds and unique patient care needs that require a care transition that is outside of 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.

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.”

Emplify Health is a not-for-profit, patient-centered, community-focused healthcare network with headquarters in Green Bay and La Crosse, Wisconsin. Emplify Health has 16,000 employees, including more than 1,000 clinicians, in 11 hospitals and more than 100 clinic locations in Wisconsin, Minnesota, Upper Michigan, and Iowa. With community partners, Emplify Health strives to lead local, regional and national healthcare transformation to enrich individuals for their healthiest lives at every stage. Learn more at emplifyhealth.org.

Homecare Hub was created to help expedite discharges from hospitals and to address the housing and home care needs of individuals by offering exceptional housing with more personalized, higher-quality care at a lower cost when compared to large nursing homes or retirement facilities. Homecare Hub does this by creating small, high quality shared care homes of 2-15 people on-demand at an affordable price by matching people by care needs, language, disease process, and interests. For more information on Homecare Hub, visit homecarehub.com.

The Edge mission is to radically transform the future of healthcare through innovation. Fueled by internal and community ideas, energized by other disruptors, and funded by our corporate ventures, we will harness the power of entrepreneurship, creativity, open-mindedness, and curiosity. Together we'll inspire, build, and distinguish ourselves by sharing healthcare innovations to benefit our organization, our community and our world. Learn more at ghsedge.com.

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