Emplify Health has achieved a major milestone in its partnership with Homecare Hub by transitioning its first 12 patients to supportive housing and care, addressing a critical gap in post-acute care. The partnership, announced in 2025, leverages Homecare Hub's technology platform and Emplify Health's clinical expertise to provide transitional placement services (TPS) for patients with complex needs who face barriers to hospital discharge.
The TPS model, developed by Emplify Health's innovation arm Edge, targets patients with multiple chronic conditions, specialized medical equipment needs, or ongoing therapy requirements. These patients often cannot return home safely or find appropriate long-term care beds, leading to prolonged hospital stays and poor outcomes. The initial TPS site in Tomah, Wisconsin, run by Blackberry Hill, has already shown promising results: in its first week, it surpassed one-month milestones and achieved a readmission rate in the single digits, well below the national average.
"As a hospitalist, I'm thrilled we can provide a new post-acute option that offers the personalized environment of small homes," said Homecare Hub CEO Vipan Nikore, MD. "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."
Emplify Health CEO Scott Rathgaber, MD, emphasized the importance of addressing the "silver tsunami"—the aging baby boom generation—which has created a surge in older adults requiring healthcare services. "This innovative model ensures patients receive high-quality care in a timely manner, and it provides our staff with tools to manage increasingly complex patient needs," he said.
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. Homecare Hub then matches patients to a transitional small home in its network of nearly 100 homes across multiple regions. Homecare Hub also collaborates with patients and community supports to identify the next suitable care setting, whether another small home, a traditional care facility, or back home with in-home care.
Mandi Pericak, Emplify Health by Gundersen Clinical Operations Director for Post-Acute Care, highlighted the model's impact: "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 is expected to expand to La Crosse and other regions based on demand. Homecare Hub has already achieved success with Froedtert ThedaCare Health System in Milwaukee, with positive outcomes presented at the Wisconsin Hospital Association's Post Acute Seminar. The company also received a nationwide SBIR grant from the National Institutes of Health to research small home outcomes.
"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.
