Emplify Health Partnership with Homecare Hub Addresses Critical Post-Hospital Care Gap

Emplify Health has successfully transitioned its first 12 patients to supportive housing and care through its partnership with Homecare Hub, marking a significant milestone in addressing a critical gap in post-hospital care. The collaboration centers around an innovative model called Transitional Placement Services (TPS), which provides an intermediate care option for patients with complex needs who face barriers to hospital discharge.

The TPS model represents a comprehensive approach designed for patients with multiple chronic conditions, specialized medical equipment requirements, or ongoing therapy needs. According to Homecare Hub CEO Vipan Nikore, MD, the program focuses on providing personalized environments in small homes rather than simply discharging patients to any available bed. ‘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.

Homecare Hub’s technology platform streamlines care coordination by connecting patients with vetted care and housing options through their network of nearly 100 small homes across multiple regions. The process begins with interdisciplinary evaluation of hospitalized patients ready for discharge but unable to leave due to care needs exceeding their current living environment’s capacity. Homecare Hub then matches patients to appropriate transitional small homes and collaborates with community supports to identify the next suitable care setting.

Emplify Health CEO Scott Rathgaber, MD, emphasized the program’s importance in addressing healthcare challenges, particularly the demographic shift marked by the aging baby boom generation. ‘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,” Rathgaber stated. The initial implementation at an existing Adult Family Home in Tomah, run by Blackberry Hill, represents the first TPS site in Western Wisconsin, with another site planned in Green Bay.

The partnership has demonstrated immediate impact, with the TPS home surpassing its one-month milestones in the first week and providing an immediate return on investment for the health system. Despite serving a complex population with many Medicaid patients, the Homecare Hub TPS home has maintained a readmission rate in the single digits, well below the national average. Mandi Pericak, Emplify Health by Gundersen Clinical Operations Director for Post-Acute Care, noted that the model helps ensure hospital beds remain available for those who truly need them while providing appropriate care settings for patients with diverse needs.

Homecare Hub has previously demonstrated success through its partnership with the Froedtert ThedaCare Health System in Milwaukee, with positive outcomes data presented at the Wisconsin Hospital Association’s Post Acute Seminar. The organization also recently received a nationwide SBIR grant from the National Institute of Health / National Institute for Aging to research small home outcomes across the country. Emplify Health and Homecare Hub plan to expand the program to La Crosse and throughout the region based on demand and patient outcomes, addressing the growing need created by decreasing long-term care bed availability and unique patient care requirements.

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