Emplify Health and Homecare Hub Partnership Addresses Critical Post-Hospital Care Gap with Transitional Placement Services

Emplify Health has transitioned its first 12 patients to supportive housing and care through its partnership with Homecare Hub, marking a major milestone in efforts to address a critical gap in care that can occur once patients leave the hospital. The partnership centers around an innovative model called Transitional Placement Services (TPS), which targets patients with complex needs who face barriers to hospital discharge. This model provides an intermediate option for patients who require specialized medical equipment, ongoing therapy, or monitoring before returning home or transitioning to long-term care.

The TPS model works through Homecare Hub's technology platform, which streamlines care coordination by connecting patients with a network of vetted care and housing options. The 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's capacity. Homecare Hub then matches patients to appropriate transitional small homes in their curated network and collaborates with patients and community supports to identify the next suitable care setting. Homecare Hub identifies barriers to discharge and creatively removes them to allow timely transitions from the transitional space.

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 establishing a TPS site in Green Bay, which would be the first in the Northeast Region of the state. The partnership's implementation in Tomah provides seamless transitions for patients who still require clinical care and have psychosocial needs that their previous living environment cannot meet.

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 and Emplify Health's clinical expertise, the partnership delivers enhanced patient care with smoother transitions and reduced readmissions. 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 many Medicaid patients, the Homecare Hub TPS home has had only one readmission, putting its readmission rate well below the national average.

The "silver tsunami" demographic shift has created a surge in older adults requiring healthcare services, compounded by decreasing availability of long-term care beds and unique patient care needs that exceed current post-acute care capabilities. 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. For more information on Homecare Hub, visit https://homecarehub.com.

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. The TPS model reduces the burden on hospital staff, allowing them to focus on acute care while optimizing resources and improving discharge efficiency. This innovative approach represents a practical solution to one of healthcare's most pressing challenges as the aging population continues to grow and strain existing healthcare systems.