Emplify Health has 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 care that occurs when patients leave the hospital. The partnership centers around Transitional Placement Services, an innovative model designed for patients with complex needs who face barriers to hospital discharge.
The TPS model provides an intermediate option for patients who require specialized care before returning home or transitioning to long-term care. This approach is particularly crucial for patients with multiple chronic conditions, those needing specialized medical equipment, or individuals requiring ongoing therapy and monitoring. The model was concepted within Edge, Emplify Health's innovation investment team, and vetted through operations after review of data.
"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 initial implementation at an existing Adult Family Home in Tomah, run by Blackberry Hill, represents the first TPS site in Western Wisconsin. Emplify Health by Bellin is working to establish a TPS site in Green Bay, which would be the first in the Northeast Region of the state. The partnership leverages Homecare Hub's technology platform that streamlines care coordination by connecting patients with vetted care and housing options at homecarehub.com.
"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."
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's capacity. Homecare Hub then matches patients to appropriate transitional small homes in their curated network and collaborates to identify the next suitable care setting. The organization identifies barriers to discharge and creatively removes them to facilitate timely transitions.
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. Despite caring for 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.
The demographic shift of aging baby boomers 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. The TPS model reduces this burden on hospital staff, allowing them to focus on acute care while optimizing resources and improving discharge efficiency.
"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."
Homecare Hub has already demonstrated success through its partnership with 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 Institutes of Health and National Institute on Aging to research outcomes of small homes across the country. Emplify Health provides additional information about their healthcare network at emplifyhealth.org.
The initial implementation is expected to help Emplify Health prevent hundreds of hours in avoidable patient days and result in significant savings. 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, addressing one of healthcare's most pressing challenges in the era of demographic change.
