Home-Based Care Remains Popular Among Senior Living Operators, But Adult Day Could Be in Trouble

Over half of the U.S.’s largest nonprofit senior living organizations now offer some sort of home- and community-based services.

That’s according to the LZ 200, an annual report conducted by the aging-focused advocacy organization LeadingAge and Ziegler Healthcare Investment Banking. Chicago-based Ziegler is a privately held investment bank specializing in home health care and senior living, among other areas.

“This LZ 200 report is one of our most important publications in helping inform the senior living and care industry during such a critical year,” Dan Hermann, the president, CEO and head of investment banking at Ziegler, said in a press release. “As the industry strives to provide the best care during the COVID-19 pandemic, these insights on the largest not for-profit senior living organizations provide an opportunity for providers and industry stakeholders to further adapt to this challenging moment.”


The LZ 200 examines the characteristics each year of the largest nonprofit senior living organizations. This year, it found that 51% of the top-200 now offer some sort of home- and community-based services, a 1% increase from 2019.

Trinity Health Senior Communities, the Evangelical Lutheran Good Samaritan Society, Presbyterian Village of Michigan, Holland Home and Concordia Lutheran Ministries are the five largest providers.

The home- and community-based services include home health care, home care, continuing care at home (CCaH) models, PACE programs, hospice and adult day services.


Three organizational offerings grew this year: home health, CCaH models and adult day care, while the remaining areas stayed on par with the 2019 report. Still, home care remained the most popular, with 34% of the organizations including that service line in 2020.

Of the largest 25 providers, 64% offered some sort of home- or community-based service.

“I am heartened to see that even through the pandemic, these organizations that are part of the LZ 200 continue to offer the home- and community-based services,” Brendan Flinn, the director of home- and community-based services at LeadingAge, told Home Health Care News. “It’s promising that there’s stability and frequency in home- and community-based services being offered.”

It makes sense, too. Even before COVID-19, non-home-based care providers were recognizing a shift into the home.

In fact, a LeadingAge report that came out before the public health crisis showed that well over 500 nursing home operators had closed since June 2015. The disruption since has been well documented and considerable, but the overall devastation is not yet totally clear.

“I think there’s definitely a lot of opportunity for home- and community-based services just based on that,” Flinn said. “I’d say there’s a continued and increased want among older adults for different options.”

LeadingAge represents more than 5,000 aging-focused organizations nationwide, including home-based care agencies.

CCaH continues to grow

CCaHs, sometimes referred to as home-based continuing care retirement communities (CCRCs), are a concept that has been gaining traction in recent years.

CCRCs are long-term care living situations that allow seniors to age in the same place during their advanced years through an all-encompassing approach. CCaHs take the same approach into the home.

In a post-COVID-19 world, the concept makes even more sense. Over 10% of nonprofit senior living providers now offer CCaH, according to the LZ 200, and that number is likely to increase moving forward.

“We’re hearing that across the board in the CCRCs and the PACE programs, [for instance],” Chris Hendrickson, managing director and a home health expert at Ziegler Healthcare Investment Banking, told HHCN in August. “Anything that involves some type of resident, these programs are contemplating and starting to actually migrate more toward in-home models.”

Dee Pekruhn, LeadingAge’s director of life plan community services and policy, has noticed the same trend.

“There has been enhanced interest among CCRCs in learning more about the CCaH model since the pandemic, and more are starting to see why diversification into this service line can really be a pipeline for their communities,” Pekruhn told HHCN.

Though the number of operators offering the model — 11% — seems low, CCaH has only gained notoriety as a concept in the last few years.

But more providers offering CCaH, coupled with COVID-19 implications, could mean significant growth for the model over the next five years or so.

“Once providers resurface from the haze and start to look at home- and community-based programs more seriously, I think we’ll see a surge in CCaH,” Pekruhn said. “That, coupled with increased consumer demand and understanding of the CCaH model, will potentially create a real uptick in patronage of the model.”

“As people realize what that can mean for their lives and their organizations, I do think it will gain in prevalence and popularity,” she added.

Adult day concerns

It’s not all rosey for home- and community-based providers, however. While adult day offerings increased this year among senior living providers, operators are generally not in a great place due to the COVID-19 crisis, Flinn said. 

Many adult day centers have remained closed months after the pandemic took foot in the U.S., either on a voluntary basis or by law.

Even for the ones that have opened, they’ve done so at an extremely limited basis. A center that generally has a capacity of 50 may be operating at say, 30% to 40% capacity, with only 15 to 20 clients allowed in at a time.

“There’s implications for the folks who were receiving those services in person who may not be anymore,” Flinn said. “There’s implications for family members of folks who receive those services who lost that support or don’t have that support in the same capacity. But also, there’s harsh implications for the providers themselves.”

While most aging-focused industries have taken a hit due to COVID-19, that trouble has either subsided or been mitigated by government assistance. That’s not necessarily the case for adult day.

“Other types of organizations that have seen significant impact from COVID, like nursing homes, also have the income of being reimbursed for providing that care,” Flinn said. “When adult day facilities closed, the revenue went right out the door with them.”

Nursing homes — and even Medicare-certified home health providers — have been provided significant relief from the federal government during the public health emergency.

Adult day centers, on the other hand, have been spared very little.

“When a new relief package comes together, adult days need to be included to ensure not only that they’re able to reopen in a safe manner, but also so they are able to continue to operate as the pandemic comes to an end — and beyond that,” Flinn said.

Adult day services are a key source of support for middle- to lower-income families caring for senior loved ones.

That’s because the pricing can be more manageable. At an adult day center, one caregiver can take care of a handful of patients at a time, which is an alternative to private, one-on-one care.

“If those types of providers are not able to survive as a result of not having revenue and not receiving relief, there could be huge implications for those communities down the line,” Flinn said.

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