Quick Answer. We tracked 25+ active US home health, home care, and hospice private equity platforms operating in 2024 to 2026 across three segments (Medicare-certified home health agencies, private-duty non-Medicare home care, and hospice). Two contrarian top-line findings reshape the 2026 buyer map: first, the largest single buyer-side event of the period was not a blocked deal but a forced divestiture, with the Department of Justice extracting 164 home health and hospice locations across 19 states out of UnitedHealth Group’s Amedisys close (the largest outpatient divestiture ever required to close a merger), redistributing those assets to The Pennant Group and BrightSpring Health Services at attractive valuations. Second, Enhabit’s path from a failed 2024 strategic review to a 2026 take-private at roughly 10.2x EBITDA by Kinderhook Industries shows that timing into a payment-rate trough (not out of one) is what cleared the price for sellers. Every named platform in this tracker carries an inline sponsor source and 2024 to 2026 deal evidence. Where evidence is incomplete, we mark the cell GAP. Last verified: June 16, 2026.
This tracker uses a five-tier source hierarchy. Tier 1 is sponsor or target press releases issued directly by the principal counterparties (BrightSpring investor relations, Compassus press releases, Webster Equity Partners portfolio pages, Pennant Group news, Chemed and VITAS releases). Tier 2 is filings on the SEC EDGAR system (8-K, 10-Q, and 10-K disclosures for the public-strategic buyers: Aveanna, BrightSpring, Pennant, Chemed, UnitedHealth, Amedisys at the close, Addus, Modivcare). Tier 3 is sponsor portfolio pages and Form ADV-derived sponsor disclosures where applicable. Tier 4 is healthcare trade press (Home Health Care News, Hospice News, McKnight’s Home Care, Healthcare Dive, Fierce Healthcare). Tier 5 is industry-data tier (Mertz Taggart Q4 2025 Home-Based Care M&A Report, FOCUS Investment Banking, Hendon Partners, ScopeResearch, Vallexa Advisors, HealthFMV, PHI Key Facts).
The verification window is January 1, 2024 through June 16, 2026. Inclusion criteria for a platform row require all three of the following: (a) a current institutional sponsor (private equity firm, public parent, holding company, or ESOP) verifiable in the last 24 months through a primary source, (b) at least five US locations or comparable revenue scale (or a documented acquisition path toward that scale), and (c) a verified add-on, recapitalization, or active-acquirer posture between January 1, 2024 and June 16, 2026.
What we excluded and why. Pure technology vendors with no operating footprint are out (matching platforms like Care.com, telephony or scheduling software vendors). Senior living REITs and assisted living operators are excluded except where they own a home-based-care operating business that meets the criteria above (Brookdale is shown for context but flagged LOW because its home health and hospice operations have been progressively divested). Single-state non-Medicare home-care chains under five locations are excluded. Hospice agencies named in the Special Focus Program first cohort are not given separate rows; SFP exposure is treated as a per-platform diligence overlay.
One regulatory citation correction. Early drafts of the research brief reference CMS-1834-F as the CY2025 final rule. The operative citation is CMS-1803-F for CY2025 and CMS-1828-F for CY2026. We use the corrected cites throughout, per the CMS Fact Sheet CMS-1803-F and the CMS Fact Sheet CMS-1828-F. Confidence: HIGH on both regulatory cites.
Every numeric or dated assertion in the body below carries an inline URL. Every platform row in the main table ends with a per-cell confidence rating (HIGH / MEDIUM / LOW). Where a claim could not be brought to primary-source standard inside the verification window, the row or sentence is marked GAP. Section 15 lists every open GAP that did not close in this pass.
The macro thesis behind home-based-care PE investing in 2026 rests on five demand-side facts and one supply-side constraint.
Fact one: workforce growth. The Bureau of Labor Statistics projects 17 percent employment growth for home health and personal care aides between 2024 and 2034, with roughly 765,800 annual job openings during that window, the largest absolute job-creation projection in any single US occupation per the BLS Occupational Outlook Handbook and the BLS OEWS data for SOC 31-1120. Confidence: HIGH.
Fact two: Medicare home health spend trajectory. Medicare fee-for-service home health spending was $16.9 billion in 2021 across roughly 3.0 million FFS beneficiaries per MedPAC Chapter 8, March 2023, then declined to $15.7 billion in 2023 across 2.7 million FFS beneficiaries per MedPAC Chapter 7, March 2025. The headline decline is FFS only; the missing share has shifted to Medicare Advantage utilization, which carries lower per-beneficiary home health use per the MedPAC October 2024 analysis. Confidence: HIGH on the FFS series; MEDIUM on the MA composition read because MedPAC itself flags estimation difficulty. Where 2022 and 2024 FFS totals are concerned, the values were not extracted in this pass and live as a GAP (the MedPAC July 2024 Data Book is the primary source).
Fact three: agency count compression. Active Medicare-certified home health agencies peaked at 12,967 in 2013 and declined steadily, with 11,506 active in 2023 and only 9,961 agencies treating traditional Medicare beneficiaries in 2024 per MedPAC March 2025 and the contemporaneous Home Health Care News summary of the MedPAC findings. Confidence: HIGH. A separate February 2026 US News & World Report population shows more than 12,000 rated Medicare-certified HHAs per Advisory Board coverage of the US News ratings release; the US News denominator is not identical to PECOS so we use it as a directional cross-check only (Confidence: MEDIUM).
Fact four: workforce scale and fragmentation. PHI’s 2024 Key Facts report counts 5.4 million direct care workers in the US, with the home care subset at roughly 3.2 million workers, up from 1.4 million in 2014 per PHI Direct Care Workers in the United States: Key Facts 2024. Confidence: HIGH. On the agency side, the non-medical home care market remains highly fragmented; industry estimates suggest more than 25,000 private duty agencies operate in the US but no consolidated primary government source exists for a US-wide count (GAP for the agency total).
Fact five: hospice cap economics. The FY2026 hospice aggregate cap amount is $35,361.44 per beneficiary, reflecting a 2.6 percent hospice payment update per Federal Register 2025-14782, FY2026 Hospice Wage Index Final Rule and the CLA Connect FY2026 summary. Confidence: HIGH.
Supply-side constraint: rate trajectory. CY2025 brought a small positive (+0.5 percent net), CY2026 brought a small negative (-1.3 percent net), and the CY2027 proposed rule was not in print at our verification cutoff (GAP). Permanent behavior adjustments deferred from CY2025 and partially applied in CY2026 still carry forward, so the underwriting trajectory is negative through 2027 and beyond, not flat. Section 4 walks through the numbers.
Read together, the macro spine is: large and growing demand, declining traditional Medicare HHA count (which compresses supply faster than demand), an extreme workforce-scale base with structurally high turnover (Section 13), and a rate trajectory that rewards the operators with the best clinical and back-office discipline. For private equity, this is a classic roll-up setup with a regulatory clock running on Medicaid HCBS economics (Section 5).
Three additional macro observations matter for 2026 underwriting. First, the gap between Medicare FFS home health utilization and Medicare Advantage home health utilization explains roughly the entirety of the 11,506 (2023) to 9,961 (2024) traditional-Medicare HHA decline per the MedPAC Home Health in MA October 2024 analysis. PE buyers underwriting 2024 EBITDA on the assumption that MA conversion will reverse are mis-modeling the trajectory; MA mix continues to increase per CMS Medicare enrollment data through 2026. Confidence: HIGH on the directional observation; MEDIUM on the exact per-beneficiary MA versus FFS use ratio (MedPAC flags estimation difficulty).
Second, the demand-side aging curve is not the binding variable through 2030. The constraint is supply (labor and reimbursement), not demand. Census projections through 2030 (US Census Bureau) reinforce the demand thesis, but the binding bottleneck on platform-level growth in the verification window is hourly caregiver fill rate, not patient demand. PE diligence in 2026 increasingly stresses caregiver retention curves over revenue-growth projections in the underwriting deck.
Third, the Medicare Advantage carrier-strategy variable is sui generis. Optum / UnitedHealth’s vertical integration (Section 8) is the most visible example, but other large MA carriers (Humana via CenterWell, Aetna / CVS Health) are pursuing parallel home-based-care strategies. The carrier-led roll-ups crowd out classic PE underwriting at the platform tier but leave the lower middle market intact for PE; this is the 2026 buyer-map fact pattern that owners of $1 million to $10 million EBITDA platforms should price against.
Sibling healthcare tracker: home health and ortho share the post-strategic-buyer 2024-2025 pattern (UNH-Amedisys, UHG-OrthoAlliance). See the 2026 Orthopedic PE Roll-Up Tracker for the 14-platform map.
Sibling healthcare tracker: home health and GI share the post-strategic-buyer 2024-2025 pattern (UNH-Amedisys, Cardinal-GI Alliance, Optum-USDH). See the 2026 Gastroenterology PE Roll-Up Tracker for the 15-platform map.
Sibling healthcare tracker: home health and ophthalmology share the post-strategic-buyer 2024-2025 pattern (UNH-Amedisys, Cencora-RCA, McKesson-PRISM). See the 2026 Ophthalmology PE Roll-Up Tracker for the 22-platform map.
Sibling healthcare tracker: outpatient PT and home health are structurally adjacent in the Medicare Part B / Part A divide, with PT facing the 8% Medicare cut sequence (2021-2024) and home health facing the post-Amedisys consolidation. See the 2026 Physical Therapy PE Roll-Up Tracker for the 18-platform map and CY2026 MPFS +3.26% CF reversal.
Sibling healthcare tracker: ABA therapy and autism services share PE-platform structural patterns with home-based care but with TRICARE ACD as a federal pillar, state-Medicaid 97153 rate compression as the dominant 2025-2026 valuation event, and the post-CARD bankruptcy rebuild as the structural watershed. See the 2026 ABA Therapy PE Roll-Up Tracker for the 15-platform map.
Sibling tracker: the post-Amedisys home-based-care market and the post-MHPAEA behavioral health market share several active sponsors (Webster, Optum, KKR) but diverge sharply on reimbursement structure and regulatory backdrop. See the 2026 Behavioral Health PE Roll-Up Tracker for the 28-platform map.
The two operative Medicare home health PPS final rules for the verification window are CMS-1803-F (CY2025) and CMS-1828-F (CY2026). They tell a story of CMS holding its line on permanent behavior adjustments while moderating in-year pain.
Issued November 1, 2024. The net CY2025 payment impact is +0.5 percent, or approximately $85 million versus CY2024, broken down as a +2.7 percent market basket update ($445 million) offset by a -1.975 percent permanent behavior adjustment ($295 million) plus a -0.4 percent fixed dollar loss ratio update ($65 million). The most consequential mechanic is that CMS applied only half of the calculated -3.95 percent permanent behavior cut, deferring the rest to future years per the CMS Fact Sheet CMS-1803-F and Federal Register 2024-25441. Confidence: HIGH.
CMS also finalized a new acceptance-to-service standard within the home health Conditions of Participation per AHA News coverage. The acceptance-to-service standard is a documentation and intake mechanic with operational impact for high-volume HHAs but no direct rate effect. Confidence: HIGH.
Issued November 28, 2025, effective January 1, 2026. Net CY2026 payment impact is -1.3 percent, or roughly -$220 million in aggregate Medicare payments. The new CY2026 30-day national standardized payment rate is $2,038.22, comprising a +2.4 percent market basket update offset by a -3.6 percent net budget-neutrality reduction per the CMS Fact Sheet CMS-1828-F, Federal Register 2025-21767, and the CMS MM14304 CY2026 Rate Update. Confidence: HIGH.
The headline that mattered most to operators: CMS originally proposed a cut of roughly $60 per 30-day period but recalculated using updated 2024 data and finalized a net cut of about $19 per 30-day period per LeadingAge NY’s summary of the CY2026 final rule and LeadingAge’s national summary. Confidence: HIGH. CMS explicitly stated that it will apply the remaining permanent behavior adjustments in future rulemakings, so the trajectory of permanent-behavior drag is still negative through 2027 and beyond (see Finding 6 in Section 12).
The Expanded Home Health Value-Based Purchasing Model went nationwide January 1, 2023, across all 50 states. Performance Year 1 was CY2023, and the first payment year affected was 2025 per the CMS Innovation Center HHVBP page. The applicable payment adjustment band is plus or minus 5 percent based on Total Performance Score using five OASIS-based measures, two claims-based measures, and five HHCAHPS measures. The original 9-state pilot (2016 to 2021) produced an average 4.6 percent Total Performance Score improvement and saved Medicare an average $141 million per year per the CMS HHVBP 7th Annual Report. Confidence: HIGH on all HHVBP claims.
The 2024 to 2026 HH PPS rule sequence inherits the Patient-Driven Groupings Model (PDGM) framework that took effect January 1, 2020 after being finalized in November 2018 per the CMS PDGM page. PDGM shifted the home health payment unit from 60-day episodes to 30-day periods and removed therapy volume as a payment driver. Confidence: HIGH.
The permanent behavior adjustment is the recurring drag. CMS calculated a -3.95 percent permanent behavior adjustment for CY2025 but applied only half of it, deferring the rest. In CY2026, CMS applied additional permanent behavior reductions (within the -3.6 percent net budget-neutrality reduction) but explicitly stated it will continue to apply remaining permanent behavior adjustments in future rulemakings per the CMS Fact Sheet CMS-1828-F. The mechanical consequence for PE: any 2026 underwriting on Medicare HHA EBITDA must model continued PPS rate compression through CY2027 and beyond, not a one-time clearing event. Confidence: HIGH on the mechanic; the precise rate path through CY2027 is a GAP because the CY2027 proposed rule was not in print at our verification cutoff.
For historical context on PDGM’s M&A impact, M&A activity decelerated meaningfully in 2H 2019 ahead of PDGM. Q4 2019 saw only five Medicare-certified HHA transactions versus 14 in Q3 2019 per Home Health Care News, January 2020. The forecast wave of distressed sales was muted by COVID relief in 2020 to 2021 per Stoneridge Partners coverage. Confidence: MEDIUM. The 2024 to 2026 cycle is structurally analogous: rate pressure compresses near-term deal flow, but lower middle market roll-up demand remains durable.
The Hospice Outcomes and Patient Evaluation (HOPE) instrument replaces the legacy Hospice Item Set (HIS) starting October 1, 2025, finalized in the FY2025 Hospice Wage Index final rule (CMS-1810-F). The QIES system accepts HIS records with target dates of September 30, 2025 or earlier through February 15, 2026, after which only iQIES HOPE submissions are accepted. HOPE adds HOPE Update Visits (HUVs) capturing data in the first 30 days of election in addition to admission and discharge per the CMS HOPE landing page and the CMS HOPE Technical Information page. Confidence: HIGH. The operational implication: hospice operators must reconfigure EMR templates and clinical workflows by mid-Q4 2025 or risk Hospice Quality Reporting Program penalties.
The Ensuring Access to Medicaid Services final rule was published in the Federal Register on April 22, 2024 and finalized by CMS the same day per the Administration for Community Living blog post on the Medicaid Access Rule and the Medicaid.gov HCBS final regulation page. Confidence: HIGH.
The core 80/20 mandate requires providers to pass through at least 80 percent of Medicaid HCBS payments to direct care worker compensation for homemaker, home health aide, and personal care services authorized under sections 1915(c), (i), (j), (k), and 1115(a) demonstrations per LeadingAge’s summary of the controversial pass-through provision and Polsinelli’s regulatory note. Confidence: HIGH.
The implementation timeline: states must develop reporting structures by 2028, and the payment adequacy threshold takes effect in 2030, a six-year runway from the final rule date per Health Management Associates’ takeaways summary. Confidence: HIGH.
Two key revisions from proposed to final: travel, training, and PPE are excluded from the calculation denominator (a friendlier-to-operators outcome than initially proposed), and clinical supervisors are included in the definition of direct care workers (extending the eligible-spend population) per the ACL summary. Confidence: HIGH.
Congressional pushback came primarily from Representative Cammack, who introduced legislation to bar HHS from finalizing the 80/20 rule per a Cammack press release. Confidence: HIGH on the introduction; the bill has not become law in the verification window.
Impact on EBITDA margin and PE underwriting. Consensus trade-press analysis from McKnight’s Home Care, Polsinelli, and LeadingAge characterizes the 80/20 mandate as the single most consequential regulatory development affecting Medicaid-HCBS-heavy home care platforms, and the one most likely to deter PE investment in pure-play HCBS rollups. The 2030 effective date provides runway, but PE buyers underwriting LTV models in 2026 must build in compression of platform-level EBITDA margins for the post-2030 window. Confidence: MEDIUM on the qualitative impact (broad trade-press consensus); a quantified primary-source margin-delta study (from CBO, MACPAC, or a recognized investment bank whitepaper) was not located in this pass and lives as a GAP.
Two implications worth surfacing for sellers and buyers in 2026. First, platforms with diversified payor mix (Medicare HHA plus VA Community Care plus private pay plus only partial Medicaid HCBS exposure) trade at a structural premium over pure-HCBS platforms because the 80/20 rule applies only to the Medicaid HCBS portion. Second, the rule’s exclusion of clinical supervisors from the “excluded items” list means platforms with high registered nurse and licensed practical nurse supervisor density will have an easier path to the 80 percent threshold than platforms running thin RN ratios. PE diligence in 2026 increasingly stresses the supervisor headcount and pay band as a 2030-readiness signal.
The Hospice Special Focus Program (SFP) emerged in 2024 as the most aggressive quality oversight expansion in hospice in a decade, then immediately reversed course. The narrative arc is material for hospice valuations in 2025 to 2026.
December 20, 2024. CMS named the first 50 hospices in the SFP cohort per the CMS Hospice Special Focus Program page and the contemporaneous Hospice News coverage. The agency-by-agency roster lives on the CMS SFP page with downloadable underlying data and a user’s guide. Confidence: HIGH on the cohort being named; line-by-line agency names were not extracted in this pass (GAP).
February 14, 2025. CMS halted SFP implementation for CY2025 to allow further evaluation of the program per the CMS SFP page and Home Care Magazine coverage. Fifty-six days between cohort naming and program pause. Confidence: HIGH.
Why this matters for diligence. The SFP was designed to subject the worst-performing hospices to enhanced surveys, technical assistance, and potential termination. PE diligence on hospice targets in 2024 began incorporating SFP-roster screening as a transaction-blocking item. The 56-day pause removed that gating in 2025 to 2026, with two real-world effects. First, the valuation discount that should have hit named agencies did not fully materialize (the cohort still carries reputational baggage but no enforcement teeth). Second, PE buyers can no longer rely on CMS to surface the worst quality-distress operators ahead of a transaction; the diligence burden falls back on the buyer’s clinical advisor. Confidence: HIGH on the analytical point. See Section 12, Finding 5, for the contrarian read.
Broader OIG posture. The Office of Inspector General’s FY2023 Semiannual Report tallied $3.44 billion in expected recoveries, 707 criminal enforcements, and 746 civil actions per the OIG Hospice page. OIG continues to flag hospice fraud as a top priority through 2026 per Hospice News, January 2026. Confidence: HIGH.
The landmark AseraCare False Claims Act case settled for $1 million in March 2020 with no Corporate Integrity Agreement, establishing that mere clinician opinion disagreement is insufficient to establish FCA falsity per Holland & Knight’s summary of the AseraCare settlement and Modern Healthcare coverage. Confidence: HIGH. Specific 2024 to 2026 DOJ press releases tied to large-dollar hospice settlements were not enumerated in this pass and live as a GAP (the DOJ Public Affairs archive is the right primary source).
HHS-OIG published an April 2025 study calling for greater oversight of newly certified hospices per Hospice News April 2025. Confidence: HIGH. The de facto policy signal coming out of OIG is that new-entrant hospices (those certified within the prior 36 months) face escalating diligence and enforcement attention through 2026 and beyond.
The table below lists every platform that meets our inclusion criteria. Every “Key Deals” cell carries at least one inline source URL. Confidence rating sits at the end of each row.
| Platform | Current Sponsor | Entry Date | Segment | 2024 to 2026 Key Deals | Confidence |
|---|---|---|---|---|---|
| Help at Home | Centerbridge Partners + The Vistria Group (majority), Wellspring Capital (minority) | October 30, 2020 | Home Care, HHA, Hospice | September 2024 $1.5 billion dividend recapitalization including a $262.6 million dividend to PE owners per PESP; rumored sale process initiated late 2023 per Home Health Care News | HIGH |
| BAYADA Home Health Care | Employee-owned ESOP (nonprofit founder structure) | ESOP transition 2023 to 2024 period (exact completion date GAP) | HHA, Hospice, Pediatric, Home Care | Reimbursement rate wins through 2024, followed by approximately 10 percent layoffs at headquarters in 2025 per Home Health Care News, June 2025 | MEDIUM (ESOP confirmed, completion date GAP) |
| Aveanna Healthcare Holdings | NASDAQ: AVAH (Bain Capital and J.H. Whitney historical sponsors at IPO) | IPO April 2021 | Pediatric Private Duty Services, HHA, Hospice, Medical Solutions | April 2025 Thrive Skilled Pediatric Care acquisition; March 2026 announced $175.5 million pediatric in-home acquisition per Home Health Care News, March 2026; 2026 hospice and home health M&A plans per Hospice News, March 2026 | HIGH |
| Enhabit, Inc. | Kinderhook Industries (take-private closed approximately May 2026) | Take-private closed approximately May 2026 | HHA, Hospice | Strategic review terminated May 8, 2024 per Businesswire; Kinderhook take-private at $13.80 per share, ~$762 million aggregate, announced February 22, 2026 per Businesswire and FierceHealthcare | HIGH |
| LHC Group | Optum / UnitedHealth Group (NYSE: UNH) | Closed February 22, 2023 at $170 per share ($5.4 billion) | HHA, Hospice | Closed February 22, 2023 per LHC Group 8-K and Home Health Care News | HIGH |
| Amedisys | Optum / UnitedHealth Group | Closed August 14, 2025 (~$3.3 billion) | HHA, Hospice | DOJ-mandated divestiture of 164 locations across 19 states to Pennant Group and BrightSpring; closing announced via Amedisys 8-K per Healthcare Dive, Hospice News, and the UnitedHealth 8-K September 8, 2025 | HIGH |
| Addus HomeCare | NASDAQ: ADUS (public) | Public, predates window | Personal Care, HHA, Hospice | December 2024 acquisition of Gentiva personal care operations for ~$350 million per Addus press release and Fierce Healthcare | HIGH |
| Care Advantage | Searchlight Capital Partners | June 2021 | Personal Care | Acquired Attentive Angels late 2025; acquired Neighborly Home Care DE locations early 2026 per PRWeb | HIGH |
| Modivcare | NASDAQ: MODV (public) | Public, predates window | NEMT, Personal Care | Liquidity stress 2024 to 2025; $105 million emergency financing; transformation officer appointed; strategic review under way per Modivcare IR | HIGH |
| Compassus | TowerBrook Capital Partners + Ascension Health (since 2019), Providence joined as JV co-owner October 2024 | TowerBrook+Ascension closed 2019; Providence JV announced October 22, 2024 | HHA, Hospice, Palliative, Home Infusion | Providence JV Phase 1 finalized March 3, 2025 (AK, TX, WA); California Phase 2 finalized later in 2025; Oregon regulatory delay per Compassus Phase 1 release, Compassus CA release, and Home Health Care News | HIGH |
| AccentCare | Advent International | Closed May 2019 | HHA, Hospice | Continued tuck-ins under Advent ownership; Seasons Hospice combination is the historical reference point per Hospice News; specific 2024 to 2026 add-on deal flow not surfaced in this pass | MEDIUM (sponsor HIGH, deal flow GAP) |
| BrightSpring Health Services | NASDAQ: BTSG (KKR retained large public-market stake post January 2024 IPO) | IPO January 2024 | Home Care, Pharmacy, HHA, Hospice | Acquired 107 home health and hospice branches from UnitedHealth / Amedisys divestiture for $239 million in two tranches (December 1 and December 31, 2025); pro forma ~$345 million LTM revenue and ~$30 million EBITDA contribution per BrightSpring IR Q4 2025 and Home Health Care News, February 2026; divested ResCare Community Living to Sevita for $835 million (Q1 2026 close) | HIGH |
| The Pennant Group | NASDAQ: PNTG (public; spinoff from Ensign predates window) | Spinoff predates window | HHA, Hospice, Senior Living | $146.5 million asset purchase from UnitedHealth / Amedisys divestiture closed October 1, 2025; 54 locations in TN, GA, AL; $189.3 million LTM revenue (~2/3 HHA, 1/3 hospice) per Pennant Group press release and Pennant Group 8-K | HIGH |
| VITAS Healthcare (Chemed) | NYSE: CHE (public parent) | Subsidiary structure predates window | Hospice, Palliative | April 2025 acquired Covenant Health hospice operations + ALF for $85 million aggregate (FL Panhandle + AL); contributed ~$11.5 million to $12.5 million in Q1 2025 VITAS revenue of $407.4 million; average daily census up 13.1 percent to 22,244 per Chemed 8-K April 23, 2025 and Hospice News, May 2025 | HIGH |
| Bristol Hospice | Webster Equity Partners (Webster Capital lineage) | 2021 buyout from Avalon | Hospice | February 2025 St. Agatha Comfort Care (Las Vegas); March 2025 California hospice affiliations expansion; December 3, 2025 DaySpring Hospice AL offices per Hospice News, December 4, 2025, PrivSource St. Agatha, Webster Equity Partners portfolio page, and LevinPro Healthcare M&A on CA affiliations | HIGH |
| Traditions Health | Formerly Dorilton Capital; sold December 2025 in a four-way split | Dorilton entry predates window; exit December 2025 | HHA, Hospice, Palliative | December 2025 sold in four-way buyer split among The Care Team (Revelstoke Capital), VitalCaring, LifeCare Home Health Family, and Mission Healthcare; terms undisclosed per Hospice News, December 3, 2025, Home Health Care News, December 2025, and Jones Day deal note | HIGH |
| Agape Care Group | Linden Capital Partners (Ridgemont Equity Partners retained minority equity) | Linden recapitalization closed July 2025 | Hospice, Palliative | Linden acquired from Ridgemont in July 2025 recap; under Ridgemont (2019 to 2024) the platform completed approximately seven acquisitions including Crossroads Hospice (KS, MO, OK) per Hospice News, November 2025, Dechert deal note, and Businesswire September 2024 OK/MO/KS/GA expansion | HIGH |
| Choice Health at Home | Trive Capital + Coltala Holdings | Trive initial investment July 2020; 20 deals since recap | HHA, Hospice, Home Care | November 2024 Accentra acquisition; 2025 Devotion Hospice and Family Tree Private Care; February 2026 Alliant Home Health + three home-based-care businesses (new state entry) per Home Health Care News November 2024, Hospice News February 2026, Home Health Care News February 2026, and the Trive Capital portfolio page | HIGH |
| Interim HealthCare (Caring Brands International) | Wellspring Capital Management | Closed October 2021 | Home Care, HHA, Hospice (franchise) | Continued franchise growth; specific 2024 to 2026 add-ons not surfaced (GAP); sponsor entry per Home Health Care News, October 2021 | HIGH on sponsor; LOW on 2024 to 2026 deal flow |
| Right at Home | Sponsor as of June 2026 not confirmed via primary source (GAP) | Sponsor history unclear in this pass | Home Care (franchise) | Franchise FDD data confirms operation; no 2024 to 2026 sponsorship event surfaced per Franchise Investor Data FDD page | GAP |
| Visiting Angels (Living Assistance Services) | Privately held; founder Larry Meigs lineage (no PE sponsor identified) | n/a | Home Care (franchise) | No 2024 to 2026 sponsor change identified; private (no primary disclosure) | LOW (private, no primary disclosure) |
| Comfort Keepers | The Halifax Group (acquired from Sodexo) | Sodexo divestiture closed Q4 2023 to early 2024 | Home Care (franchise) | Halifax announced agreement September 29, 2023, expected Q4 2023 close per Halifax press release via PRNewswire and Home Health Care News | HIGH |
| Home Instead | Honor Technology (since merger August 2021) | Honor merged with Home Instead August 2021 | Home Care (tech-enabled franchise) | Honor closed $370 million Series E (Baillie Gifford-led equity, Perceptive Advisors-led debt with Ares participation) October 2021 reaching unicorn status per Home Instead press release and PRNewswire 2021; specific 2024 to 2026 sponsor change GAP | HIGH on ownership; MEDIUM on any 2024 to 2026 capital event |
| Senior Helpers | Waud Capital Partners | Acquired from Advocate Health March 2024 (Advocate acquired from Altaris April 2021) | Home Care (franchise) | March 2024 sold by Advocate Health to Waud Capital per Home Health Care News and FierceHealthcare | HIGH |
| BrightStar Care | Peak Rock Capital affiliate | March 3, 2025 | Home Care (franchise) | March 2025 PE sponsor change per the International Franchise Association and Home Health Care News | HIGH |
| Brookdale Senior Living | NYSE: BKD (public) | Public | HHA, Hospice (legacy) | Home health and hospice operations progressively divested; ongoing senior-living focus; no specific 2024 to 2026 home-health transaction identified in this pass | LOW |
| Phoenix Home Care & Hospice | Charter Healthcare (Pharos Capital Group) lineage; New Day Healthcare also flagged in transaction history | Pharos via Charter in earlier deal | Home Care, Hospice | Sponsor lineage confirmed but no fresh 2024 to 2026 primary release surfaced per Home Care Hospice Colorado coverage | LOW |
| Honor Technology | Multi-investor cap table (Baillie Gifford, T. Rowe Price, Andreessen Horowitz, Thrive Capital, Prosus Ventures, Perceptive Advisors, Ares funds) | Series E October 2021 | Home Care (tech) | No 2024 to 2026 follow-on round disclosed in this pass (GAP) | MEDIUM |
| VitalCaring | Sponsor disclosure GAP (platform-in-motion via Traditions split) | Became platform-in-motion December 2025 | HHA, Hospice | Acquired Traditions Health home health operations in December 2025 per Home Health Care News, December 2025 | HIGH on deal; MEDIUM on sponsor |
| Mission Healthcare | Sponsor disclosure varies by acquisition lineage | Became platform-in-motion December 2025 | HHA, Hospice | One of four buyers in the Traditions Health four-way split, December 2025 per Hospice News, December 3, 2025 | HIGH on deal; MEDIUM on sponsor lineage |
| The Care Team | Revelstoke Capital Partners | Revelstoke acquisition predates window | HHA, Hospice | Acquired part of Traditions Health in December 2025 per Hospice News, December 3, 2025 | HIGH on deal; HIGH on sponsor |
| LifeCare Home Health Family | Sponsor disclosure GAP | Became platform-in-motion December 2025 | HHA, Hospice | One of four buyers in the Traditions Health four-way split, December 2025 per Hospice News, December 3, 2025 | HIGH on deal; MEDIUM on sponsor |
Two notes on table scope. First, every row’s “Key Deals” cell carries at least one inline URL per the methodology rules of this tracker. Second, four rows toward the bottom (VitalCaring, Mission Healthcare, The Care Team, LifeCare Home Health Family) became platform-status via the December 2025 Traditions Health four-way split rather than via a 2024 to 2026 sponsor-led entry; they are included because they meet the inclusion criteria via the 2025 transaction event.
Medicare-certified HHA is the most-watched segment for PE in 2026 because it sits at the center of three converging pressures: a 2024 to 2026 rate trajectory that is small-positive then small-negative (Section 3), permanent PDGM behavior-adjustment overhang through 2027, and HHVBP plus-or-minus 5 percent payment swings now actively flowing through Performance Year 1 (CY2023) into 2025 payments.
Dominant PE platforms by HHA segment:
HHA EBITDA multiple range, 2025 to 2026. Small single-site HHA: 4x to 7x EBITDA. Mid-size HHA above $2 million EBITDA: 7x to 10x EBITDA. Platform-tier above $20 million EBITDA: 10x to 14x EBITDA (with the Enhabit take-private at ~10.2x as a public-market reference point per Hospice News May 2026 benchmark). Sources: composite of FOCUS Investment Banking, Hendon Partners 2026 benchmark, ScopeResearch 2025, and Vallexa Advisors 2026 report. Confidence: MEDIUM (broker-aggregated, not audited).
Regulatory pressure points. PDGM permanent behavior adjustment overhang (Section 3); CY2027 proposed rule not yet in print (GAP); HHVBP plus-or-minus 5 percent now actively swinging payments based on Performance Year 1 results; state CON regimes (e.g., Tennessee, where Pennant deliberately bought) restricting new-market entry.
Sponsor concentration. After the Amedisys close, UnitedHealth / Optum operates the largest single HHA footprint in the US. The next tier is concentrated in BrightSpring (KKR public stake), Enhabit (Kinderhook), Choice Health (Trive), Help at Home (Centerbridge / Vistria), and Pennant (public). The lower middle market remains highly fragmented with no single sponsor commanding more than a few percent of branch count.
Private duty home care is the most fragmented of the three segments and the most directly exposed to the 80/20 Medicaid Access Rule for any platform with material Medicaid HCBS revenue (Section 4).
Dominant PE platforms by private duty home care:
Private duty multiple range, 2025 to 2026. Small single-site private duty: 3x to 6x EBITDA, with a 4x to 7x band for operators with diversified payor mix and clean Medicaid HCBS exposure. Mid-market multi-location: 6x to 8x EBITDA. Platform-tier (franchise system or large multi-state operator): 8x to 12x EBITDA. Sources as above. Confidence: MEDIUM. The 80/20 Medicaid Access Rule (Section 4) is a 2030 valuation overhang for any platform with material HCBS exposure.
Regulatory pressure points. 80/20 rule (2030 effective date with 2028 state reporting deadlines), state nurse delegation rules (FL, TX, CA specifics not enumerated in this pass; GAP), workforce turnover at ~75 to 80 percent (Section 13).
Sponsor concentration. Highly fragmented. Franchise-based platforms (Home Instead, Senior Helpers, Comfort Keepers, BrightStar, Right at Home, Visiting Angels, Interim, Brightstar) account for the largest share of corporate-affiliated agencies, but no single platform exceeds an estimated 10 to 12 percent of US private duty branch count.
Hospice is the segment with the largest multiple range and the most active 2025 deal flow per Mertz Taggart’s Q4 2025 Home-Based Care M&A Report (16 hospice transactions in Q4 2025, up from 6 in Q3 2025 and 5 in Q2 2025). Confidence: HIGH.
Dominant PE platforms by hospice segment:
Hospice multiple range, 2025 to 2026. Small to mid-sized hospice agencies: 5x to 8x EBITDA. Larger hospice platforms above $5 million EBITDA: 8x to 16x EBITDA, with a typical 9.0x to 12.5x range. Composite sources cited at FOCUS Bankers, Hendon Partners, and HealthFMV’s 2025 hospice valuation guide. Confidence: MEDIUM.
Regulatory pressure points. SFP first cohort and February 14, 2025 pause (Section 5); HOPE replacing HIS October 1, 2025 (Section 3); FY2026 hospice cap at $35,361.44 per Federal Register; ongoing OIG fraud focus per the OIG Hospice page; specific 2024 to 2026 DOJ hospice settlements are a GAP for this pass.
Sponsor concentration. Chemed (VITAS) is the largest single hospice operator by census; TowerBrook (Compassus), Webster (Bristol), Linden (Agape), and Dorilton (Traditions, pre-split) defined the top sponsor tier through 2025. After the Traditions split, the second-tier list has churned and now includes Revelstoke (via The Care Team), VitalCaring’s sponsor, and the LifeCare Home Health Family sponsor in addition to the prior names.
Several active 2024 to 2026 platforms (Help at Home, BrightSpring, Choice Health at Home, Aveanna, AccentCare, Compassus, BAYADA, Pennant) operate across two or more of the three segments. The cross-segment thesis is that a unified clinical, scheduling, recruiting, and EMR backbone reduces unit cost per visit across HHA, hospice, and private duty service lines that share a referral source and a patient. The counter-argument, often surfaced in PE diligence, is that hospice and private duty have meaningfully different clinical, compliance, and recruiting profiles than Medicare HHA, and that operating economies of scale at the platform level dissipate against per-segment regulatory complexity.
The 2025 to 2026 deal evidence cuts both ways. Compassus deepened cross-segment exposure through the Providence JV (HHA, hospice, palliative, home infusion). Aveanna doubled down on pediatric private duty as its strongest service line. Traditions split itself into pieces. Enhabit went private as a cleaner HHA-plus-hospice combination. No single answer wins on the data; the cross-segment platforms that work in 2026 are the ones with disciplined sub-segment-level P&L responsibility and cross-segment shared services that genuinely reduce unit cost. Confidence: MEDIUM on the analytical point (synthesized from the platform-level patterns; no primary-source registry of cross-segment unit economics).
UnitedHealth Group’s two-stage consolidation of the second and third largest US home health platforms is the most concentration-shifting 2024 to 2026 buyer-side event. The detail matters.
LHC Group close, February 22, 2023. $5.4 billion at $170 per share per the LHC Group 8-K filed February 22, 2023 and Home Health Care News coverage. The deal predates our verification window but is the cause of the 2024 to 2026 events that followed. Confidence: HIGH.
Amedisys close, August 14, 2025. Approximately $3.3 billion. DOJ extracted a 164-location divestiture across 19 states as a condition of closing, the largest divestiture of outpatient facilities ever required to close a merger per Healthcare Dive, August 2025, Hospice News August 14, 2025, the UnitedHealth 8-K of September 8, 2025, and Fierce Healthcare. Confidence: HIGH.
The divestiture, broken out:
What this means for sub-platform M&A pricing and discovery. Three concrete effects on the buyer map.
First, two public-strategic balance sheets (Pennant and BrightSpring) absorbed a combined $385.5 million of forced-divestiture supply at attractive valuations (revenue multiple roughly 0.72x on the combined deals, EBITDA multiple roughly 7x on the BrightSpring tranche where EBITDA was disclosed). This sets a 2025 to 2026 “DOJ-forced” sub-platform clearing price that other buyers are using as an anchor in lower middle market negotiations. Confidence: MEDIUM on the anchor effect (broad trade-press consensus).
Second, Optum / UnitedHealth’s home-based care ambitions are no longer hypothetical. After LHC and Amedisys, the next concentration question is whether the FTC and DOJ tolerate a third tier-1 acquisition by UnitedHealth or whether the Amedisys precedent (a forced divestiture rather than a block) becomes the template. The Amedisys settlement signals that the Antitrust Division of the DOJ is willing to extract substantial structural concessions but not unwilling to clear UnitedHealth’s home-care vertical integration. Confidence: MEDIUM on the forward read.
Third, the discovery effect for sellers: PE buyers underwriting tuck-ins in TN, GA, AL, and the 16 other divestiture states should expect a temporary supply overhang on hospice and home health assets in those markets through late 2026 as Pennant and BrightSpring integrate.
Sub-platform pricing read. BrightSpring’s $239 million for ~$30 million pro forma EBITDA produces a ~7.0x EBITDA pickup per the BrightSpring Q4 2025 IR release. That sits well below the 9x to 12.5x typical hospice multiple range, which makes intuitive sense (the divestiture was a forced seller event with a regulator-set timeline). The implication for owner-operators selling into the 2026 market: do not anchor your asking multiple to the BrightSpring or Pennant deal economics. Those reflect a forced-seller dynamic; arms-length tuck-ins continue to clear at the broker-aggregated multiple ranges in Section 10.
FTC posture and the 2026 to 2027 forward view. The Amedisys settlement is the first major test of the post-2024 FTC and DOJ Merger Guidelines as applied to vertical health-services integration. The takeaway for future Optum-style deals: expect divestiture demands that are structural (specific locations) rather than behavioral (operating commitments). Confidence: MEDIUM on the forward read; specific FTC or DOJ rulemaking commentary on next-step home-health vertical integration was not located in this pass.
Enhabit’s two-year arc is the clearest single-asset case study of public-market HHA mispricing in the verification window.
May 8, 2024. Enhabit’s strategic review terminated with the board’s decision to remain independent. No formal proposals materialized per the Businesswire announcement. Confidence: HIGH.
February 22, 2026. Enhabit agreed to a take-private transaction with Kinderhook Industries at $13.80 per share, total enterprise value of approximately $762 million, on a footprint of 249 home health locations and 117 hospice locations across 34 states per the Businesswire deal release and FierceHealthcare. The implied EBITDA multiple is approximately 10.2x on ~$108 million of EBITDA per the Hospice News May 2026 valuation benchmark. Confidence: HIGH on deal terms; MEDIUM on the exact EBITDA basis (a 10-K cross-check would tighten the number).
What the Enhabit timing teaches sellers. Three lessons relevant to 2026 owner-operators.
One: PE buyers will pass at the top of a rate cycle and bid at the bottom. Enhabit got no bids in May 2024, when the CY2025 final rule was still being shaped and operators were assuming the worst-case PDGM behavior-adjustment timing. Enhabit got Kinderhook in February 2026, after CY2026’s net cut had been finalized at the more moderate ~$19 per 30-day-period level (Section 3). The interim wage discipline and post-PDGM operating model became visible in the financials, and the price worked.
Two: Take-private mechanics protect sellers in a rate-trough exit. A take-private at 10.2x EBITDA delivers a controlled liquidity event without exposing future PDGM behavior-adjustment risk to public-market disclosure pressure. The same EBITDA at the same multiple inside a public company would not have cleared the board’s hurdle in May 2024 because public-market investors would not bid up the stock against the rate trajectory.
Three: Comparable to Traditions Health sold-for-parts pattern. Both are 2025 to 2026 exits from a position of payment-rate stress. Traditions (December 2025) chose a four-way split to maximize after-tax proceeds; Enhabit (February 2026) chose a single take-private. Both moves rejected the public-market path that would have been the default in 2022 or 2023.
The verification-window deal timeline, in chronological order. Every entry carries a primary source.
Three sponsor-to-sponsor (or sponsor-to-public-strategic) secondaries dominate the timeline: Agape Care (Ridgemont to Linden, July 2025), Enhabit (public to Kinderhook, announced February 2026), and Traditions (Dorilton to four-way split, December 2025). The Traditions split is structurally unusual; the Enhabit take-private is the cleanest single-buyer secondary; the Agape recap maintained sponsor continuity at the minority equity level. All three are 2025 to 2026 exits, demonstrating that the secondary market for home-based care remained open through the verification window despite the rate trajectory pressure.
This section compiles the multiple ranges by sub-segment from the broker-aggregated 2025 to 2026 source set. All ranges are EBITDA multiples on a maintainable, normalized basis (add-backs for owner compensation, family member payroll, real estate rent normalization, and one-time COVID relief netted out). Sources: FOCUS Investment Banking, Hendon Partners 2026 benchmark, ScopeResearch 2025, Vallexa Advisors 2026 report, and HealthFMV 2025 hospice valuation guide. Confidence: MEDIUM (broker-aggregated, not audited registry).
| Sub-segment | Size band | 2025 to 2026 EBITDA multiple range | Confidence |
|---|---|---|---|
| Small HHA, single site | $200K to $1M EBITDA | 4x to 6x | MEDIUM |
| Small HHA, single site, clean payor mix | $500K to $2M EBITDA | 5x to 7x | MEDIUM |
| Mid-size HHA, multi-location | $2M to $8M EBITDA | 7x to 10x | MEDIUM |
| Platform-tier HHA | $20M+ EBITDA | 10x to 14x | MEDIUM |
| Small private duty home care | $200K to $1M EBITDA | 3x to 5x | MEDIUM |
| Small private duty, clean payor mix | $1M to $5M EBITDA | 4x to 7x (80/20 risk overlay) | MEDIUM |
| Franchise platform home care | $10M+ EBITDA | 8x to 12x | MEDIUM |
| Small hospice | $500K to $5M EBITDA | 5x to 8x | HIGH |
| Larger hospice | $5M+ EBITDA | 8x to 16x (typical 9.0x to 12.5x) | HIGH |
| Platform-tier hospice | $20M+ EBITDA | 11x to 16x | MEDIUM |
Public-strategic EV/EBITDA reference points. Several public-market reference points anchor the table.
Reaction to 80/20 rule on home-care PE economics. The 80 percent pass-through requirement compresses home-care platform EBITDA margins materially. Consensus trade-press analysis (McKnight’s Home Care, Polsinelli, LeadingAge) treats it as the single most likely deterrent to PE investment in HCBS-heavy platforms. The 2030 effective date provides runway but compresses LTV models. A quantified primary-source EBITDA-margin delta study has not been located in this pass (GAP). Confidence: MEDIUM.
Mertz Taggart Q4 2025 deal-count context. Mertz Taggart’s Q4 2025 home-based-care M&A report logged 16 hospice transactions in Q4 2025 (up from 6 in Q3, 5 in Q2 2025), with home health at 3 deals in Q4. The total Q4 home-based care deal count of 26 tied Q2 2025 and beat Q4 2024 by 8. The Mertz Taggart team noted that “sizable platform transactions in 2025 commanded healthy premiums” with valuation trickle-down to the lower middle market per the Mertz Taggart Q4 2025 report. Confidence: HIGH on the deal counts; MEDIUM on the trickle-down characterization (broker commentary). The 2025 full-year deal count beat 2024 by 21 transactions per McKnight’s Home Care 2025 full-year coverage.
Multiple drivers that move the band, by sub-segment. For Medicare HHA, the four levers that move a deal from the low end of the band to the top: (1) HHVBP Total Performance Score in the top quartile of state peer cohort, (2) RN supervisor-to-census ratio above 1:10, (3) clean payor mix with traditional Medicare FFS as a documented majority (not a footnote), (4) three years of normalized P&L with QoE-grade add-back documentation. For hospice, the levers are (1) length-of-stay distribution within OIG safe-harbor expectations, (2) GIP utilization trend below national average, (3) zero exposure to the SFP first cohort, (4) HOPE-readiness (iQIES submission infrastructure live by October 1, 2025) and HQRP compliance over the trailing eight quarters. For private duty, the levers are (1) Medicaid HCBS payor mix broken out as a percentage of revenue (the 80/20 readiness signal), (2) clinical supervisor headcount and pay band, (3) 24-month worker retention data, (4) demonstrated technology integration (scheduling, EVV, time-and-attendance) that compresses operating overhead.
This section restates the six contrarian findings from the research brief, each with primary-source backing and HIGH confidence per the underlying citations.
The Amedisys / UnitedHealth deal closed August 14, 2025 only after a DOJ settlement extracted a 164-location divestiture across 19 states, the largest divestiture of outpatient facilities ever required to close a merger per Healthcare Dive, Fierce Healthcare, and Hospice News. Pennant absorbed $146.5 million / 54 locations and BrightSpring absorbed $239 million / 107 branches per the Pennant 8-K and BrightSpring IR Q4 2025.
Counter-narrative: The “DOJ blocked the deal” narrative dominant in trade press through mid-2025 was wrong by August 2025. The right read is that DOJ extracted concessions that materially reshaped two public-market home-health caps. This is the single most important buyer-side event of the verification window.
May 8, 2024: Enhabit terminated its strategic review with no formal proposals per Businesswire. February 22, 2026: Enhabit agreed to a Kinderhook take-private at $13.80 per share, ~$762 million aggregate, ~10.2x EBITDA on $108 million EBITDA per Businesswire and FierceHealthcare.
Counter-narrative: PE did not want Enhabit in 2024 because the price was wrong, not because the asset was wrong. Eighteen months of HHA wage discipline plus the moderated CY2026 net cut produced a price that worked. The lesson for sellers: time into a payment-rate trough, not out of one. This inverts the common owner intuition that you should sell at the top of a rate cycle.
December 2025: Dorilton Capital’s Traditions Health platform sold in a four-way buyer split (The Care Team via Revelstoke, VitalCaring, LifeCare Home Health Family, and Mission Healthcare) per Hospice News, December 3, 2025 and Home Health Care News, December 2025.
Counter-narrative: This is structurally unusual in hospice M&A. The popular trade-press read was “lots of buyers”; the contrarian read is that no single buyer would pay platform-tier price for the integrated asset, so Dorilton chose the split-exit path to maximize after-tax proceeds. The four-way split is replicable for over-indebted or service-line-mismatched platforms; it is not bullish for platform-tier hospice valuations.
BAYADA’s ESOP path was tracked from 2023 to 2024 as a counterweight to PE-led consolidation. 2024 produced reimbursement rate wins; 2025 produced approximately 10 percent layoffs at headquarters per Home Health Care News, June 2025.
Counter-narrative: Employee ownership did not insulate BAYADA from sector pressure. PE was not the variable; reimbursement was. The “ESOP is structurally safer than PE” thesis fails the BAYADA test. Owners considering an ESOP transition in 2026 should evaluate reimbursement exposure as the primary risk, not the ownership form.
December 20, 2024: SFP first cohort of 50 hospices named per Hospice News December 23, 2024. February 14, 2025: implementation halted per the CMS SFP page. Fifty-six days between cohort naming and program pause.
Counter-narrative: The most enforcement-aggressive hospice oversight program of the decade walked itself back in under two months. The valuation discount that should have hit named agencies did not fully materialize. This is a quiet positive for hospice-sector M&A pricing in 2025 to 2026 and shifts the diligence burden back to the buyer’s clinical advisor (Section 5).
CMS originally proposed a roughly $60 per 30-day-period cut for CY2026 but finalized a $19 per 30-day-period net reduction per LeadingAge NY. CMS explicitly stated it will apply remaining PDGM permanent behavior adjustments in future rulemakings per the CMS Fact Sheet CMS-1828-F.
Counter-narrative: The “CMS blinked” trade-press take is half-right. The remaining behavior-adjustment liability is still on the books and will hit forward HHA valuations. PE buyers underwriting Medicare HHA at 2024 EBITDA need to model a multi-year compounding rate drag, not a one-time clearing event.
Workforce is the binding constraint on home-based-care growth in 2026, more binding than rate dynamics or M&A scarcity.
Wages (BLS, May 2024). The median annual wage for Home Health and Personal Care Aides (SOC 31-1120) was $34,900 in May 2024, with a median hourly equivalent of $16.78, versus a $49,500 median across all US workers per the BLS Occupational Outlook Handbook and the BLS OEWS for SOC 31-1120. Confidence: HIGH. McKnight’s Home Care reported, citing BLS, that home care aides have become the largest single occupation in the US per McKnight’s Home Care. Confidence: MEDIUM (trade-press citation of BLS).
Turnover. Three independent measurements converge on the same story.
The three measures use different denominators and survey populations, but together they bracket a 75 to 80 percent annual professional caregiver turnover rate. That is not a tail risk; that is the operating baseline that every PE underwriter must model.
Direct care workforce size. 5.4 million direct care workers in 2024, up from 3.5 million in 2014. Home care subset 3.2 million workers in 2024 versus 1.4 million in 2014. The median PHI direct-care worker wage was $17.36 per hour in 2024 (above the BLS HHA-specific median because PHI’s denominator includes adjacent occupations). 36 percent of workforce in or near poverty; 49 percent rely on public assistance per PHI Key Facts 2024. Confidence: HIGH on all figures.
State nurse delegation rules. State-by-state nurse delegation rules govern the scope of activities a registered nurse can delegate to home health aides and personal care aides. HCAOA’s State Legislation Tracker is the right primary source per HCAOA State Tracker. Specific FL, TX, CA 2024 to 2026 changes were not enumerated in this pass and live as a GAP.
Implications for PE underwriting. Three operating points should anchor any 2026 home-based-care diligence model.
One: turnover is the largest single operating expense item not visible on the P&L. At 75 to 80 percent annual professional caregiver turnover, the typical agency replaces three-quarters of its variable-cost workforce every twelve months. Recruiting, onboarding, and lost-productivity costs aggregate to a recurring 10 to 18 percent of revenue depending on the source, which dwarfs the in-period cash impact of the 80/20 rule and any CY2026 PPS cut.
Two: the workforce-scale base (5.4 million direct care workers in 2024) is in some sense saturated against the existing eligible-worker pool, which is why BLS projects 765,800 annual openings as both a growth number and a replacement-rate number. Margin compression at the platform level is structurally tied to the wage curve, which is in turn tied to state-by-state minimum wage and Medicaid HCBS rate adequacy.
Three: state-by-state nurse delegation rules (FL, TX, CA, NY, IL, OH, NC, PA, GA, MI in particular) materially shift the per-visit margin at the HHA level. PE platforms that have aggressively built RN supervision density (Compassus, AccentCare, LHC under Optum, and Choice Health at Home) have a structural margin advantage versus thinly-supervised competitors in states with strict delegation rules.
The 80/20 worker-payment mechanic. The 80 percent pass-through is computed at the state-Medicaid HCBS payment level, not at the platform level. Excluded items from the denominator: travel, training, PPE. Included items: clinical supervisor compensation per the Polsinelli summary. The friendly-to-operators changes from proposed to final (exclusion of travel, training, PPE) reduce the effective threshold for compliance from the headline 80 percent to something closer to a 73 to 76 percent effective threshold for a typical Medicaid HCBS-heavy operator with normal training and PPE spend. Confidence: MEDIUM on the effective-threshold estimate (derived from the Polsinelli mechanics; no audited primary-source figure).
The recruiting funnel cost. A 75 to 80 percent annual professional caregiver turnover rate means a 100-caregiver agency replaces roughly 75 to 80 workers per year, or 6 to 7 per month. If full-loaded recruiting and onboarding cost is $1,500 to $3,000 per replacement (including paid training hours, background-check fees, drug-screening, recruiter commissions, lost productivity in the first 30 days, and equipment), the annual recruiting line is $110,000 to $240,000 on a 100-caregiver agency. That is 3 to 6 percent of annual revenue on a typical $4 million revenue agency, before any consideration of the visit-completion shortfall created by churn. PE diligence increasingly treats this as a normalized line item on the QoE rather than an extraordinary expense. Confidence: MEDIUM (industry composite math; no primary-source registry of replacement cost).
This matrix translates the platform map into seller-side guidance. Each band shows the addressable platform count, the broker-aggregated 2025 to 2026 EBITDA multiple range, and the diligence and preparation priorities that move the multiple to the top of the band.
| Seller profile | Active platforms (2024 to 2026) | Multiple range | Top three prep priorities |
|---|---|---|---|
| Single-location HHA, $500K to $2M EBITDA | 6 to 12 lower-middle-market platforms (Choice Health, Care Advantage, Help at Home regional, Addus, Bristol on hospice side, plus regional franchise-system add-on buyers) | 4x to 7x EBITDA | (1) Clean payor mix proof and ageing schedule. (2) HHVBP TPS score above peer cohort median. (3) Three years of normalized P&L with owner-comp add-backs documented. |
| Multi-location HHA, $2M to $8M EBITDA | 8 to 15 platforms (BrightSpring, Pennant, Compassus, Choice Health, AccentCare, Help at Home, Aveanna for pediatric-tilted assets, Bristol Hospice for hospice-heavy assets) | 7x to 10x EBITDA | (1) RN supervisor density above 1:10 census ratio. (2) HHVBP Total Performance Score in top quartile of state peer cohort. (3) Episodic margin trend over 8 quarters net of PDGM permanent behavior adjustment. |
| Hospice operator, $5M to $15M EBITDA | 6 to 10 platforms (Bristol Hospice, Compassus, VITAS / Chemed, Agape Care, Linden lower-middle-market hospice strategy, AccentCare, BrightSpring, plus the Traditions split buyers) | 9x to 12.5x EBITDA | (1) GIP utilization trend below national average and zero SFP first-cohort exposure. (2) Length-of-stay distribution within OIG safe-harbor expectations. (3) HOPE-readiness (iQIES submission infrastructure live by Oct 1, 2025). |
| Private duty home care, $1M to $5M EBITDA | 5 to 8 platforms (Care Advantage, Senior Helpers via Waud, Comfort Keepers via Halifax, BrightStar via Peak Rock, Home Instead via Honor, Help at Home regional, plus regional franchise-system add-on buyers) | 4x to 7x EBITDA (80/20 risk overlay applies to HCBS-heavy mix) | (1) Payor mix with explicit Medicaid HCBS percentage broken out. (2) Clinical supervisor headcount and pay band (80/20 readiness signal). (3) Worker retention data 24-month trend. |
| Platform-eligible, $20M+ EBITDA | Sponsor-to-sponsor secondaries (Linden, Waud, Peak Rock, Kinderhook, Centerbridge, Vistria, TowerBrook, Webster, Revelstoke, Searchlight, Trive, plus public-strategic capacity at BrightSpring, Aveanna, Addus, Pennant, VITAS) | 10x to 16x EBITDA | (1) Quality-of-earnings level workpapers and Q-by-Q LTM EBITDA bridge. (2) HHVBP and HOPE program-level readiness with state-level peer cohort benchmarking. (3) Documented 24-month tuck-in pipeline (named LOIs preferred). |
Two additional notes for sellers reading this matrix. First, the upper end of every band requires a clean Quality of Earnings file. The 2024 to 2026 buyer set, especially after the Amedisys divestiture absorptions, will not pay top-of-band without a third-party QoE report. Second, hospice multiples remain the most resilient sub-segment in 2026 because of Mertz Taggart’s documented Q4 2025 deal-count surge (16 hospice transactions versus 6 in Q3 2025) per Mertz Taggart Q4 2025. The home health side is more rate-sensitive and therefore more volatile through CY2027.
Diligence prep timeline for a 2026 sale. Twelve months out: assemble three years of normalized P&L with owner-comp and family-payroll add-backs documented; commission a third-party QoE; complete a HHVBP TPS benchmark report against state peer cohort. Six months out: complete HOPE-readiness audit (hospice) or PDGM permanent-behavior-adjustment exposure model (HHA) or 80/20 readiness sizing (private duty); develop named tuck-in or organic-growth pipeline for the buyer’s underwriting deck. Three months out: legal due diligence pre-clean (corporate documents, contracts with referral sources, Medicare billing compliance file); confidential information memorandum drafted. T-minus thirty days: process kickoff with a sector-credentialed M&A advisor (the home-based-care intermediary set is concentrated; the same names recur on most platform-tier deals). Confidence: HIGH on the timeline framework (standard M&A practice); the platform-specific buyer match depends on the seller-fit matrix above.
The intermediary set. The named M&A advisors most active in 2024 to 2026 home-based-care platform-tier deals include FOCUS Investment Banking, Hendon Partners, Mertz Taggart, and ScopeResearch (also a benchmark report publisher). Several large healthcare-services investment banks (Jones Day, Dechert) advised on the sponsor-to-sponsor secondaries documented in Section 10. Owner-operators selling at the lower middle market band ($500K to $5M EBITDA) typically engage a regional or sector-credentialed boutique rather than one of the platform-tier intermediaries; the platform-tier intermediaries focus on deals above ~$15 million EBITDA. Confidence: MEDIUM on the named-set characterization (synthesized from announcement-cited advisors; no consolidated league table).
This tracker is a primary-source-anchored snapshot as of June 16, 2026. The following items were attempted but did not close to primary-source standard inside the verification window. None of them are paper-claimed in the body above. They are listed here so readers can evaluate the analysis with full awareness of what is and is not nailed.
Where any of the above closes to primary-source standard in a future refresh, the tracker will be updated.
One additional note on user-prompt input correction worth surfacing for readers consulting earlier drafts: the operative CY2025 home health PPS final rule citation is CMS-1803-F, not CMS-1834-F. The CY2026 final rule is CMS-1828-F; the CY2026 proposed rule was CMS-1828-P. We use the corrected cites throughout this tracker.
There is no consolidated primary-source registry of PE-backed home health agency branches as of June 16, 2026. Directionally, the 25-plus platforms named in Section 6 of this tracker account for several thousand branches in aggregate. The 2024 MedPAC count of 9,961 active traditional Medicare HHAs (per the MedPAC March 2025 report) is the denominator. We do not paper-claim a specific PE-backed percentage; it lives as a GAP in Section 14.
By average daily census, VITAS Healthcare (a Chemed NYSE: CHE subsidiary) is the largest hospice operator in the US, with Q1 2025 average daily census of 22,244 (up 13.1 percent year over year after the Covenant Health acquisition) per the Chemed 8-K of April 23, 2025. By PE-sponsored ownership specifically, Compassus (TowerBrook + Ascension + Providence JV) and Bristol Hospice (Webster Equity Partners) are at the top of the PE-controlled list.
No. The deal closed August 14, 2025 after the DOJ extracted a 164-location divestiture across 19 states, the largest outpatient divestiture ever required to close a merger per Healthcare Dive August 2025. The divestiture was absorbed by Pennant ($146.5 million / 54 locations) and BrightSpring ($239 million / 107 branches). See Section 8 and Finding 1.
Small single-site HHAs trade at 4x to 7x EBITDA depending on payor mix cleanliness, HHVBP Total Performance Score, and PDGM permanent behavior adjustment exposure. The high end of the band requires HHVBP scores in the top quartile of state peer cohort. Sources: composite of FOCUS Investment Banking, Hendon Partners, ScopeResearch, and Vallexa per the FOCUS Bankers benchmark. Confidence: MEDIUM.
The 80/20 rule requires Medicaid HCBS providers to pass through at least 80 percent of payments to direct care worker compensation, effective 2030 per the Medicaid.gov HCBS final regulation. PE buyers in 2026 are modeling EBITDA-margin compression for the post-2030 window, especially for platforms with material Medicaid HCBS exposure. Confidence: MEDIUM on directional impact; quantified margin delta is a GAP.
Most-active PE sponsors by named 2024 to 2026 transactions include Kinderhook Industries (Enhabit take-private), Linden Capital (Agape recap), Peak Rock Capital affiliate (BrightStar Care), Waud Capital (Senior Helpers), Webster Equity Partners (Bristol Hospice add-ons), Searchlight Capital (Care Advantage add-ons), Trive Capital (Choice Health add-ons), TowerBrook (Compassus / Providence JV), Centerbridge + Vistria (Help at Home dividend recap), and Revelstoke Capital (The Care Team in the Traditions split). Public-strategic acquirers BrightSpring (KKR public stake), Pennant, Aveanna, Addus, Chemed (VITAS), and UnitedHealth round out the top buyer set.
HOPE (Hospice Outcomes and Patient Evaluation) is the new CMS hospice assessment instrument that replaced the Hospice Item Set (HIS) on October 1, 2025, finalized in the FY2025 Hospice Wage Index final rule (CMS-1810-F) per the CMS HOPE landing page. HOPE adds HOPE Update Visits (HUVs) capturing data in the first 30 days of election, in addition to admission and discharge.
Traditions Health, formerly a Dorilton Capital platform, was sold in December 2025 in a four-way buyer split rather than as a single platform. The buyers were The Care Team (Revelstoke Capital), VitalCaring, LifeCare Home Health Family, and Mission Healthcare per Hospice News December 3, 2025. See Section 11, Finding 3 for the contrarian read.
The active buyer set for small HHAs is 6 to 12 lower-middle-market platforms including Choice Health at Home (Trive), Care Advantage (Searchlight), Help at Home regional (Centerbridge / Vistria), Addus HomeCare (public), and Bristol Hospice (Webster) for hospice-tilted assets, along with regional franchise-system add-on buyers. Multiple range is 4x to 7x EBITDA; the top of the band requires clean payor mix and above-median HHVBP scores. See Section 13.
MA enrollment growth is the largest single contributor to the FFS HHA agency-count decline. MA enrollees use home health at a lower per-beneficiary rate than FFS, and MA reimbursement to HHAs is set through plan-level contracts rather than the PPS rate per the MedPAC October 2024 MA analysis. PE diligence in 2026 increasingly treats MA contract mix as a primary diligence item alongside FFS payer mix.
The CY2026 30-day national standardized payment rate is $2,038.22 per the CMS MM14304 CY2026 Rate Update. The net CY2026 impact versus CY2025 is a 1.3 percent reduction, or about $220 million in aggregate Medicare payments, per the CMS Fact Sheet CMS-1828-F.
CT Acquisitions refreshes this tracker quarterly, or upon a material sponsor transition (such as a take-private, a sponsor-to-sponsor secondary, or a forced divestiture). The next scheduled refresh is September 16, 2026.
This tracker was researched and written by Christoph Totter, founder of CT Acquisitions. CT Acquisitions publishes primary-source-anchored research for owner-operators preparing to sell in healthcare services, manufacturing, and home-based-care verticals. Connect on LinkedIn or get in touch via the CT Acquisitions contact page.
Last updated: June 16, 2026. CT Acquisitions refreshes this tracker quarterly. Next refresh: September 16, 2026 OR upon next material sponsor transition.