Reflections on NPA 2026 in Denver
About 1,500 people came to the NPA Annual Conference in Denver this year, the biggest crowd yet, and most of my conversations came back to one problem: programs need more centers at the moment buildings and the money to build them are hardest to get. What I took home from one session, two center tours, and a conversation with a team new to PACE: wait for two or more expansion signals before committing capital, confirm zoning before you buy, put spare space to work with partners, and keep shared services like kitchens and specialty clinics out of every new center.
This was my third NPA, and every year the national PACE census grows and the conference grows with it. I saw a lot of faces I recognize, and finally met a few people I had only known over Zoom.
The hallway conversations this year were about capital. Acquisitions, leases, and construction are all taking longer and costing more. Debt for acquisition or construction is expensive when you can find it. Private equity and real estate investors told me they have plenty of money to deploy and very little appetite for de novo builds right now. And PACE still has no purpose-built buildings to lease. Every center is a gut renovation or ground-up, which is why I spend so much time on finding a PACE building when the market doesn't have one.
Last year I wrote about growth and clarity at NPA 2025. This year, everything I saw was a program working out how to build its next center inside those constraints.
When should a PACE program open another center?
The session I got the most out of was "From Concept to Center: Practical Site Planning and Design Strategies for New PACE Centers," presented by Maria Lane, COO, and Amber Hulon, AVP of Business Development and Consulting, from Miami Jewish Health, which runs Florida PACE Centers. They have been operating for about 24 years and run seven centers, and they walked through how they decide when and where to expand.
Their rule: a single waitlist name or a single referral call does not justify a new center. Look for two or more of these signals at the same time, and treat crossing a threshold as permission to run a feasibility study, not approval to build.
- Day center at capacity: 90 to 95% of licensed capacity for two consecutive quarters
- Staffing maxed out: two or more disciplines at maximum caseload with no physical room to add staff
- Space fully used: utilization above 90% with documented service delays
- Transportation bottleneck: average ride times over 60 minutes for a defined cluster of participants
- Active waitlist: more than 45 to 60 days, or 20 or more active candidates
- Access gap: regular referrals from ZIP codes more than 55 minutes away
On where to expand, they start with the highest density of PACE-eligible seniors within a 5-mile radius and expect enrollment to fall off with distance. Miles alone don't capture it. In Miami, 5 miles can be 80 minutes on a bus, and participants often won't cross a bridge or a set of railroad tracks into a neighborhood that isn't theirs.
A few of their real estate points match what I see on my own projects:
- Confirm zoning before you buy. In Florida the building has to be zoned for adult day health. They have watched operators buy a property and then find out they couldn't get the license there.
- Surveyors measure every door. On one center, door frames were a quarter inch off on ADA clearance, and they reframed six doors after the surveyor went through with a tape measure.
- Bring in an architect who knows PACE, not just healthcare, and the general contractor, before the lease is signed.
- They built out part of a 27,000 square foot building and left the rest as a white box so they could expand without moving.
I'd add one thing to the white box approach: price it. At $30 per square foot, holding 10,000 square feet in reserve costs about $300,000 a year before you build anything in it. If your waitlist and enrollment trend say you'll fill it in the next couple of years, that can still beat a second permit, a second contractor, and construction next to an operating center. Run the number before you decide.
What did I see at Rocky Mountain PACE?
I got off the plane, dropped my bag at the hotel, and got on the bus to Colorado Springs. It was a long trip from Denver and absolutely worth it.
Rocky Mountain PACE is an independent nonprofit with three centers serving more than 1,100 participants. Their main center is a converted hospital, and they run it as a hub. Dental, podiatry, optometry, and audiology are centralized there for participants from all three centers, while primary care and the day program happen at each participant's own center. The old hospital rooms make very large exam rooms.
Two things stood out from a real estate perspective:
- A full pharmacy on site, run by a third party. Rocky Mountain PACE gave Genoa Healthcare the space, and Genoa built it out. Rocky Mountain PACE pays Genoa for its services and medications, and Genoa provides them to participants. The program gets a full pharmacy in the building without funding the build-out.
- The van fleet will soon live on a lot that used to be a taxi company, which was already set up for vehicle maintenance.
They also merged with a senior housing operator this year. PACE isn't housing, but programs keep running into the housing problem, and this is one of the more direct attempts I've seen to solve it. The constraint they described is one I hear everywhere: their service area runs about 20 miles end to end, and 45-minute rides keep some participants from attending.
If you centralize specialty services at a hub, every other center in your network can be smaller and cheaper to build. If you are planning a second or third center, decide which services live at the hub before you program the new site.
What did I see at InnovAge Denver Downtown?
InnovAge Denver Downtown is a single-story center laid out as a loop. The center director contrasted it with two-story centers, where staff can spend 15 minutes finding a participant when the bus is ready to leave. On a one-floor loop, everyone is a short walk from the door.
- Day rooms divided by accordion doors. They stay open most of the day and close for chair exercise and smaller groups, which gives the program several room sizes out of one footprint.
- A low-stimulation room for participants who find the main rooms too much, along with on-site showers and laundry. The director described a population with more behavioral health and substance use needs than a few years ago, and the space reflects it.
- A warming kitchen instead of a full kitchen. Meals come from one central commercial kitchen that serves several InnovAge centers, so each site carries a much smaller kitchen.
- The center director works out of the clinic, next to the medical director and nursing director.
Small world note: the general contractor I worked with on a center in LA is the contractor on a renovation they mentioned on the tour.
You make every one of those choices in the test fit, months before construction. If you are programming a PACE center from the care model out, decide the kitchen model, the number of floors, and how the day rooms divide before you commit to a building, because each one changes how much building you need.
What are people new to PACE asking?
I also spent time with a team coming into PACE from health tech, exploring how they can make an impact in the space. They have great advisors behind them, and I enjoyed their happy hour.
Their questions were the same ones I heard from operators all week, from a team without years of PACE habits behind them. If a program puts $10 million into a landlord's building and then pays $40 a square foot in rent, who ends up with the equity? When does owning make sense, and when does a sale-leaseback with a developer who shares the tenant improvement cost make more sense? Do the economics of a rural center work on fewer participants at the same capitation rate?
None of those have one answer. Each depends on how long the program will stay in the building, what it can borrow at today's rates, and how confident it is in enrollment. I was glad to hear them asked out loud.
What am I taking back from NPA 2026?
Every program I talked to is building its next center around the same constraints: no purpose-built buildings, expensive capital, and a population that can't ride an hour to get there. The programs handling it well decide early which services each building has to hold, find partners to fill spare space, and confirm zoning, licensing, and capacity before they spend on design.
And the offer from my building search post still stands. If you are a developer or investor interested in building PACE-ready buildings, call me. There is an opportunity here that nobody has organized yet.
Thank you to Rocky Mountain PACE, InnovAge, and Miami Jewish Health for sharing their work, and to NPA for another great conference.
Key takeaways
- About 1,500 people attended NPA 2026 in Denver, the largest NPA conference yet. The main topic in the hallways was how to finance and find new centers when debt is expensive and investors are cautious on de novo builds.
- Miami Jewish Health looks for two or more expansion signals at once (day center at 90 to 95% of capacity for two quarters, rides over 60 minutes, a waitlist over 45 to 60 days) before starting a feasibility study.
- Confirm zoning for adult day health before buying or leasing a building. Operators have bought properties they could not license.
- Rocky Mountain PACE runs a converted hospital as a hub for specialty services and gave space to a third party, Genoa Healthcare, to build and run a full pharmacy on site.
- InnovAge Denver Downtown's single-story loop, divisible day rooms, and warming kitchen fed by a central kitchen show design decisions that reduce how much building each center needs.
Frequently asked questions
When should a PACE organization open a new center?
Miami Jewish Health, presenting at NPA 2026, recommends waiting for two or more signals at once: day center attendance at 90 to 95% of licensed capacity for two consecutive quarters, staff at maximum caseload with no room to grow, average ride times over 60 minutes for a cluster of participants, a waitlist over 45 to 60 days or 20 or more candidates, or regular referrals from ZIP codes more than 55 minutes away. Crossing a threshold justifies a feasibility study, not the expansion itself.
What kinds of buildings become PACE centers?
Almost always conversions or ground-up builds, because no one builds PACE centers on spec. At NPA 2026, Rocky Mountain PACE showed a converted hospital run as a hub for specialty services, and Miami Jewish Health described white-boxing part of a 27,000 square foot building for future growth. Retained CRE screens retail, office, and medical buildings against zoning, floor plate, van circulation, parking, utilities, and capacity before a program spends on design.
How far should PACE participants travel to a center?
Miami Jewish Health starts site selection with the highest density of PACE-eligible seniors within 5 miles and treats average rides over 60 minutes as a signal to add a center. Travel time matters more than distance: in dense markets, 5 miles can take 80 minutes on a bus, and long rides reduce day center attendance.
Should a PACE program lease or own its center?
It depends on how long the program will stay, what it can borrow, and how confident it is in enrollment. A program that puts $10 million of improvements into a leased building and pays market rent builds the landlord's equity. Owning or a sale-leaseback with a developer who shares the improvement cost can make more sense for a long hold. In Retained CRE's work, we model lease, own, and sale-leaseback side by side before a program commits to a site.
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