Aveanna Healthcare Holdings Inc

NASDAQ:AVAH

Earnings Call Transcript 2024-Q3

[Operator]

Good morning, and welcome to the Aveanna Healthcare Holdings Third Quarter 2024 Earnings Conference Call. Today's call is being recorded, and we have allocated 1 hour for prepared remarks and Q&A.

At this time, I'd like to turn the call over to Debbie Stewart, Aveanna's Chief Accounting Officer. Thank you. You may begin.

[Debbie Stewart, executive]

Good morning, and welcome to Aveanna's Third Quarter 2024 Earnings Call. I am Debbie Stewart, the company's Chief Accounting Officer. With me today is Jeff Shaner, our Chief Executive Officer; and Matt Buckhalter, our Chief Financial Officer.

During this call, we will make forward-looking statements. Risk factors that may impact those statements and could cause actual future results to differ materially from currently projected results are described in this morning's press release and the reports we file with the SEC. The company does not undertake any duty to update such forward-looking statements.

Additionally, during today's call, we will discuss certain non-GAAP measures, which we believe can be useful in evaluating our performance. The presentation of this additional information should not be considered in isolation or as a substitute for results prepared in accordance with GAAP. A reconciliation of these measures can be found in this morning's press release, which is posted on our website, aveanna.com, and in our most recent quarterly report on Form 10-Q when filed.

With that, I will turn the call over to Aveanna's Chief Executive Officer, Jeff Shaner. Jeff?

[Jeffrey Shaner, executive]

Thank you, Debbie. Good morning, and thank you for joining us today. We appreciate each of you investing your time this morning to better understand our Q3 2024 results and how we are moving Aveanna forward in 2024 and beyond. My initial comments will briefly highlight our third quarter, along with steps we are taking to address the labor markets and our ongoing efforts with government and preferred payers to create additional capacity. I will then provide insight on how we are thinking about year 2 of our strategic transformation and our enhanced outlook for 2024 prior to turning the call over to Matt to provide further details into the quarter and our outlook.

Let's move to highlights for the third quarter. Revenue for the third quarter was approximately $509 million, representing a 6.5% increase over the prior year period. Third quarter adjusted EBITDA was $47.8 million, representing a 32.2% increase over the prior year period, primarily due to the improved payer rate environment, as well as cost reduction efforts taking hold. As we have previously discussed, the labor environment represented the primary challenge that we needed to address to see Aveanna resume the growth trajectory that we believed our company could achieve. It is important to note that our industry does not have a demand problem. The demand for home and community-based care continues to be strong with both state and federal governments and managed care organizations asking for solutions that can create more capacity.

Our Q3 results highlight that we continue to align our objectives with those of our preferred payers and government partners. By focusing our clinical capacity on our preferred payers, we achieved solid year-over-year growth in revenue and adjusted EBITDA. We also experienced improvement in our caregiver hiring and retention trends by aligning our efforts to those payers willing to engage with us on enhanced reimbursement rates and value-based agreements. While we continue to operate in a challenging labor and inflationary environment, our preferred payer strategy allows us to return to a more normalized growth rate in our business segments.

Since our second quarter earnings call, I am pleased with the continued progress we have made on several of our rate improvement initiatives with both government and preferred payers, as well as continued signs of improvement in the caregiver labor market. Specifically, as it relates to our Private Duty Services business, our goal for 2024 was to execute on our legislative strategy to improve reimbursement rates in our various states with particular emphasis on Georgia, Massachusetts and California, which represented approximately 15% of our PDS revenue.

As we reported in Q2, we secured double-digit rate improvements in both Georgia and Massachusetts, effective the second half of 2024. These states demonstrate our government affairs strategy to partner with state legislatures, governors to identify shortfalls in private duty nursing wages and to align reimbursement rates to improve access to care for patients with complex medical conditions. We are experiencing accelerated caregiver hiring trends, patient discharges from children's hospitals and improved staffing levels in both Georgia and Massachusetts. Year-to-date, we have secured 12 Private Duty Services state rate increases and expect a few remaining states to be effective in early 2025.

While we are pleased that our PDS legislative messaging has been well received by state legislatures, there is still work to do. As an example of the work ahead, California continues to be a challenging landscape to secure funding for an appropriate PDN rate increase. We've made significant strides with the Governor, Medi-Cal Department and California Legislature, demonstrating the importance of private duty nursing rate investments and how it supports an overall lower healthcare cost, improved patient satisfaction and quality outcomes.

During the latest legislative session, we were successful in obtaining an increase to the Medi-Cal PDN rates, despite the headwinds with the anticipated California budget deficit. Our PDN rate investment would have been effective on January 1, 2026 and funded under the MCO tax provision similar to numerous other Medi-Cal rate investments. However, our PDN rate investment, along with the other Medi-Cal rate investments, was tied to a voter referendum on the November 5 election ballot designated as Proposition 35. As we expected, Proposition 35 was approved, and therefore, our PDN rate investment will not be included in the MCO tax provision on January 1, 2026.

We will continue to partner with the Governor and the Legislature on a rate increase in the 2025/2026 budget process. We are committed to advocating for California's children with complex medical conditions and won't stop until an appropriate rate investment has been secured. We have a proven track record of expanding our preferred payer programs, and we'll continue to enhance our efforts in California, similar to our approach in other states.

Now, moving on to our preferred payer initiatives in other states. Our goal for 2024 was to increase the number of PDS preferred payer agreements from 14 to 22. Year-to-date, we have added 7 additional preferred payer agreements, increasing our total to 21. With a robust payer pipeline, we expect to exceed our goal of 22 preferred payers by the end of the year. I am proud of our payer relations team as they continue to develop partnerships with managed care organizations to find solutions for children with complex medical conditions. Aveanna's preferred payer strategy is gaining momentum and allowing us to invest in caregiver wages and recruitment efforts to accelerate hiring and staffing of nurses for our patients.

Additionally, our Q3 preferred payer agreements account for approximately 47% of our total Private Duty Services MCO volumes, up from 45% in Q2. This positive momentum in preferred payer volumes continues to highlight the shift in our caregiver capacity and recruitment efforts towards our Private Duty Services preferred payer partners.

Moving to our preferred payer progress in Home Health. Our goal for 2024 was to maintain our episodic payer mix above 70%, while returning to a more normalized growth rate. In Q3, our episodic mix was 76%, and we achieved positive episodic volume growth of approximately 1% over the prior year period. We also signed 3 additional episodic agreements in the quarter, bringing our total episodic agreements to 38. I am proud of our Home Health & Hospice leadership teams and their commitment to driving positive clinical outcomes, episodic growth and profitability. We will continue to remain focused on aligning our Home Health caregiver capacity with those payers willing to reimburse us on an episodic basis and focus on improved clinical and financial outcomes.

And finally, as we have achieved our desired preferred payer model in both Private Duty Services and our Home Health & Hospice businesses, we now embark on a similar strategy in our Medical Solutions segment. We are in the early stages of implementing our preferred payer strategy in Medical Solutions and believe it will be fully realized by the end of 2025. As the nation's leading provider of enteral nutrition, it's critical for us to ensure our capacity is aligned with those payers who value our services and our partnerships. Our goal is to improve clinical outcomes and customer service, while protecting our margins and collecting our cash. Matt will comment further on how we think about our margins and volumes in Medical Solutions moving forward. I look forward to updating you on our progress in the coming quarters, similarly as we have in our PDS and Home Health & Hospice segments.

We are encouraged by our 2024 rate increases, preferred payer agreements and subsequent recruiting results. Our business is demonstrating solid signs of recovery as we achieve our rate goals previously discussed. Home and community-based care will continue to grow, and Aveanna is a comprehensive platform with a diverse payer base, providing a cost-effective, high-quality alternative to higher-cost care settings. And most importantly, we provide this care in the most desirable setting, the comfort of the patient's home.

Before I turn the call over to Matt, let me comment on our strategic plan and our improved outlook for 2024. As we navigate year 2 of our strategic transformation, we remain highly focused on those initiatives that created positive momentum in 2023 and continued execution in 2024. We will continue to focus our efforts on 4 primary strategic initiatives: one, enhancing partnerships with government and preferred payers to create additional caregiver capacity; two, identifying cost efficiencies and synergies that allow us to leverage our growth; three, managing our capital structure and collecting our cash, while producing positive free cash flow; and fourth, engaging our leaders and employees in delivering our Aveanna mission.

Based on the strength of our third quarter and year-to-date results and the continued execution of our key strategic initiatives, we now expect full year 2024 revenue to be approximately $2 billion and adjusted EBITDA to be greater than $168 million. We believe our enhanced outlook provides a prudent view considering the challenges we still face with the evolving labor market.

In closing, I am so proud of our Aveanna team and their dedication to executing our strategic transformation, while holding our mission at the core of everything we do. We offer a cost-effective, patient-preferred and clinically-sophisticated solution for our patients and families. Furthermore, we are the right solution for our payers, referral sources and government partners. By partnering with preferred payers, we can and will move rate and wage metrics in meaningful ways that support our growth. This strategy allows us to hire, retain and engage more caregivers in providing the mission of Aveanna every day.

With that, let me turn the call over to Matt to provide further details on the quarter and our 2024 outlook. Matt?

[Matt Buckhalter, executive]

Thank you, Jeff, and good morning. I'll first talk about our third quarter financial results and liquidity before providing additional details on our refreshed outlook for 2024.

Starting with the top line, we saw revenues rise 6.5% over the prior year period to $509 million. We achieved year-over-year revenue growth in all 3 of our operating divisions, led by our Private Duty Services, Medical Solutions and Home Health & Hospice segments, which grew by 6.4%, 12.6% and 2.2%, respectively, compared to the prior year quarter. Consolidated gross margin was $159.7 million or 31.4%. Consolidated adjusted EBITDA was $47.8 million, a 32.2% increase as compared to the prior year, reflecting the improved payer rating environment, as well as cost reduction efforts taking hold.

Now, taking a deeper look at each of our segments, starting with Private Duty Services, revenue for the quarter was approximately $409 million, a 6.4% increase, and was driven by approximately 10.5 million hours of care, a volume increase of 3.8% over the prior year. While core volumes have improved over the prior year, we continue to be constrained in our top line growth due to the shortage of available caregivers, although we are continuing to see signs of improvement in the labor markets. Q3 revenue per hour of $39.10 was up $0.97 or 2.6% as compared to the prior year quarter. We remain optimistic about our ability to attract caregivers and address market demands for our services when we obtain acceptable reimbursement rates.

Turning to our cost of labor and gross margin metrics, we achieved $109.8 million of gross margin or 26.8%. The cost of revenue rate of $28.62 in Q3 was down slightly from Q2. Despite ongoing wage pressures in the labor markets, our Q3 spread per hour was $10.48. We expect spread per hour to remain in the $10 to $10.50 range going forward.

Moving on to our Home Health & Hospice segment, revenue for the quarter was approximately $54.1 million, a 2.2% increase over the prior year. Revenue was driven by 8,900 total admissions, with approximately 76% being episodic and 11,300 total episodes of care, up approximately 1% from the prior year quarter. Medicare revenue per episode for the quarter was $3,104, up 1.9% from the prior year quarter. We continue to focus on right-sizing our approach to growth in the near term by focusing on preferred payers that reimburse us on an episodic basis. This episodic focus has accelerated our margin expansion and improved our clinical outcomes. With episodic admissions well over 70%, we achieved our goal of right-sizing our margin profile and enhancing our clinical offerings. We are committed to a disciplined approach to growth, while shifting our capacity to those payers who value our clinical resources.

We are pleased with our Q3 gross margins of 53.9%, up 6% from the prior year period, representing our continued focus on cost initiatives to achieve our targeted margin profile. Our Home Health & Hospice platform is dedicated to creating value through effective operational management and the delivery of exceptional patient care.

Now, to our Medical Solutions segment results for Q3. During the quarter, we produced revenue of $45.3 million, a 12.6% increase over the prior year. Revenue was driven by approximately 92,000 unique patients served, a 4.5% increase over the prior year period, and revenue per UPS of approximately $493. Gross margins were approximately $20.7 million or 45.6% for the quarter, up 18.8% over the prior year period. Revenue and gross margins were impacted by some timing-related revenue adjustments in the quarter. We expect gross margins to normalize in the 43% to 44% range moving forward.

As Jeff mentioned, we continue to implement initiatives to be more effective and efficient in our operations to leverage our overhead as we continue to grow. We are accelerating our preferred payer strategy in Medical Solutions by aligning our capacity with those payers that value our services and appropriately reimburse us for the services we provide. As I said before, we expect gross margins to normalize in the 43% to 44% range and UPS to settle around $90,000 per quarter before returning to a more normalized growth rate. We will continue to update you on our progress as we execute on this initiative.

In summary, we continue to fight through a difficult labor environment, while keeping our patients' care at the center of everything we do. It's clear to us that shifting caregiver capacity to those preferred payers who value our partnership is the path forward at Aveanna. Our primary challenge continues to be reimbursement rates. With the positive momentum we experienced year-to-date, we remain optimistic that such trends will continue into 2025. As we continue to make progress with the rate environment, we will pass through wage improvements and other benefits to our caregivers and the ongoing effort to better improve volumes.

Now, moving to our balance sheet and liquidity. At the end of the third quarter, we had liquidity of approximately $285 million, representing cash on hand of approximately $79 million, $38 million of availability under our securitization facility and approximately $168 million of availability on our revolver, which was undrawn as of the end of the quarter. We had $32 million in outstanding letters of credit at the end of Q3. Our ample liquidity provides room to operate the business and invest in the company to support our continued growth.

On the debt service front, we had approximately $1.48 billion of variable rate debt at the end of Q3. Of this amount, $520 million is hedged with fixed rate swaps and $880 million is subject to an interest rate cap, which limits further exposure to increases in SOFR above 3%. Accordingly, substantially all of our variable rate debt is hedged. Our interest rate swaps extend through June 2026, and our interest rate caps extend through February 2027. As a reminder, we have no material term loan maturities until July 2028. Lastly, in early Q4, we successfully extended our revolving credit facility, ensuring that we have ample access to liquidity to support our growth initiatives.

Looking at year-to-date cash flow, cash provided by operating activities was $19.2 million and free cash flow was approximately $17 million. Q3 cash flow exceeded our expectations, and we continue to expect to be a positive operating cash flow company for full year 2024. We also expect to see continued cash flow benefits as our top line and cost management initiatives come to fruition.

Before I hand the call over to the operator for Q&A, let me take a moment to address our revised outlook for 2024. As Jeff mentioned, we currently expect full year revenue to be approximately $2 billion and adjusted EBITDA greater than $168 million. These results would not be possible without the hard work and dedication from all of our Aveanna team members. I look forward to the continued execution of our 2024 strategic plan and updating you further at the end of Q4.

With that, let me turn the call over to the operator.

[Operator]

[Operator Instructions] Our first question comes from Ben Hendrix with RBC Capital Markets.

[Benjamin Hendrix, analyst]

Congratulations on the quarter, guys. Just a couple of questions on the Home Health side. Just wanted to know what inning we are in, in terms of your progress with your preferred payer relationships in that segment. And clearly, that's kind of garnering strong episodic volume recovery there. Just wanted to see what your outlook is for kind of long-term episodic growth as we move forward, given those relationships you've made.

[Jeffrey Shaner, executive]

Awesome. Ben, great question. Yes, I think as Matt and I both said in the prepared remarks, especially as we start to focus on our Medical Solutions business, we believe really our preferred payer strategy in Home Health & Hospice and in PDS is really -- I'd say, is in the back half of those innings, seventh, eighth inning, but we feel it's fully baked into our business at this point, and now it's really growing those relationships.

Specifically to your question on Home Health, we're really not trying to drive the business past the 75%, 76% episodic mix. We think that's probably running a little bit hot. We'd like to be, as we've said, kind of between that 70% and 75%. We were proud of our 1% organic year-over-year growth, as that was the first time we've had both organic growth in revenue and in volume growth in Home Health year-over-year on a comp basis. So it's been a long time coming. Yes, I think as we said before, we expect the Home Health business and Hospice business to kind of land in that 3%, 3-plus percent growth rate. And we think we're there now. We think we've got the right infrastructure. We've got the right clinical capacity. We are entering season as our Florida business kicks in. I will say, like our peers, we did have a disruption at the end of September, first 2 weeks of October with the double hurricanes that kind of -- we've got a decent amount of business up through Florida and through the Carolinas and Georgia. So, a little bit of disruption in that first month of the quarter, but back to business. The last few weeks have been great for both Home Health and PDS, and we're really just focused on our business. So landing in that kind of 3-plus percent growth rate for our Home Health & Hospice business organically, I think, is where we think we can land.

[Benjamin Hendrix, analyst]

Just as a follow-up. Any observations, thoughts about the final Home Health rules? It feels like more of the same in terms of kicking the can on that budget neutrality assumption. Just wanted to get your take.

[Jeffrey Shaner, executive]

Yes. No, it's a great question. I'll comment on both Home Health and Hospice. Obviously, continued support of the hospice benefit, which we think makes a ton of sense. We, like our peers, are very disappointed in -- not surprised, but disappointed in CMS's continued failure to really address the temporary and long-term hang around or hangover, if you will, of the PGM off a clawback. With our model, though, Ben, I think we're uniquely different in the industry, and that is we have found a way to be successful under the current reimbursement structure. So as disappointed as we are with CMS, although not surprised that they didn't do anything in the election year, we have found a way to be successful in this business, and we're going to continue to be successful at this rate.

This rate was slightly positive to us. So it's above 0%, between 0% and 1%, which is -- it doesn't keep up with inflation, but our model, we have found a way to be successful, and we can thrive under this reimbursement model today for Home Health.

[Operator]

Our next question comes from Pito Chickering with Deutsche Bank.

[Pito Chickering, analyst]

So I know that you aren't giving guidance at this point. But looking at 2025, can you help us go over the heads and tailwinds, specifically on the pricing increases for next year for new increases that you guys know about, as you comp out rate increases seen this year? And then, views on the labor market for next year? You talked about how that's improving. And then also how the preferred payer networks can grow in all 3 business segments now, and how that can potentially provide benefits for pricing for next year?

[Jeffrey Shaner, executive]

Got it. That was a lot, Pito, but thank you. All right. So I think I'd start with just a general comment of part of what was fueling Q3's Private Duty Services growth was really the rate increases, specifically in Georgia and Massachusetts. But the other 10 rate increases that were included with that.

Q3's growth rate, I think, we were very pleased with that. And I use that as a basis because, as you know, Pito, when we get the rate wins, we can solve the problem. We can get the kids out of the hospital, we can staff more cases, i.e., California, right? So I keep coming back to California, that many states have now shown the success tracker that we want to implement in California, or continue to implement in California. So I say that to just keep pushing California that they've got to do the right thing, and we got to get them to do the right thing.

With that said, we have a nice momentum of rate, just like we did coming out of '23 and '24. We have a really nice rate lift, both through our Home Health & Hospice business, as well through our PDS business that will help continue to drive both rate momentum, but also help underpin our growth rates for both PDS and Home Health & Hospice. Both Matt and I took time to focus on Medical Solutions in this call. We are going to spend the next 3 or 4 quarters implementing the exact same preferred payer strategy that we've implemented in Home Health & Hospice and in Private Duty Services in our Medical Solutions business. The team is already working on it.

So we expect a little bit of choppiness through the volume side of that business probably in Q4, Q1, Q2, as margins improve both at the gross margins and bottom line margins for the Med Solutions business. So I think I'd say without stamping 2025, there's no big negative issue staring us down in 2025. We were not expecting California in 2025. So good momentum going in, and we're going to keep our heads down, keep operating the business and keep driving positive results. Matt, would you add to that?

[Matt Buckhalter, executive]

Yes. No, I think you said it really well, Jeff. The 12 state rate increases on top of our continued preferred payer execution has really driven our volume and driven our clinical care this year. I see that momentum continue into next year. There's still a lot of opportunity for us to move forward and move specific rates. California, one of those that we keep talking about. But there's others out there where we really need to move the needle or move a specific area for our patients to allow us to get better care.

Obviously, Pito, you know the economics. The research demonstrates that we save $5,000 to $6,000 per day compared to acute care stay. Addressing the labor markets itself, we're continuing to see that softening. I'd say that little bit of softening in the market, I really attribute that to our hiring success to us being able to drive rates. Those preferred payers are seeing it. They understand the economic benefits. The states are seeing it as well. So as we continue to move rate, that allows us to push caregiver wages up and improve volumes and improve our patient care.

[Jeffrey Shaner, executive]

There's a lot to unpack there, Pito.

[Pito Chickering, analyst]

Yes. Sorry for that. Looking at your '24 guidance commentary on revenues and EBITDA, it implies a big sequential decrease of margins in 4Q. Historically, we don't see that. To Ben's question, can you quantify the impact of hurricanes or just something else that could lead to sequential decrease of margins from 3Q to 4Q? Or is this potentially just some more conservatism from you and your team?

[Matt Buckhalter, executive]

No, I think you've come to know us pretty well, Pito, on how we operate as an organization, and we like to be really rock solid and leave opportunity for us to be in front of it a little bit. Q3 did benefit from a little bit of one timing-related items in our Medical Solutions segment. You see that with that 45.6% gross margin. That should be in that 43% to 44%. So you get back into the math and say, all right, there's a dollar amount associated with that one.

And then, honestly, we're really proud about our year-to-date results. The teams continue to execute in all 3 of our operating divisions, all 3 of them being positive year over year revenue growth. Jeff did mention in his script or in the answer here that there's a little bit of impact from that hurricane that's going to go through and hit our Southeast business. The good news is that we rebound very quickly. Our patients need care. They're highly acute. So we do rebound quickly. But that couple of week interruption does have some impact to us. That's the reason you're seeing that tick down into Q4, but I think we'll rebound nicely into Q1 and continue that momentum into 2025.

[Jeffrey Shaner, executive]

And I think, Pito, I think to Matt's point as well, Q3 was probably a little bit hotter than we -- in a good way. Profitability is probably a little bit above what we thought, and we were expecting. And Q4 will come in on a normalized basis. I think to your point, we will continue to beat and raise as we think of Q4 and feel very confident for how we end the year and ramp into '25.

[Operator]

Our next question comes from Brian Tanquilut with Jefferies.

[Brian Tanquilut, analyst]

Just first question, free cash flow generation was strong in Q3. So just curious how you're thinking about the sustainability of that, or if there's anything that we need to be thinking about in terms of what went into that cash flow strength.

[Matt Buckhalter, executive]

Great question, Brian. Really proud of it as well. We're pleased with our current year-to-date free cash flow and its performance and where it's currently sitting through Q3. Q3 is our seasonally high period. If you go back and look at last year, you can see where it upticks into Q3 as well. So a lot of that DSO and the delayed billing comes through in Q3. So a little bit of net working capital changes. I will say that our teams over-performed as well, and that's throughout our RCM operations, payer relations teams did a phenomenal job of bringing in cash in Q3 as well.

We will continue to be a positive free cash flow company for all of 2024. I think Q4 last year was slightly negative at $45 million. That's probably not unreasonable to think how our Q4 lands, plus or minus a few million dollars. But overall, pleased with our performance, pleased with the team coming out on top of it, and really happy to be a positive 2024 free cash flow generating company.

[Brian Tanquilut, analyst]

And then, as I think about, maybe asking Peto's question a little differently. On PDS gross margins at 26.8% in Q3, is that the right way to be modeling 2025 at this point? Or how should we be thinking about that number?

[Jeffrey Shaner, executive]

Yes. And let me start with the top, and then we'll bring it back -- Matt will bring it back, Brian, to really ask the question. I think the key thesis here is every time we win rate, our commitment to both the governor, the legislature, or the payer is, we're pushing the rate through to drive to fill more shifts, to get more kids home and ultimately to hire more nurses and engage more nurses. So we are taking an absolute focus to not just winning the rate, but to pushing it through. And I use Georgia as a great example. Governor Kemp really stood firm and made his words, "A historic investment into home-based nursing", and what he meant was private duty nursing for the state of Georgia this year. And it's crucial for us to be able to go back to him and the rest of the legislature and show him that we have passed the majority of that through to the nurses. We can feel that volume. You can see that volume in Q3. You'll see it in Q4. It's lifting our volume because of the historic nature of the investment they made. Matt, as we think about the actual margin profile, how do you think about that?

[Matt Buckhalter, executive]

Yes, Brian, and I always go back to the spread per hour being the end all be all there for us. That $10.00 to $10.50 range, obviously, we know Q1 has some seasonality to it, so it's going to be significantly below that, but play catchup for the full year on how we view it. And it goes back to, you might continue to see some margin compression that happens. But if we continue to stay in that $10.00 to $10.50 spread per hour range, that's right where we want to be. And that's doing exactly what Jeff just talked about, winning rate, investing into our caregivers, investing into our clinical outcomes, and providing better care to our patients. And in tail, that drives our volume and gets more kids from home from the hospital.

[Jeffrey Shaner, executive]

And it's a winning -- as you know, Brian, especially in Medicaid, 30-ish, sub-30-ish the legislature understands that gross margin. So being in that 27% range, we can be proud of what that means, proud of the investment we're making, and as you know, it does matter when you go back to these payers and legislators that you can show them that you have invested these dollars that they gave you into incremental nursing wages and incremental nurses, which, again, we will continue to tell that story in California because it's the same outcome in California. We just got to get the legislature and the Governor to validate that.

[Operator]

Our next question comes from David MacDonald with Truist Securities.

[Grayson Joshua McAlister, analyst]

This is actually Grayson McAlister on for Dave. Congrats on the quarter. First question for me, just, obviously, margins came in quite a bit better than we were thinking and better than last year. Could you just talk a little bit about the cost savings initiatives in place, what inning you're in? And just any low-hanging fruit or obvious opportunities at this point?

[Jeffrey Shaner, executive]

Grayson, well, we certainly said in Q2, we were not a 9% company moving forward and Q3 we validated we are a 9% business 2 quarters in a row. I think as Matt said in his prepared remarks, there were a couple of things that were timing related, specifically in our AMS business, we had some revenue-related adjustments. But I do think that the takeaway -- and Matt will answer the detail of your question, but the takeaway is the cost reduction efforts that we've been talking about now for almost 7 quarters really have taken hold. And I think for the most part, we can tell you we're really done with Home Health & Hospice. We're done with our PDS business. We're pretty much done with our corporate office and corporate support, and we're really just heightened focus on Medical Solutions as we roll into '25.

So I think the majority of the work is done. I will tell you that we never stop. We're always looking for efficiencies and always looking for areas where we can find ways to be more efficient in our RCM and other areas of the business. But the majority of our work in our businesses, with the exception of Med Solutions is really done at this point.

[Matt Buckhalter, executive]

Yes, Jeff, I'd just pile on to your statements, which I believe are 100% accurate in here. Really, we're just proud of the teams and the hard work they've done to address costs on the direct and obviously mostly indirect side of things. Home Health & Hospice last year, you're seeing the full benefit of that come through this year. PDN in this year, and you continue to see the benefit of that in the back half of 2024, and you'll see that to 2025. Medical Solutions, to Jeff's point, is the last area of focus for us to go take out significant savings.

But, Grayson, as we always talk about, it's just not take it away, but reinvesting back into the organization, reinvesting back into technology, into automation, so that we're able to leverage that going forward as well. So our goal is to continue to hold that relatively, I'll say, flat. There's a lot of takes, but then reinvestments into that, and you'll see that throughout 2025, adding on to our growth where we're currently been performing. That's where we get that leverage profile and increase that margin on the bottom line.

[Grayson Joshua McAlister, analyst]

And then just a quick follow-up for me. Just want to follow up on hiring trends in Georgia and Massachusetts. Just any color you could provide around the number of hires there or how quickly you're able to see that labor begin to come online when you do get those rate increases passed through.

[Jeffrey Shaner, executive]

And Grayson, I'll just use Georgia because I think Georgia is one -- last year, we would have used Oklahoma in '23. This year, Georgia will end up being the story we highlight. We're actually building a case study with a third party around Georgia to be able to show to other state governors. But we started -- I think we told in Q2, we started passing the wage rate through in our Georgia nursing community back in -- starting mid- to late-April, as soon as we knew the governor's budget was signed. So we had a ramp of about 75 days, and we hit July 1, when the rate became effective, already running.

And we can see significant, significant improvement in actual percentage of fill rate, number of cases we're actually filling compared to the authorized hours, the number of new cases, the cases we're able to get children out of the hospital. And we ran into a great phenomenon in Georgia. And Matt and I have been here 9 years. This has never happened in our 9 years, and that is, some point mid-August, we didn't have any pending discharges in the children's hospitals in Georgia. That's the first time in a decade that, that has happened.

Now, flu season comes in, infection season. So that will recreate itself. But we had a point in Georgia where we didn't have any pending patients to admit. And again, our pending list in any state could be 30, 40, 50 families, or it could be a few hundred. So the fact that we were able to push through that many pending cases -- and our peers, our peers did as well, just shows how powerful a rate investment can be in a state like Georgia or like any of our state. So it will settle in over the course of Q4, Q1, Q2. But we've seen material changes in hiring nurses. Even the nurses that we had working for us are working more hours and filling more shifts. So we are solving the exact issue that we put forth in the state of Georgia. Massachusetts similarly, but I think Georgia is the best example. And again, as Matt would say, we're almost 2 full years into the story in PDS, and I think it continues to just hammer home how important investing in private duty nursing really is. And the overall savings and the outcomes for these families are just tremendous.

[Operator]

Our next question comes from A.J. Rice with UBS.

[Unknown Analyst]

This is [ James ] on for A.J. I just had one question for you all. You've previously talked about expanding geographies and possibly doing this through acquisitions of smaller assets. Just wanted to get your updated thoughts on this geographic expansion to build your base in the Southeast and Midwest. And just, yes, any color there would be helpful.

[Jeffrey Shaner, executive]

No, it's a great question and very well-timed. I think as we sit today, we feel like we're putting year 2 of our strategic transformation to bed here in Q4. We feel like we have not only stabilized the company, but put the company back on the rightful path for growth and success. And we believe it's time for us to reenter the M&A market. As we go into 2025, I don't think we'll close anything in Q4 at this point. But as we go into 2025, both organic and inorganic growth becomes really priority number 1 for the company. And we do expect to close transactions within our capital structure -- to your point, James, within our capital structure, both in private duty nursing, Private Duty Services business, as well as Home Health & Hospice. Those are the 2 businesses we'll focus on and are focused on. So we've already started ramping up the M&A engine. We are looking at transactions as we speak, with the intent that as we move into '25, we would move back into the M&A market. And again, we'll stay focused on the PDS and Home Health & Hospice businesses for most of our M&A activity. But great question. Thank you.

[Operator]

There are no further questions at this time. I would now like to turn the floor back over to Jeff Shaner for closing comments.

[Jeffrey Shaner, executive]

Thank you. I just want to say thank you, everyone, for your continued interest in our Aveanna story, and thank you to our Aveanna teammates, caregivers, and leaders for making these results possible. We will look forward to talking to you after the first of the year and updating you on our 2025 guidance and our full year 2024 results. Thank you.

[Operator]

This concludes today's teleconference. You may disconnect your lines at this time. Thank you for your participation.