Deborah Stewart; Principal Accounting Officer; Aveanna Healthcare Holdings Inc
Jeff Shaner; Chief Executive Officer, Director; Aveanna Healthcare Holdings Inc
Matthew Buckhalter; Chief Financial Officer, Principal Financial Officer; Aveanna Healthcare Holdings Inc
Meghan Holtz; Analyst; Jefferies
Michael Murray; Analyst; RBC Capital Markets, LLC
Benjamin Rossi; Analyst; JPMorgan Chase & Co.
Scott Fidel; Analyst; Stephens Inc.
Unidentified Participant
Operator
Good morning and welcome to Aveanna Healthcare Holdings fourth-quarter 2024 earnings conference call. Today's call is being recorded, and we have allocated one hour for preparing marks 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.
Deborah Stewart
Good morning and welcome to Aveanna's fourth-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 annual report on Form 10-k when filed.
With that, I will turn the call over to Aveanna's Chief Executive Officer, Jeff Shaner. Jeff?
Jeff Shaner
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 Q4 in full year 2024 results and how we are moving Aveanna forward in 2025.
My initial comments will briefly highlight our fourth quarter and full year 2024 results, along with the 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're thinking about year three of our strategic plan and our initial outlook for 2025 prior to turning the call over to Matt to provide further details into the quarter.
Moving to highlights for the fourth quarter in full year 2024. Revenue for the fourth quarter was approximately $520 million, representing an 8.6% increase over the prior year period. Fourth quarter, adjusted EBITDA was $55.2 million, representing a 42.6% increase over the prior year period, primarily due to the improved payer rate environment as well as cost reduction efforts taking hold.
Full year 2024 revenue was approximately $2.024 billion, representing a 6.8% increase over the prior year and full year 2024 adjusted EBITDA was $183.5 million, representing a 31.8% increase over the prior year. We continue to execute our strategic transformation strategy, focused on preferred payers and obtaining adequate rates from our government partners for the services we provide, which is clearly evidenced in our fourth quarter results.
Our Q4 results also benefited from some timing related items that positively impacted our private duty services division in the quarter. Matt will provide some further details in his prepared remarks.
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 while reducing the total cost of care.
Our Q4 and full year 2024 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 with those payers willing to engage with us on enhanced reimbursement rates and value-based agreements. While we continue to operate in a challenging environment, our preferred payer strategy allows us to return to a more normalized growth rate in our business segments.
Since our third 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 a particular emphasis on Georgia, Massachusetts and California. As we previously reported, 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 and 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 continue to experience accelerated caregiver hiring trends, patient discharge from the children's hospitals and improved staffing levels in both Georgia and Massachusetts. In total, we secured 12 private duty services state rate increases for the full year 2024.
Now moving to our preferred payer initiatives in other states. Our goal for 2024 was to increase the number of private duty services preferred pay agreements from 14 to 22. We added eight additional preferred pay agreements in 2024, achieving our goal of 22.
I am proud of our payer relations teams 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 to our patients.
Additionally, our Q4 preferred payer agreements account for approximately 50% of our total PDS MCO volumes, up from 47% in Q3. This positive momentum and preferred payer volumes continues to highlight the shift in our caregiver capacity and recruitment efforts towards our PDS 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 Q4, our episodic mix was 76%. However, our total episodic volume growth was slightly lower as compared to the prior year period.
We ended 2024 with a total of 38 episodic agreements and are well positioned for growth in 2025. We are committed to growing our home health volumes, and I expect us to return to positive year over year growth trends in the first half of 2025. We will 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.
Finally, as we have achieved our desired preferred payer model in both private duty services and home health and hospice, we have embarked on a similar strategy in our medical solutions business. We are in the early stages of implementing our preferred payer strategy and medical solutions and believe it will be fully realized by the end of 2025.
As the nation's leading provider of enteral nutrition, it is critical for us to ensure our capacity is aligned with those payers who value our services and partnership. Our goal is to improve clinical outcomes and customer service while protecting our margins and collecting our cash. We do expect volume growth to be muted throughout 2025 as we achieve the realization of our medical solutions target operating model.
Matt will comment further on how we think about margins and volumes of medical solutions moving forward. I look forward to updating you on our progress in coming corners similarly as we have in our PDS and HHH segments.
We are encouraged by our 2024 rate increases, preferred pay agreements and subsequent recruiting results. Our business has demonstrated 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 initial outlook for 2025. We will continue to focus our efforts on five primary strategic initiatives in 2025. First, enhancing partnerships with government partners and preferred payers to create additional capacity and growth.
Second, identifying cost efficiencies and synergies that allow us to leverage our growth. Third, modernizing our medical solutions business to achieve our top target operating model. Fourth, managing our capital structure and collecting our cash while producing positive free cash flow. And finally, engaging our leaders and employees and delivering our Aveanna mission.
Based on the strength of our fourth quarter in full year 2024 results and the continued execution of our key strategic initiatives, we anticipate 2025 revenue range of $2.1 billion to $2.12 billion and adjusted EBITDA range of $190 million to $194 million. We believe this initial '25 outlook provides a prudent view considering the challenges we still face with the evolving environment.
In closing, I'm incredibly 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.
With that, let me turn the call over to Matt to provide further details on the quarter and our '25 Outlook. Matt?
Matthew Buckhalter
Thank you, Jeff, and good morning. I'll first talk about our fourth quarter financial results and liquidity before providing additional details on our initial outlook for 2025. Starting with the topline, we saw revenues rise 8.6% over the prior year period to $520 million.
We achieved year over year revenue growth in all three of our operating divisions led by our private duty services, medical solutions and home health and hospice segments which grew by 10.1%, 4.8% and 0.6% compared to the prior year quarter.
Consolidated gross margin was $171.7 million or 33%. Consolidated adjusted EBITDA with $55.2 million, a 42.6% increase as compared to the prior year, reflecting the improved payer rating environment as well as cost reduction efforts taking hold.
As Jeff mentioned, Q4 benefited from a timing-related rate enhancement in our PDS segment, which had a positive EBITDA impact of approximately $3 million. Additionally, Q4 saw a favorable true-up in our insurance reserves, and this adjustment contributed approximately $3.5 million to EBITDA for the quarter.
Now taking a deeper look into each of our segments. Starting with private duty services. Revenue for the quarter was approximately $422.2 million, a 10.1% increase and was driven by approximately 10.5 million hours of care, a volume increase of 4% over the prior year.
While core volumes have improved over the prior year, we continue to be constrained in our topline growth due to the shortage of available caregivers, although we are continuing to see signs of improvement in the labor markets.
Q4 revenue per hour of $40.25 was up $2.21 or 6.1% as compared to the prior year quarter, primarily driven by preferred payer volume growth and the rate enhancement previously discussed. 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 $123.6 million of gross margin or 29.3%. The cost of revenue rate of $28.47 in Q4 was down slightly from Q3. Despite ongoing wage pressures in the labor markets, our Q4 spend per hour was $11.79. We expect spread per hour to normalize in the $10 to $10.50 range moving forward.
Moving on to our home health and hospice segment, revenue for the quarter was approximately $54.4 million, a 0.6% increase over the prior year. Revenue was driven by 8,500 total admissions with approximately 76% being episodic and 11,200 total episodes of care, down approximately 1% from the prior year quarter.
Medicare revenue per episode for the quarter was $3,128, up 2.1% 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 admission well over 70%, we have 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're pleased with our Q4 gross margin of 53.2%, up 2.3% over the prior year period, and representing our continued focus on cost initiatives to achieve our targeted margin profile. Our home health and 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 Q4. During the quarter we produced revenue of $43.3 million, a 4.8% increase over the prior year. Revenue was driven by approximately 89,000 unique patients served, a 1% decrease over the prior year period, and revenue per UPS of approximately $486, up 5.9% over the prior year period.
Gross margins were approximately $19.2 million or 44.3% for the quarter, up 10.5% over the prior year period. As Jeff mentioned, we continue to implement initiatives to be more effective and efficient in our operations to achieve our targeted operating model.
We're accelerating our preferred payer strategy and medical solutions by aligning our capacity with those payers that value our resources and appropriately reimburse us for the services we provide. We expect the gross margin to normalize in the 43% to 44% range and UPS to settle around the 89,000 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 is 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 in 2024, we remain optimistic that such trends will continue into 2025. As we continue to make progress with the rate environment (inaudible) improvements and other benefits to our caregivers and the ongoing effort to better improve volumes.
Now moving on to our balance sheet and liquidity. At the end of the fourth quarter, we had liquidity of approximately $260 million, representing cash on hand of approximately $84 million, $38 million of availability on our securitization facility and approximately $138 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 Q4. Our ample liquidity provides room to operate the business and to 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 Q4. 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 2026and 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 continued growth.
Looking at year-to-date cash flow, cash provided by operating activities was $32.6 million and free cash flow was approximately $25.7 million. We expect to see continued cash flow benefits as our topline and cost management initiatives come to fruition in 2025.
Before I hand the call over to the operator for Q&A, let me take a moment to address our initial outlook for 2025. As Jeff mentioned, we expect full year revenue range of $2.1 billion to $2.12 billion and adjusted EBITDA range of $190 million to $194 million. I'd like to highlight that our guidance includes a 53rd week in Q4, which is expected to contribute additional revenue to our overall results for the year.
As a reminder, Q1 generally sees lower performance due to payroll taxes and post-holiday seasonality. However, we expect EBITDA to build into Q2 and into the second half of 2025. We believe this outlook is prudent and hopefully proves to be conservative as the year progresses.
As we reflect on our 2024 results, I'd like to take a moment to express my sincere gratitude to all of our Aveanna teammates. These strong results would not have been possible without your hard work and dedication. Looking ahead, I'm excited for the execution of our 2025 strategic plan and look forward to providing you with further updates at the end of Q1.
With that, let me turn the call over to the operator.
Operator
(Operator Instructions) Brian Tanquilut, Jefferies.
Meghan Holtz
Good morning, guys. This is Meghan Holtz on for Brian Tanquilut. Congrats on the quarter first off. I like to start out on the guide. As I look at the topline growth, it's slightly above 4%, implying flat EBITDA of margins year over year. Would you consider this conservative as you've spoken to EBITDA margin expansion in '25 previously?
Jeff Shaner
Hey Meghan. Good morning. Thank you and thanks for getting us started. I think our thoughts today on guidance is to continue to stay in the mode that we've operated as a management team in the last two years. We've gotten very comfortable with the expectations of beat and rates, and we like to stay as that team that sets a prudent -- we use the word prudent versus conservative.
You can use the word conservative if you like, but we use the word prudent, both on our revenue growth and our EBITDA, but I think as Matt will talk about, we're very confident as the year 2025 is setting up for us and we're expecting to have a third very, very significant year of transformation Aveanna.
Matt, you want to talk through.
Matthew Buckhalter
Yeah. Meghan, we're really excited to continue executing on our 2025 strategic plan. We have really solid momentum leaving Q4 and 2024 with great rate increases from our governor partners, continued preferred payer execution on there. We have really nice line of sight with the final home health and hospice rules in place. So great visibility into 2025.
Now, as Jeff mentioned, we believe our guidance for 2025 is prudent, but we believe that we'll continue to capitalize on all the hard work that our teams have put in the past two years and those results will really flourish into 2025 as well.
I will throw a little bit of plug in there and just reiterate Q1 does have some seasonality in our EBITDA numbers itself, due to higher payroll taxes, getting caregiver engagement kind of back in post holidays, it kind of settles in Q1, but then you will see it build in Q2 and then the back half of 2025.
Meghan Holtz
Okay. Thanks. And just as a quick follow up, you guys have commented on looking to turn M&A kind of back on. I mean, can you speak to the pipeline? What areas are you focused on and any specific characteristics you require when looking at assets?
Jeff Shaner
That's a great question. And we continue to have a prudent view of M&A. We're focused on our home health specific and our private duty services business as it relates to tuck in M&A. We probably won't be in the medical solutions M&A focused in '24, '25 as you heard us talk about.
We're excited to be kicking off and fully initiating that, a target operating model and preferred payer strategy for med solutions. So we're going to stay focused on home health specifically and private duty services, both skilled and unskilled in that business unit.
I will say we plan to stay within our capital structure, right? So we've got ample liquidity within our current capital structure but think of us being a tuck in oriented acquire in '25 and '26. But as we said in '24, we do expect to be back in the acquisition business in fiscal year 2025. So more to come as the year plays out. But great question, Meghan.
Operator
Ben Hendrix, RBC Capital Markets.
Michael Murray
Hi. This is Michael Murray on for Ben. Congrats on the quarter. Just drilling down into the PDS segment. You previously noted expectations for some pressure in spread rate in the first quarter. How should we think about modeling the cadence of both rate growth and gross margin progression in 2025?
Jeff Shaner
Yeah. It's a great question. I think Matt laid out we've got great clarity in all of our businesses, but specifically PDS for 2025. So that's, I think, the really good news is we had a lot of momentum in the second half of 2024 that is carrying through '25 and our 12 PDS rate increases plus the two preferred payers plus good insight on home health and hospice rates give us really good certainty throughout the fiscal year 2025.
I think as Matt talked about, remember, Q1 is our high payroll tax. We are a labor driven company. So we expect Q1 to be a little bit of a headwind. There's also some holiday seasonality that plays into the first month of Q1, but I think as we think about our guidance, we're very confident about our PDS business and kind of its current growth rates.
Matthew Buckhalter
Yeah. I mean it's spread per hour. We believe we'll be back in that $10 to $10.50 range. That's a great core area for us. I pointed out those two how we kind of believe a one time in nature items in Q4 that enhanced to $11.79 for the quarter, which is a little bit strong. So we just wanted to be upfront and honest about backing that out a little bit for taking the full year of 2025.
Though we do have seasonality with (inaudible) in Q1. It kind of picks up in the back half of the year. There's some holiday payroll differentials, PTO utilization in there and Q4 as well. But for the entire totality for 2025, I would sit between that $10.10 and $10.50 range.
Michael Murray
That's helpful. And just as your cash flow increases, how are you thinking about capital allocation? I know you touched on M&A. If the right opportunity presented itself, what sort of leverage would you be comfortable going up to? Thank you.
Matthew Buckhalter
Yeah. I mean, we're really excited about where we've been as an organization and deleveraging significantly. If you look at our deleveraging profile over the past 24 months, it's been very impressive as an organization, and we don't plan on slowing that down.
As we've alluded to in the past, our goal is to continue to deleverage a turn to a turn in a quarter on an annual basis. We looked to that being a very realistic expectation for us in 2025 as well. We were obviously very pleased with our Q4 and full year 2024 operating free cash flow. This was driven by a lot of rate improvements, great operational efficiencies from our team, cost management that we've gained throughout the organization.
And we'll expect to be a continued free cash flow business for 2025 as well. We will allude though we will be a larger federal taxpayer in 2025. So that could create a little bit of a headwind for us and just I'll throw this plug in there as well.
As a reminder, Q1 does experience some seasonality for that cash flow impact as well due to [TPL] seasons, it enhances or extends out our collection cycle. And so, we'll have a pretty significant negative in Q1 but then continue to build in the sequential quarters.
Jeff Shaner
And I think as you think about, you said it, the excess cash that we're generating, we think about as accelerating growth in EBITDA, both organically to continue to invest in our preferred payer strategy, our government affairs team, our clinical innovations team that underpins our clinical outcomes data for our preferred payers and then just accelerating the M&A strategy.
I mean, we are well, well positioned in home health and hospice and in private duty services to be a choir. And I think Matt said it well, we don't plan on opening the capital structure this year. We're very comfortable with our caps and swaps, and we will continue to accelerate both revenue and EBITDA growth organically and inorganically.
Operator
Benjamin Rossi, JPMorgan Chase & Company.
Benjamin Rossi
Hey. Thanks for the question. Just regarding your medical solutions payer strategy, you mentioned the comments on the segment modernization as you start this process during 2025, and the expected volume drag. I want to drill down here. Could you walk us through your approach to payer negotiations here and how you're sizing your contract conversions and potential rate changes within there.
Jeff Shaner
Yeah. Hey Ben. Good morning. It's a great question. I think as you look backwards -- we would say look backwards to look forwards, meaning look what we did in 2023 to home health and hospice to right size that business model both clinically and financially. Look at what we did in the PDS business in 2024, same thing, to align with our preferred payers and ultimately to improve clinical outcomes and right size margins, both gross and contribution margins.
It's the exact same strategy with med solutions, which is to make sure that we're aligning our clinical capacity around those payers that not only pay the most, but really our good partners that give us the opportunity to drive great clinical outcomes, appropriate gross margins.
Matt highlighted in his comments, the gross margins in the 43% to 44% range. I think you can see that in our Q4 results that you can see that we're already have improved gross margins. And then the cash collections of this business --the med solutions is a tough cash collection.
So part of what we are evaluating in our customers is are you going to pay us in anp appropriate amount of time. So making sure that not only our clinical outcomes in line, but financial outcomes in line, but also cash collection. So as we did with home health and hospice, we'll narrow our network, we'll align our capacity with a narrowed network.
You'll see in our investor deck that I think we're going to post tomorrow that we've identified 17 preferred payers in that business that we're aligning with those 17 preferred payers first, and we will continue as we execute the target operating model this year, we will broaden that preferred payer network.
And I think, as Matt said, 89,000 UPS is probably a good number to anchor to in the near term, probably Q1 and Q2. But you'll see that number get back to mid single-digit, high single-digit growth the back half of the year as we turn back on the growth curve and med solutions. Matt?
Matthew Buckhalter
Yeah, Great question, Ben, there. I mean, I'll lead with we're really excited about implementing our preferred payer strategy and our target operating on model medical solutions. To date, we have identified 17 preferred payers in this business, and we've actually exited quite a few payer contracts that didn't fit our operating model.
We do expect year-over-year volume growth to be relatively muted, as we alluded to and as Jeff said so well just moments ago. But we do expect clinical outcomes to get better, margin expansion to happen, as well as cash collections to improve in that division as well.
As we see UPS settle and be negative, we will see positive revenue growth still as you can see in Q4 of 2024 as it already started to take hold and go into place. So we'll stay close to it. We'll update you guys as we go on. And throughout 2025, we'll give you an update on it.
Benjamin Rossi
Great. Really appreciate the background commentary there. And then just on the follow up on the macro Medicaid regulatory changes, I can certainly appreciate very good here with a lot of moving pieces, but just with the broader headlines on potential program changes in Medicaid and more details coming into the fold, curious how you're approaching these policy discussions with your regulatory counterparts and you finding them to be receptive to some of the changing dynamics on the provider side for Medicaid and [CHIP].
Jeff Shaner
Great question, Ben. And I think it -- while it still remains to be seen how this whole government sponsored programs may be impacted by pending legislation, and we'll start with if at all, right? It's possible that core Medicaid programs are not touched at all.
But with that being said, I think to your question, we at Aveanna are fully aligned with the goals of the federal government, state governments, which is to be cost efficient and to produce high quality outcomes for every dollar of healthcare spend.
And I think if you think about Aveanna, that is exactly what Aveanna does every day. We produce a cost -- we are cost saver to federal and state governments. We have external studies that show we say between $5,000 and $6,000 per day in our private duty nursing business.
For every day, we keep a medically complex pediatric patient at home and not in a NICU, PICU setting. So we're a major, major cost saver for the federal government and state governments. And so, I think as this plays out, I think we are incredibly well positioned.
We have a great government affairs team. We continue to have great dialogue with our governors on both sides, Republicans and Democrats. We have good dialogue with the new administration with the new CMS team, and I think this is an area where Aveanna ends up being on the right side of healthcare and being an ultimate winner.
So we're excited about the things that are going on. We certainly look for certainty like the rest of the market does, but we're excited that Aveanna ultimately will be a net-net winner with us.
Operator
Scott Fidel, Stephens.
Scott Fidel
Hi. Thanks. Good morning. Actually, going to try to stick on that topic we're just on the Medicaid reform and, Jeff, appreciate your high-level observations there. Going to try to see if we can get you to maybe peel the onion back a little bit more and just we think about some of the different specific options that the GOP is considering.
Obviously, it sort of changes every day, but as we think about per capita caps and changes to tax maps and provider tax reform, work requirements, sort of the main options that they've been looking at that were also proposed by CBO, can you give us your thoughts on which of those you would be most supportive of or which of those you could see as more disruptive to the PDS part of the market?
Jeff Shaner
Hey, Scott. Good morning. One, it's difficult to speculate on the guessing game and like you, we watch it every single day. Our team is in DC this week working with the industry. So it's hard to speculate on what may or may not. I think at its core though, the most important thing to remember is we have demonstrated with our preferred payers with state governments.
Georgia is a great example. Massachusetts, Oklahoma last year, Colorado, you can go on and on, that the more you can shift institutional spend to home care spend, the better off that we do, especially with our core PDN patient population because of how expensive the NICU, PICU settings are.
So the idea that we're able to shift $5,000 a day has really played out well for us over the last two years with the states that have leaned into us as well as preferred payers. So being a net cost saver to the system, we ultimately feel like what we'll carry the day.
We're prepared for different models, Scott. There's different models played through. We're excited about the new Medicaid leader for CMS. He comes from the state of Mississippi, right? They have the highest F-Map percentage in the country. So we're excited to work with him and his team.
We're also excited to work with the new CMS leader from Medicare. We think he's got a great approach to how business should operate for the geriatric population in America. So without commenting on any specific one potential if and but, our core of our company is built around the idea that we take patients out of the hospital, keep them at home. That's good for healthcare. It's good for cost savings, and it's good for patients and clinical outcomes.
So again, we're underpinned with just the right mechanics as an organization. We're also nimble enough to be able to execute on opportunities that this administration may put forth, whether that's block grants or other things. So we see it as an opportunity, not a risk. We see it as an opportunity to continue to execute on our strategy.
Scott, I will say in the meantime, we're going to control what we can control. So this management team has done a phenomenal job the last two years of just owning what we can control and leaving the noise outside of our business plan.
And if you look at our 2025 business plan, the noise will eventually get sorted out. This team is going to stay focused on executing our business plan that we know how to control. So in the short term we're going to continue doing what we've done, which is just providing great clinical outcomes and great financial outcomes.
Scott Fidel
Okay. And then as my follow up, just I was hoping if we can maybe drill in a bit more on what's implied in the revenue guidance for PDS, revenue growth within that and how you're thinking about how that splits out between rate and balls.
And then even if you want to get a little more detail on the rate side, how that may break out on yields? How you're thinking about that between the states and then the MCOs as you guys continue to focus on the preferred payers. Thanks.
Matthew Buckhalter
Yes. Scott, as you look at in Q4, we had a lot of success with 4% volume growth and over 6% rate growth in our PDS segment. We do want to lob out there that we did have some rate enhancements or improvements that we looked at to be a little bit one time in nature in there.
We had a specific payer that was originally supposed to go live on [11] of '25, and they ended up going live. [71] of '24. So it's about a $3 million kind of retro rate increase in there that dropped down to EBITDA but really inflated our reimbursement rates as well. We expect this to be our guidance implies that 3%, 4%, 5% of total revenue growth and our PDS segment.
As we alluded to earlier, we like to be prudent. You might call it conservative. That's okay. And we'll continue to update that as the year goes on. We do have really good line of sight from our momentum in 2024 with our rate enhancements that we had and our preferred payers.
Jeff talked about it earlier, 50% MCO volume on our preferred payer. That's phenomenal to see. That will continue to grow throughout the year and that will actually increase our reimbursement rates as well.
Jeff Shaner
And Scott, as we did last year, we went 14 to 22 in the PDS preferred payers. We've set an internal goal to go from 22 to 30. It's aggressive in this year, but that's our team's goal internally. And as Matt talked about, we've now tipped the 50% volume scale, and we expect that number to keep growing quarter by quarter. I don't know it touches 60% this year, but it'll get to the mid to high 50% this year, which is great.
And then we haven't said it, but we feel confident on home health and hospice growth too. So we're pleased with where we are in home health and hospice, gross margins of 53%, great clinical outcomes if you saw our five star ratings, we're off the charts. Our hospice HCAHPS scores are off the charts.
So we're in a growth focused area in our home health and hospice team and really bullish on our team's ability to get to a 2%, 3% year over year organic growth rate in home health and hospice, which would be really nice for that team.
Scott Fidel
30 preferred payers by the end of '25, Jeff, that's the new target.
Jeff Shaner
That is our target. If you ask our preferred payer team, internally 30 is our target, and we've not set a specific target on the on the volume percentage. But I think it's broad to say that it'll be in the mid to 50s in 2025 and continues to show that we lean and shift our capacity to those payers.
Operator
Pito Chickering, Deutsche Bank.
Unidentified Participant
Hi there. You've got a [Karen Ryan] on for Pito. Thanks for taking the question. I'm just looking to go back to margins here. The guide calls for flat EBITDA margins at the midpoint, which I know you characterized as prudent.
If we back out kind of the $6.5 million combined from those two one-offs in 4Q, I'm getting to about 40 bps of margin expansion for 2025. Would you say that's about the right level on an underlying basis. And then is it fair to think that most of that would come from PDS and HHH just given the initiatives you have underway in MS.
Matthew Buckhalter
Yeah. Great question. And you nailed it kind of on the margin profile itself. We do expect a little bit of increase in margin on the medical solution side though we might -- we'll have some more muted growth on there. But on private duty services, once you back out kind of that $6.5 million for the full year and leaving HHH flat, we expect margins to be relatively in line with 2024.
Whenever we win rate increases, whenever we sign a new preferred payer, we take those dollars and we pass them down to our caregivers to really drive volume, and that's our goal is to provide more care, drive volume growth there, and then leverage that SG&A.
We've talked about it over the past two years. Our teams have been very good at leveraging that, taking cost out, investing where we need to be able to leverage that SG&A flow. So that 45 bps that you alluded to on that EBITDA margin expansion really comes from SG&A leverage.
Unidentified Participant
Thank you. And then just on the little bit slower growth in home health and hospice in 4Q, I was just wondering if you might be able to unpack that a little bit more. Does that have anything to do with how you're jumping up on where you want to be on the episodic mix already or was it just hiring or is there any other dynamic, we should be thinking about there? Thank you.
Jeff Shaner
Great question, Karen, as well thought out. A little bit of noise and turbulence in Q4 that we had to work through. We had a few sales positions in key markets that were open. I think you heard my voice, we're really excited. Obviously, we see the trends of the first two months in '25, and we're pleased with where we are today.
It's certainly season for us in our Florida business, which is important, right? We have to be ready to execute during season in Florida. But we're pleased with where that business is today. I'm pleased with the team that that that's leading that business. They have filled the majority of our open sales positions and we're already starting to see some of that lift.
76% is still a little bit hot for us. I think, as Matt and I both said in our prepared remarks, 70% is our goal. 70 70% episodic is our goal. So as long as we're above that 70%, we're pleased. And I think we could give up a few percentage points there to trade for organic growth.
As I mentioned, where we sit today in our operating model, we want to do tuck-ins. And so, I think you'll see us do some tuck-ins this year in the home health business just so we can continue to bring people into our operating model with our clinical outcomes being where they are and our financial outcomes being where they are.
It's too good not to expand this business geographically. So we're going to stay focused on organic growth with our home health and hospice team. Again, I think we'll be in that 1% to 3% organic growth rate in '25, but I think you'll see us tuck-in a few markets and geographically expand our home health and hospice business.
Operator
Thank you. And we have reached the end of the question-and-answer session. I'd like to turn the floor back to Jeff Shaner for closing remarks.
Jeff Shaner
Awesome. Thank you so much for your interest in our Aveanna story, and we look forward to updating you on our continued progress at the end of Q1. Thank you and have a great day.
Operator
And this concludes today's conference. You may disconnect your line at this time. hank you for your participation.
