Debbie Stewart; Principal Accounting Officer; Aveanna Healthcare Holdings Inc
Jeff Shaner; Chief Executive Officer, Director; Aveanna Healthcare Holdings Inc
Matthew Buckhalter; Chief Financial Officer and Principal Financial Officer; Aveanna Healthcare Holdings Inc
Operator
Good morning, and welcome to Aveanna Healthcare Holdings' first quarter 2025 earnings conference call. Today's call is being recorded, and we have allocated one 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
Good morning, and welcome to Aviana's first quarter 2025 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?
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 Q1 2025 results and how we are moving Aveanna forward in 2025.
My initial comments will briefly highlight our first quarter 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 are thinking about year three of our strategic plan and our improved outlook for 2025.
Lastly, I will provide some insight into the recently announced Thrive Skilled Pediatric acquisition and how we are thinking about the combined company prior to turning the call over to Matt to provide further details into the quarter.
Moving to our highlights for the first quarter. Revenue for the first quarter was approximately $559 million, representing a 14% increase over the prior year period. First quarter adjusted EBITDA was $67.4 million, representing a 93.1% increase over the prior year period, primarily due to the improved payer rate environment and continued cost savings initiatives.
We continue to execute our strategic transformation strategy, focusing on obtaining adequate rates from our payer and government partners for the services we provide, which is clearly evidenced in our first quarter results. Our first quarter performance benefited from some timing-related revenue items that favorably impacted our PDS division. Matt will provide further details on this 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 create more capacity while reducing the total cost of care.
Our Q1 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 significant 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 supports our ability to achieve normalized growth rates in all three of our business segments. Since our fourth quarter earnings call, I am pleased with the continued progress we have made on several of our rate improvement initiatives with both government and payer partners, as well as continued signs of improvement in the caregiver labor market.
Specifically, as it relates to our private duty services business, our government affairs strategy for 2025 is twofold. First, we plan to execute on our legislative strategy to improve reimbursement rates in at least 10 states. And second, we are advocating for Medicaid rate integrity on behalf of children with complex medical conditions. We have a strong advocacy presence with both federal and state legislatures, as well as solid support from our governors across our national footprint.
Legislatures have recognized how meaningful private duty nursing is to the overall cost savings and improved outcomes of our nation's most vulnerable children. We achieved five rate enhancements for our PDS segment in Q1 and are well on our way to reach our legislative goals for 2025. I am proud of our government affairs and our advocacy teams for their commitment to protecting children with complex medical conditions.
Now, moving on to our preferred payer initiatives, our goal for 2025 is to increase the number of PDS preferred payer agreements from 22 to 30. We added two additional preferred payer agreements in Q1 and are currently positioned at 24 agreements in total. Managed care organizations continue to ask us for solutions for their members to receive nursing care in the home. 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 Q1 preferred payer agreements now account for approximately 54% of our total PDS MCO volumes, up from 50% in Q4. This continued positive momentum in preferred payer volumes highlights 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 2025 is to maintain our episodic mix above 70% while returning to a more normalized growth rate. In Q1, our episodic mix was 77%, and our total episodic volume growth was essentially flat with the prior year period. We added three episodic agreements in the quarter and currently sit at 45 preferred payer agreements in total. Our focus on aligning our home health caregiver capacity with those payers willing to reimburse us on an episodic basis has led to solid improvement in our clinical and financial outcomes.
Finally, as we have achieved our desired preferred payer model in private duty services and home health and hospice, we have embarked on a similar strategy in our medical solutions business. We're still in the early stages of implementing our preferred payer strategy in medical solutions, but believe it will be fully realized by the end of the year.
To date, we have 17 preferred payers in medical solutions, and we expect that number to grow as we achieve our desired preferred payer model. Our gross margins are stabilizing in the 42% to 44% range as we are aligning our clinical capacity with those payers that value our services and pay us in a timely fashion.
While our volume growth will be muted this year, we expect our clinical outcomes, customer satisfaction, and financial outcomes to improve as we achieve our target operating model. I look forward to updating you on our medical solutions progress over the coming quarters.
We are encouraged by our rate increases, preferred payer 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 enhanced outlook for 2025. We will continue to focus our efforts on five primary strategic initiatives. 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 target operating model. Fourth, managing our capital structure and collecting our cash while producing positive free cash flow. And lastly, engaging our leaders and our employees in delivering our Aveanna mission.
Based on the strength of our first quarter results and the continued execution of our key strategic initiatives, we now anticipate 2025 revenue to be greater than $2.15 billion and adjusted EBITDA to be greater than $207 million. We believe this enhanced 2025 outlook provides a prudent view, considering the challenges we still face with the evolving macro environment.
As it relates to our recently announced transaction to acquire Thrive Skilled Pediatric, I am pleased to report that we are on target to close this transaction in the coming weeks. Our combined leadership teams are collaborating on integration plans, communications, and post-close strategies to optimize the care delivery for our patients and families. Thrive SPC will be a fantastic addition to our Aveanna family and further enhance our preferred payer and government affairs strategies. I look forward to updating you on our progress in the coming quarters.
In closing, I am 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 2025 outlook. Matt?
Matthew Buckhalter
Thank you, Jeff, and good morning. I will first talk about our first quarter financial results and liquidity before providing additional details on our improved outlook for 2025. Starting with the top line, we saw revenues rise 14% over the prior year period to $559 million. We achieved year-over-year revenue growth in all three of our operating divisions, led by our private duty services, home health and hospice, and medical solution segments, which grew by 16.5%, 3.9%, and 3.6% compared to the prior quarter.
Consolidated gross margin was $183.6 million, or 32.8%. Consolidated adjusted EBITDA was $67.4 million, a 93.1% increase as compared to the prior year, reflecting the improved payer rate environment as well as continued cost savings initiatives. As Jeff mentioned, Q1 benefited from some timing-related rate enhancements and revenue reserve improvements in our PBS segment, which had a positive EBITDA impact of approximately $11 million.
Now taking a deeper look into each of our segments. Starting with private duty services, revenue for the quarter was approximately $460 million, a 16.5% increase, and was driven by approximately 10.9 million hours of care, a volume increase of 6.1% over the prior year.
Q1 revenue per hour of $42.25 was up 10.4% as compared to the prior quarter, primarily driven by preferred payer volume growth and rate enhancements 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 $134.7 million of gross margin, or 29.3%. The cost of revenue rate of $29.88 in Q1 was up $1.15, or 4.2% from the prior year period. Despite ongoing wage pressures and labor markets, our Q1 spread per hour was $12.37. We anticipate this metric will normalize over time as we continue to adjust caregiver wages to support our improved volumes and clinical outcomes.
Moving on to our home health and hospice segment, revenue for the quarter was approximately $56.7 million, a 3.9% increase over the prior year. Revenue was driven by 9,700 total admissions, with approximately 77% being episodic and 12,100 total episodes of care, essentially flat from the prior year quarter. Medicare revenue per episode for the quarter was $3,152, up 2.7% 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 have achieved our goal of right-sizing our margin profile and enhancing our clinical offerings. We're pleased with our Q1 gross margin of 54.2%, up 1.1% 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 Q1. During the quarter, we produced revenue of $42.5 million, a 3.6% increase over the prior year. Revenue was driven by approximately 89,000 unique patients served, a 3.3% decrease over the prior year period, and revenue per UPS of approximately $477, up 6.9% over the prior year period. Gross margins were approximately $18.1 million, or 42.7% for the quarter, up 1.9% 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 are 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.
Expect gross margins to normalize in the 42% to 44% range, and UPS to continue around 89,000 per quarter before returning to a more normalized growth rate. We'll continue to update you on our progress as we continue to 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 in Q1, we remain optimistic that such trends will continue throughout 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 efforts to better improve volumes.
Now, moving on to our balance sheet and liquidity. At the end of the first quarter, we had liquidity of approximately $266 million, representing cash on hand of approximately $72 million, $56 million of availability under our securitization facility, and approximately $138 million of availability on a revolver, which was undrawn as of the end of the quarter. We had $32 million in outstanding letters of credit at the end of Q1.
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 $1.47 billion of variable rate debt at the end of Q1. 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.
Looking at year-to-date cash flow, cash used by operating activities was $8.6 million, and free cash flow was negative $12.9 million. As a reminder, the first quarter typically represents our seasonal low point for both operating and free cash flows, and we expect to see continued improvement over the course of the year.
Before I hand the call over to the operator for Q&A, let me take a moment to address our improved outlook for 2025. As Jeff mentioned, we expect full-year revenue to be greater than $2.15 billion and adjusted EBITDA to be greater than $207 million. I'd like to highlight that our improved guidance currently does not include any impact from the anticipated Thrive SPC acquisition.
As we reflect on our Q1 results, I would like to take a moment to express my sincere gratitude to 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. I look forward to providing you with further updates at the end of Q2.
With that, let me turn the call over to the operator.
Operator
(Operator Instructions) Meghan Holtz, Jeffries.
Good morning, guys. This is Meghan on for Bryan. Congrats on a really strong quarter. It's nice to see the work you guys are doing on rates finally coming through. I guess can you just discuss where you are in those ten states that you're targeting for the year and then the remaining six and the preferred payers and how to think about that long-term pipeline on the rate side?
Jeff Shaner
Yeah, Megan, good morning. Thanks for your comments. As you suggested, we expected this year to be a little bit more muted on the government affairs rate front. We were optimistic that we could reach ten states, which, as you know, over the last three years would be a moderated year for us over the last couple of years.
We are pleased that out of the gate we've got five GA rate increases and already two preferred payer wins, so five plus two, seven in total in Q1. So it's been a great start to the year. We still are playing through the noise on a macro level, and I think we expect to achieve our ten GA rate increases, but I think we're still expecting that to be a relatively muted year.
I think we'll learn a lot between now and August as the majority of our states finish their annual budget cycles and as the federal government works through their macro processes. As it relates to the preferred payer start, those two -- we talked about the percentage of PDS MCO volumes up from 50% of our volumes at the end of the year to 54%. That was really driven by those two signings of those two additional preferred payers.
They were meaningful in nature, so really nice job to our preferred payer team. They continue to have a very robust pipeline, and the thesis behind our preferred payer strategy continues to play out. Our preferred payers, especially on the PDS front, continue to just ask for more and more clinical capacity.
So we expect that to be a robust year for us on the preferred payer standpoint, and we think that will play through even the macro environment that's going on today. So setting up to be a nice year for us, still a little bit early. We want to see how things play out through the summer, but setting up to be a really nice year for us.
Great. And then, Matt, I appreciate your comments on the cash flow and the seasonality to it in 1Q, but can you walk us through the thoughts on the operating cash flow for the second quarter.
And then how to think about the right EBITDA to cash flow conversion just given the improvement in margins we've seen?
Matthew Buckhalter
Yeah, Meghan, we're really, really pleased with our progress in positioning Aveanna to be a free cash flow generating organization. Our Q1 cash outflow of $13 million was actually a lot better than we anticipated it being back-to-back years of having really nice Q1 cash flow numbers. As a reminder, to your point, Q1 includes a lot of our seasonality, and there's normal impacts that go through our business that get better over the course of the year.
On a standalone basis, we continue to expect Aviana to generate operating cash flow and be free cash flow in 2025. We will provide a little bit more updates as we integrate Thrive SPC into the organization, and once we get our arms wrapped around there, we'll give you better clarity in August.
Thank you.
Matthew Buckhalter
Thanks, Meghan.
Operator
Pito Chickering, Deutsche Bank.
Good morning, guys. Thanks for taking my questions. Nice job on the quarter. I guess going into sort of the quarter, I mean -- just want to think about what is the continuing, I guess, EBITDA, kind of -- as we think about the base coming from here and kind of what timers in there and any details you can give us on those one-timers.
Matthew Buckhalter
Hey, Pito. Yeah, thanks. And thanks for the question. Two primary areas here for those one-timers that resulted in $11 million of EBITDA benefit in Q1. First and foremost, we had really, really strong cash collections, and it was great cash collections. Our RCM team, working with our operations team, working with our payer relations team, were able to pull forward some really old AR that was previously fully reserved, and so that was able to drop to the bottom line, come through revenue, drop to the bottom line. That was roughly about $6 million. Really proud of the team's efforts for maintaining that.
Additionally, we benefited from a little bit of retro rate increase as well in there, so taking both of those factors into consideration, Q1 was probably closer to a normalized basis of $550 million revenue number and about a $55 million EBITDA number. Still phenomenal results. Really proud of the teams and what we were able to achieve. Jeff, any thoughts going forward?
Jeff Shaner
Yeah, and Pito, first of all, great question. I think Matt laid it out well. Our job when we receive these rate improvements is to pass that through to the caregivers. When there is a retro rate increase or rate increases, there is a bolus then of revenue that we have to catch up to with the wage pass-through.
So I think to the nature of your question, we started passing through the incremental wages to our employees literally the first day of '25 for the retro rate increases, some that went back to 7/1 of '24, others that were effective 1/1 of '25. So we're catching up to that rate even today in May.
So we're still passing wage through systematically to the specific payer, to the specific caregivers who work for those payers that gave us those retro rate increases. So I think as you think of Q2, it will still be a slightly elevated spread per hour in PDS, rate per hour as wage catches up. Our best estimation today is it's probably late Q2 by the time we have fully baked that wage pass-through through, and probably Q3 before you see spread per hour drop back down to that normalized rate, probably sub $11 at that point.
So I think it will take us a few more months to catch up to that rate. It's a phenomenal outcome for us. Thank you to our payers who have leaned into us and our partners. But I think by Q3, you'll see us back to that PDS normalized spread per hour that you're used to seeing.
That is a perfect segue into, I guess, sort of the follow-up question here is, we saw these sort of rate increases on PDS in the fourth quarter. We saw this again, obviously, pretty high in the first quarter. You sort of talked about sort of that continuing until you convert that into the wages, I guess.
How do we think about hours from here? So as you're converting these increase of rate, you're converting this into wages. Shouldn't we sort of see -- we saw the hours quite strong this quarter on the toughest comp of the year despite leap year. So how should we think about the hourly growth of PDS now that we're seeing this conversion?
And then the follow-up is, on the AR stuff, is there any, I guess, brilliant job getting fully reserved DSOs on the P&L? Is there any more that you can do there? Thanks.
Jeff Shaner
I'll start with the first part and then head back to Matt and Debbie for the AR question. Yes, 6.1% volume growth in PDS is extremely hot for us. So that is above our -- our guidance range is 3% to 5% in PDS. We've been on the higher end of that. This was one of the strongest quarters. I do think you'll see a little bit of that as we pass comps for Q2 and Q3, settle, back in that higher end of that 3% to 5%.
So I think you'll see -- it may take another quarter or two before we get there, but I think you'll see a relatively consistent volume number for us over the next couple of quarters. But as it relates to the comp of '24, it'll settle back in that roughly 5%range for the next couple of quarters.
Again, in a year that we thought GA, government affairs would be a little bit more muted, the preferred payer side of the business continues to pick up and be stronger. So, it's probably going to be on the higher end of that 3% to 5% volume. So it's a great place to be. But we are extremely cognizant that our payer partners gave us these rates to pass through wages and hire more nurses and caregivers. So we're committed to driving that wage through to the caregiver. Anyone want to talk about AR?
Matthew Buckhalter
Yes. I mean, Pito, I just want to reiterate how proud we are of the Aveanna team members and their continued efforts of driving strong cash collections. It's part of one of our five C's and something that we work for every single day.
That success and mostly collaboration between ops, RCM, payer relations is really what allowed us to achieve these results. There could be some opportunity for this in the future as well. It takes a whole lot of work to be able to bring a patient home, take care of that patient, provide that service, train it, and get a great clinical outcome.
We do believe we should be appropriately compensated for it. But it's the relationships that we've built with our payers who understand that and value us is allowing us to go back and get some of that fully reserved AR out there. So the answer is maybe, sure, we will continue to work it going forward, but Q1 was just a particularly very good quarter for us.
Jeff Shaner
And kudos to Matt and James, the gentleman who runs our RCM and our ops leaders. Matt said it well. The ability to reach out to our payers and have mature conversations about AR that's now a year, two, or three years old and to work with them to get solutions.
We just find ourselves in a much different place in 2025 from where we were two and three years ago where we didn't even know the name of the person to call these payers. Now we have a great relationship and continue to work through with them in the spirit of being a partner. So it's all part of the preferred payer strategy, as Matt well laid out. Thanks, Pito.
Operator
Ben Rossi, JP Morgan.
Great. Thanks for the question here. Just turning to the Thrive Acquisition. So on the acquisition in early April, I know you previously mentioned a prudent approach towards M&A, maybe more favoring opportunistic tuck-ins.
This seems a little bit more sizable here at 23 locations in seven states. Could you just provide any additional commentary regarding the expected contribution here in 2025 in terms of revenue, earnings, and maybe synergies within PDS? And then with the overlap in those five states and new entry into two states, was this part of a broader goal of adding density in these geographies or entering either of these new states?
Jeff Shaner
Ben, good morning. Thank you. I'll start with the first part of it and then hand it to Matt as it relates to guidance and how we think of the business. But this is the perfect acquisition for Aveanna. I've told other folks it checks all the boxes. So culturally, our two companies are very alike. Our missions are very alike. So what we do every day in both Aveanna and Thrive fit each other like hand in glove.
So that's, for us, most important. Like culturally, from a clinical standpoint, clinical accidental standpoint, do we both think alike? And the answer is yes, we do. Second, the densification of states like Texas, North Carolina, Virginia, Georgia, Arizona, just make a ton of sense for us. These are states we've got great payer partners that want more nurses. They want more densification of our resources. So the idea of adding significant densities in these states is a no-brainer for us.
And then you said it, New Mexico was on our top five states to grow into, so this is perfect. And knowing what I now know about Kansas, I should have added Kansas to the top five states. So we're really excited. A couple of our MCO partners had asked us about being in these states. So the fact that we're able to now grow in those states I think is meaningful.
The size is -- yeah, it's a little bit bigger from a revenue standpoint than probably as a pure tuck-in, but we really think of this as just tucking into the Aveanna family. You know, because we're not using any debt, this is incredibly creative to us and de-levering in nature. So, it's a great scenario -- It's an absolute win-win-win for us culturally, from a business strategy standpoint and a de-leveraging standpoint. This is a win-win-win for us.
So, Matt, you want to touch on how we think about guidance?
Matthew Buckhalter
Yeah, but we haven't included it in our guidance at this time just because based upon timing of closing. We have a pretty good line of sight, but you never want to get out in front of your skis there by a few weeks, and that materially impacts any of your guidance. So we'll update August with that number in there.
particularly back to Jeff's point about the culture of this team and organization and really bringing in good people who want to be part of Aveanna's story and continue to provide great care to our patients, that's what we're looking forward to bringing in this Thrive organization.
Jeff Shaner
And I think this fits the spirit of what you should think about us doing in the future. We will do as many Thrive-type acquisitions as we can do, both in home health and hospice as well as PDS. And once we get our medical solutions target operating model in place, we'll be back in the medical solutions, dental, nutrition, growth, M&A growth business as well.
Great. Appreciate the commentary there. I guess as a follow-up, just on Medicaid policy side, broader development in your advocacy efforts there, could you just give us any updates on where those conversations stand with your federal counterparts? And did you notice any unfreeze over the past month or so with communications now that the new administration's settled in here at the federal level?
Jeff Shaner
Yeah, I think my comments are mostly going to be positive on this topic. I think most importantly, the last few months have really demonstrated how significant the bipartisan support for Medicaid program integrity really is. I think both parties, all branches, including the new CMS appointees for both Medicaid and Medicare are really just showing thoughtful dialogue and thoughtful conversation around anticipated savings.
So I think from our standpoint, Ben, it's been positive. And I think it still remains to be seen how this plays out over the course of the summer. So there's still a lot to be done. And if any legislation does impact Medicaid, if at all, that still remains to play out. But I think our dialogue has been very positive. It's been very open. And it's great to see bipartisan support for the core of Medicaid program integrity being retained throughout these anticipated steps.
We've gone on record. We also believe in saving costs for the federal and state governments. So at our core, at Aveanna, we are a cost saver. And our studies show that we save between $5,000 to $6,000 a day for our core patients. So, again, we support the idea of saving dollars both nationally and at a state level.
And I think our dialogue has been positive with the federal counterparts as well as our state counterparts. Still, time will play out. We recognize there are months in front of us before this fully plays out on a federal basis. Thanks, Ben.
Understood. Thanks.
Operator
Ben Hendrix, RBC.
Great. Thanks, guys. Most of our questions have been answered. But just wanted to follow up on those five rate enhancements in the first quarter. Just wanted to get an idea of the size of those increases. I assume those are probably just normal course increases. But also wanted to get your comments there. And the outlook for larger double-digit wage increases. Is California still the next kind of catalytic update we're waiting for there? Thanks.
Jeff Shaner
Hey, Ben. Good morning. Thanks. I think I'd separate two pieces of the rate. Matt talked about, you know, about half of the $11 million that we benefited from in the quarter was due to retro rate increases. So I'd separate that, right, because that's really a retro catch-up of rate.
I think the part that you're focused on is really how meaningful were the five government affairs rate wins and the two preferred pay rate wins. And I think that's how we think of the core business that -- to Pito's question, like, what does this look like in two quarters?
Clearly at $12.37 and spread, we are hot. So we still have work to do to pass those wages through to the caregivers. We expect that number to come down in Q2. And we expect it to come down again in Q3. And we think, Ben, by the time we get to Q3 and you see spread per hour, we think you'll see it in more normal what you're used to seeing from us in that somewhere between $10, $11 range. And we think that kind of is the run rate moving forward.
We are not expecting material GA rate wins mid-year. So we're expecting, additional GA rate wins, but not at the level that we've been talking about over the last, three or four quarters. So we're thinking through GA rate increases that will be maybe single digits, percentage in nature, which are still beneficial to us.
And then, again, from the PR side to, our goal this year was eight additional preferred payer agreements in PDS, two nice ones out of the gate, teams dialed in, got a very robust pipeline. So I think our PR wins this year will continue to be above probably our expectations and create good momentum for us going into '26 on the PR side of the business.
The last thing I'll say is a comment. We haven't touched much on home health related to it, but signed three more agreements in Q1, signed three additional episodic agreements, 45 episodic agreements. This really gives us the underpinning to grow home health and hospice for that nature and get back to organic growth of our business. Our rate was up just shy of 4% in home health and hospice on a revenue basis.
So we're really excited about where we are from both the PDS but also at home health and hospice on the preferred payer strategy and how it's flowing through our clinical outcomes, our financial outcomes, our collections, and just making us a stronger company.
Great. Thanks. And just to get an idea on the PDS side of how much volume could be coming into these preferred payer relationships, can you -- you mentioned 54% of the volume in preferred relationships currently. Where does that go pro forma for getting up to 30 relationships by the end of the year? Thanks.
Matthew Buckhalter
Hey, Ben. Great question. And we get to the point if you start playing law of large numbers out there, and so the larger that number is, the harder it is to churn. We do think that you will see a significant step up in Q2 as well. And then Q3 we'll get there. I mean, we'll be in the mid to high 50s exiting this year. We think that will be a great position for ourselves. We want to make sure that we're providing the most care possible through these preferred payer relationships.
So whenever we get those rates, we're passing those through our current caregiving staff that is currently under those payers, but also putting it out there for other caregivers to be able to jump on new cases and bring patients out of the hospital as well. So I think realistic, you can see a nice little jump in Q2. And then that will level off on the growth a little bit and be in that mid to high 50s exiting the year.
Great. Thank you.
Operator
David MacDonald, Truist Securities.
Hey, guys. This is Grayson McAlister on for Dave. Like Ben, most of my questions have been answered, but just wanted to follow up on home health. Episodic mix was obviously strong in the quarter, but total episodes were flat. So just wanted to check on how that compared to your expectations and how we should think about volume growth through the remainder of the year. Thanks.
Jeff Shaner
Great question, Grayson. Thank you. Yeah, I think to my comment, I think we're well positioned to grow. We are well positioned to grow. We've got the model in place. We would even accept 3% or 4% less episodic mix in 77%, getting back down to 75%, getting back down to 72%, 73%, which would tell us that we're accepting a little bit more business from our hospital partners specifically.
The model is set, right? Our clinical outcomes are off the charts fantastic in our home health and hospice. We're over 4.5 out of 5 stars in our home health business, and we've got a 99.8% hospice caps rating. So we are at the top of the clinical ladder in both home health and hospice and incredibly proud of it.
Margin profile is absolutely dialed in, -- in the low 50s gross margin. So it's really just now about growing smart admissions and smart episodes in total. And I think with the 45, you know, total episodic agreements, plus Medicare, it's just a great place for us to be. We've bolstered our sales team. We have re-bolstered some open positions, even layered in some additional growth-oriented positions in home health and hospice.
I think, we feel really good about where we are mid Q2 on our Q2 numbers, and we're not going to be at 4%, 5%, 6% year-over-year organic growth [HHH] business yet. I say yet. That is our goal to get there. But we think we can be in that 1% to 3% organic volume growth plus another couple of points on the rate to get to that 4.5%, 5%, total rate growth for home health and hospice.
But I think you'll hear us be incredibly robust. The model is dialed in. And, honestly, I've been doing this for 26 years, Grayson. It's dialed in as tight as I've seen it in the last 26 years. So even in a tough macro environment for home health, we continue to thrive, and I feel confident our team is well positioned for volume growth.
Great. Thanks, guys.
Jeff Shaner
Thanks, Grayson.
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.
Jeff Shaner
Great. Thank you, everyone, so much for your interest in our Aveanna story. We certainly look forward to updating you on our continued progress, and we'll talk at the end of Q2 in August. Thanks, and have a great day.
Operator
This concludes today's teleconference. You may disconnect your lines at this time. Thank you for your participation.
