Aveanna Healthcare (AVAH) Q2 2026 Earnings Call: Guidance Raised on Organic Growth

Aveanna Healthcare Holdings (NASDAQ: AVAH) reported broad-based growth in Q2 2026, supported by higher reimbursement rates, increased volumes and operating efficiencies. Management raised full-year guidance and increased its long-term organic growth targets for Private Duty Services and Home Health & Hospice.

Key Takeaways

• Q2 2026 revenue increased 13.7% year over year to $670.5 million, with all three operating divisions posting growth.
• Adjusted EBITDA rose 8% to $95.4 million, reflecting improved rates, higher volumes and operating efficiencies.
• Management now expects full-year 2026 revenue above $2.68 billion and adjusted EBITDA above $365 million. The latest increase reflects core operating performance, as Family First was already included in prior guidance.
• Home Health & Hospice revenue grew 14.8%, while episodes of care increased 18.5% and episodic mix reached approximately 81%.
• Aveanna raised its long-term organic growth targets to 5%-6% for Private Duty Services and 8%-10% for Home Health & Hospice. The Medical Solutions target remains 8%-10%.
• California approved a significant investment in pediatric private duty nursing rates effective January 1, 2027. Final rates remain subject to the Medi-Cal department’s updated fee schedule.

Key Financial Data

Business and Operating Performance

Private Duty Services

Private Duty Services revenue grew 14.0% year over year. Revenue per hour increased 1.7% to $44.62, primarily due to preferred-payer volume growth and updated reimbursement agreements.

Segment gross margin was $159.9 million, or 28.9%. Cost of revenue per hour was $31.74, up $2.06, or 7.8%, while spread per hour was $12.88. Management expects gross margin to remain around 28%-29% as reimbursement gains continue to be passed through to caregiver wages.

Aveanna added three Private Duty Services preferred-payer agreements during Q2, bringing the total to 37. Preferred payers represented approximately 64% of managed care organization volume, up from 60% at the end of Q1. Management expects the mix to rise modestly further in 2026 and targets a mid-80% to potentially high-80% share over three to five years.

The company secured rate enhancements in seven states during the first half and expects several more states to complete their budget processes in Q3. California’s 2027 budget also includes increased funding for pediatric private duty nursing rates from January 1, 2027. Aveanna plans to begin proactive wage increases during Q4 2026 to recruit nurses and improve staffing before the new rates take effect.

Home Health & Hospice

Home Health & Hospice revenue rose 14.8% to approximately $69 million. The segment recorded 10,500 admissions and 14,700 episodes of care, with episodes increasing 18.5% year over year.

Episodic mix reached approximately 81%, above the company’s goal of more than 75%. Medicare revenue per episode was $3,202, and gross margin was 53.9%. Aveanna reached its full-year target of 50 preferred-payer agreements during Q2.

Management said an episodic mix in the high-70% to low-80% range is sustainable, particularly as more Medicare Advantage payers adopt episodic reimbursement arrangements.

Medical Solutions

Medical Solutions revenue increased 9.4% to $47.5 million. The business served approximately 95,000 unique patients, up 4.4%, while revenue per unique patient served rose 5% to approximately $500.

Gross margin was $21.4 million, or 45.1%. Aveanna had 20 preferred-payer agreements at quarter-end versus a target of 25 by the end of 2026. Management continues to expect high-single-digit revenue growth over the next few quarters, followed by a return to double-digit growth in early 2027.

Family First Integration and Capital Structure

Aveanna completed its acquisition of Family First Homecare in early June using cash on hand. Management expects most integration work to be completed by late Q4 2026, with back-office and electronic medical record transitions representing the largest remaining steps.

At quarter-end, Aveanna had approximately $1.48 billion of variable-rate debt, of which $1.4 billion was covered by interest-rate caps. The company also repriced its term loan by 75 basis points, which management expects to reduce annual interest expense by approximately $10 million.

Management remains focused on reducing leverage to below 3x and expressed increased confidence in reaching that target during 2027. Future acquisitions are expected to remain valuation- and leverage-disciplined, with the majority of activity likely focused on Home Health & Hospice.

Management Guidance

Management attributed the higher 2026 guidance to the operating strength of Aveanna’s core businesses rather than an incremental Family First contribution. The acquisition had already been incorporated into the company’s previous outlook.

For Private Duty Services, management indicated that roughly three-quarters of expected organic growth should come from volume and one-quarter from rates. Across the company, gross margin percentages are expected to remain broadly stable because rate increases are substantially reinvested in caregiver wages. SG&A leverage and automation could support adjusted EBITDA margin, but management characterized approximately 14% as the current target area, with potential to approach 15% over time.

Risks and Points to Watch

• Caregiver availability remains the principal constraint on capacity, making reimbursement rates, wages, recruitment and retention central to volume growth.
• California’s final 2027 private duty nursing rates are still pending an updated Medi-Cal fee schedule. Management expected additional details by the end of September.
• Proactive California wage increases will begin before the new reimbursement rates take effect, creating a timing gap during the second half of 2026.
• Q2 2025 included approximately $9 million of favorable, non-recurring Private Duty Services items, affecting year-over-year comparability.
• The proposed 2027 Home Health rule showed progress, according to management, but the temporary adjustment and its effect on annual reimbursement remain unresolved.
• Family First integration is still in its early stages, with major back-office and systems transitions scheduled for the second half.

Analyst Q&A Highlights

• Margin implications of faster growth: Management expects gross margin percentages to remain relatively consistent because reimbursement gains are used to increase caregiver wages. Higher revenue should still lift gross margin dollars, while SG&A leverage provides the main opportunity for EBITDA margin improvement.
• California growth opportunity: Aveanna intends first to increase hours worked by existing caregivers, then support discharges of patients waiting in hospitals and address demand from families currently providing complex care themselves. Management said the necessary operating infrastructure is already in place.
• M&A priorities: The company’s pipeline remains active, but management emphasized disciplined valuations and continued deleveraging. Future transactions are expected to lean more heavily toward adult Home Health & Hospice assets.
• Caregiver recruitment: Beyond wages, Aveanna cited seven-day virtual onboarding, training, daily pay and caregiver technology as competitive tools. Its national onboarding infrastructure is also being deployed at Family First.
• Preferred-payer strategy: Approximately 90%-95% of recent Private Duty Services admissions were associated with preferred payers, supporting management’s expectation that the preferred-payer volume mix will continue rising over time.

Full Earnings Call Transcript

Complete Earnings Call Transcript

Management Remarks

Operator

Good morning, and welcome to Aveanna Healthcare Holdings Second Quarter 2026 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

Good morning, and welcome to Aveanna's second quarter 2026 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

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 Q2 results and how we are moving Aveanna forward in 2026. My initial comments will briefly highlight our second 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 updates on the Family First integration, how we are progressing with our 2026 strategic initiatives, our enhanced 2026 guidance, and updated long-term growth outlook before turning the call over to Matt.

Let's move to the highlights of the second quarter. Revenue for the second quarter was approximately $670 million, representing a 13.7% increase over the prior year period. Second quarter adjusted EBITDA was $95.4 million, representing an 8% increase over the prior year period, primarily due to the improved rate and volume environment and continued operational efficiencies. 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 Q2 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 all three of our business segments. 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 accelerated growth rates in all three of our business segments.

Since our first 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 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 2026 was twofold. First, we wanted to expand our strong advocacy presence with both federal and state legislatures across our national footprint and enhancing our value proposition. And second, we expected to achieve mid-single-digit state rate enhancements.

As of Q2, we have achieved seven state rate enhancements and believe we will add a few additional states as they complete their budget process in Q3. Most importantly, after four years of dedicated advocacy and focus on the state of California, I am proud to announce the 2027 California budget includes a significant investment in pediatric private duty nursing rates effective January 1, 2027. While we are awaiting the final details from the Medi-Cal department, we believe the investment represents a meaningful increase in California's private duty nursing rates. This achievement on behalf of the California medically fragile pediatric patients and families is monumental in nature as the private duty nursing rates and as a result, the nursing wages had fallen far behind the competitive market in California. We believe the California PDN rate increase will improve our ability to attract and retain nurses as well as support efficient discharges from the children's hospitals. We plan to proactively address nurse wages this fall in anticipation of the rate increase on January 1, 2027.

As I reflect on the significance of the California private duty nursing rate increase, I think it's important to comment on the success of our government affairs strategy. Roughly four years ago, we set out on a deliberate strategy to address the reimbursement rates and caregiver wages in all 32 Private Duty Services states in which we operate. California represented the final state in our goal to achieve enhanced PDN rates and caregiver wages across our national footprint. While our work is never done, we believe the disconnect that existed between reimbursement rates and caregiver wages has finally been addressed in every Aveanna state, and we can now focus on cost of living and inflation type enhancement with our government partners. I am proud of our government affairs teams and the advocacy work of our employees, caregivers, patients, and families that have made this a reality.

Now, moving on to our Private Duty Services preferred payer initiatives. Our preferred payer goal for 2026 was to achieve eight additional agreements for a total of 38 preferred payers. We signed three additional preferred payer agreements in Q2 and now have 37 agreements in total. We expect to exceed our 2026 Private Duty Services preferred payer goal of 38 as we navigate the second half of 2026. Aveanna's preferred payer strategy continues to gain momentum and allows us to invest in caregiver wages and recruitment efforts to accelerate hiring and staffing of nurses for our payer partners.

Additionally, our Q2 preferred payer agreements accounted for approximately 64% of our total Private Duty Services MCO volumes, up from 60% at the end of Q1. This positive momentum in preferred payer volumes continues to highlight the shift in our caregiver capacity and recruitment efforts towards our preferred payer partners.

Moving to our preferred payer progress in home health. Our goal for 2026 was to maintain our episodic mix above 75%, while returning to a more normalized growth rate. I am pleased to report in Q2, our episodic mix was approximately 81% and our total episodic volume growth was 18.5% compared with the prior year period. Further, we exited 2025 with 45 preferred payer agreements in home health and expected to add five agreements in 2026 for a total of 50.

I am pleased to report in Q2, we have achieved our goal of 50 preferred payers year-to-date. Our dedicated focus on aligning our home health caregiver capacity with those payers willing to reimburse us on an episodic basis has led to double-digit year-over-year growth in home health admissions and episodes, as well as improvement in our clinical and financial outcomes. Also, we're pleased with CMS's proposed Home Health rule published on July 1st, as well as the final Hospice rule published on August 6th.

The 2027 proposed Home Health rate shows positive movement by CMS aligned with a strong collaboration from the National Alliance for Care at Home. While there still is work to be done addressing the temporary adjustment and its impact on the annual Home Health rate, we have come a long way as an industry. We believe the stability of the Home Health & Hospice rates are important as we continue to meet the increasing demand for America's aging population, cared for in the comfort of their home.

Finally, as we have achieved our desired preferred payer model in Private Duty Services and Home Health & Hospice, we are continuing with a similar strategy in our Medical Solutions business. As we exited 2025, we had 18 preferred payer agreements, and expect that number to grow to 25 by the end of 2026. As of Q2, we have a total of 20 preferred payer agreements. Our gross margins have stabilized in our desired range as we align our clinical capacity with those payers that value our services and pay us in a timely fashion.

I am pleased with our Q2 volume growth of approximately 95,000 unique patients served, or a positive 4.4% over the prior year period. As we think about Medical Solutions revenue growth in 2026, I still expect us to remain in the high single digits for the next few quarters and then return to double-digit growth by the beginning of 2027. We are encouraged by our rate increases, preferred payer agreements, and subsequent growth in our businesses. Our company has demonstrated a stable return to organic growth 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 cost-effective, high-quality alternatives to higher-cost care settings.

Now, turning to our recently announced acquisition of Family First Homecare, a Florida-based company with a great reputation for quality in-home pediatric care. We closed the Family First acquisition in early June and are progressing nicely in the early stages of integration. Our leadership teams continue to focus on exceptional clinical care and supporting our branches as we navigate the necessary back office integrations. I expect us to wrap up the majority of the Family First integration efforts by late Q4. I believe the Family First team has already made a positive impact on Aveanna and is a welcome addition to our family.

Additionally, let me comment on our strategic plan and enhanced outlook for 2026. We will continue to focus our efforts on five primary strategic initiatives. First, strengthening our partnerships with government partners and preferred payers to create additional capacity and growth. Second, improving clinical outcomes and customer engagement scores while lowering the total cost of care. Third, implementing high-priority artificial intelligence and automation efforts to improve operational efficiency and productivity gains. Fourth, growing through acquisitions while improving net leverage and free cash flow. And finally, engaging our leaders and employees in delivering our Aveanna mission. Based on the strength of our second quarter results and the continued execution of our key strategic initiatives, we are increasing our full-year revenue and adjusted EBITDA guidance to a revenue range greater than $2.6 billion and adjusted EBITDA greater than $365 million.

As I reflect on the strong start to 2026 and the improved visibility with state and federal reimbursement rates a year after the One Big Beautiful Bill Act was passed into legislation. We are now poised to update our long-term core organic growth rates in Private Duty Services and Home Health & Hospice. Specifically, we are adjusting our long-term Private Duty Services organic growth rate from a range of 3% to 5% to now 5% to 6%, primarily driven by the improved state government affairs and continued preferred payer execution. Also, we are updating our long-term Home Health & Hospice organic growth rate range from 5% to 7% to now 8% to 10%, primarily driven by the improved federal government affairs and preferred payer results. We remain consistent with our current growth rates in Medical Solutions of 8% to 10%.

With the durability of our organic growth rates and thoughtful M&A activity, we believe Aveanna is well positioned to achieve double-digit revenue growth on an annual basis. Aveanna has a strong value proposition to our federal and state government partners, as well as to our MCO preferred payers, and these important relationships are underpinning our enhanced view on our future organic growth rates and our core business segments. We look forward to updating you on our continued execution of our business plans as we navigate the back half of 2026.

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

Matt Buckhalter

Thank you, Jeff, and good morning. I will first discuss our second quarter financial results and liquidity before providing additional details on our refreshed outlook for 2026. Starting with the top line, we saw revenues rise 13.7% over the prior year period to $670.5 million. We achieved year-over-year revenue growth in all three of our operating divisions, led by our Home Health & Hospice, Private Duty Services, and Medical Solutions divisions, which grew by 14.8%, 14.0%, and 9.4% compared to the prior year period. Consolidated gross margin was $218.5 million, or 32.6%. Consolidated adjusted EBITDA was $95.4 million, an 8% increase as compared to the prior year period. This growth reflects an improved rate environment, increased volumes, as well as enhanced operational efficiencies.

Now taking a deeper look into each of our segments. Starting with Private Duty Services, revenue for the quarter was approximately -- Q2 revenue per hour of $44.62 was up 1.7% compared to the prior year quarter, primarily driven by growth in preferred payer volume and updated reimbursement agreements. 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 $159.9 million of gross margin, or 28.9%. The cost of revenue rate of $31.74 in Q2 was up $2.06, or 7.8% from the prior year period. Our Q2 spread per hour was $12.88, reflecting continued normalization driven in part by ongoing caregiver wage adjustments supporting higher volumes, and improving clinical outcomes. As a reminder, Q2 2025 included approximately $9 million of non-recurring, favorable items in our PDS division, primarily driven by the timing of rate enhancements and favorable revenue reserve adjustments.

Moving on to our Home Health & Hospice segment.

Revenue for the quarter was approximately $69 million, a 14.8% increase over the prior year. Revenue was driven by 10,500 total admissions, with approximately 81% being episodic, and 14,700 total episodes of care, up 18.5% from the prior year quarter. Medicare revenue per episode was $3,202 for the quarter. Our episodic focus has accelerated our margin expansion and improved our clinical outcomes. With episodic admissions well over 75%, we have achieved our goal of right-sizing our margin profile and enhancing our clinical offerings. We are pleased with our Q2 gross margin of 53.9%, 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 Q2. During the quarter, we produced revenue of $47.5 million, up 9.4% over the prior year period. Revenue was driven by approximately 95,000 unique patients served. Revenue per UPS of approximately $500, up 5% over the prior year period. Gross margin was approximately $21.4 million, or 45.1% for the quarter. As Jeff mentioned, we are in the final stages of our preferred payer strategy in Medical Solutions, by aligning our capacity with those payers that value our resources and appropriately reimburse us for the services we provide. As a result, we expect UPS to continue to accelerate its growth in the back half of 2026.

In summary, we remain focused on keeping our patients' care at the center of everything we do. It is clear that aligning caregiver capacity with preferred payers who value our partnership is the right path forward at Aveanna. With a strong momentum through Q2, we are optimistic these trends will continue throughout 2026. We will continue to pass through wage improvements and other benefits to our caregivers in the ongoing effort to better improve volumes.

Now, turning to our balance sheet and liquidity. During the quarter, we were pleased to receive credit rating upgrades from all three major rating agencies, reflecting the continued strength in our financial profile and the consistent execution of our long-term strategy. At the end of the second quarter, we had liquidity of approximately $433 million, representing cash on hand of approximately $97 million, $110 million of availability under our securitization facility, and approximately $226 million of availability on our revolver, which was undrawn as of the end of the quarter. We had $24.5 million in outstanding letters of credit at the end of Q2. As a reminder, we funded the Family First acquisition and associated closing costs during Q2 using exclusively cash on hand.

On the debt service front, we had approximately $1.48 billion of variable rate debt at the end of Q2. Of this amount, $1.4 billion is hedged with interest rate caps, which limits exposure to increases in SOFR. Accordingly, substantially all of our variable rate debt is hedged. Additionally, during the second quarter, we successfully repriced our term loan, reducing our interest rate by 75 basis points. This refinancing will lower our annual interest expense by approximately $10 million. The repricing reflects our continued strong operational performance and the ongoing support and confidence of our lending partners.

Looking at year-to-date cash flow, cash generated by operating activities was $85.3 million and free cash flow was positive $75.4 million. We are encouraged by our strong cash collections and the cost efficiency efforts which has driven solid operating and free cash flow in 2026. We expect similar cash flow performance in the back half of the year.

Before I hand the call over to the operator for Q&A, let me take a moment to address our enhanced outlook for 2026. As Jeff mentioned, we expect full-year revenue to be greater than $2.68 billion, adjusted EBITDA greater than $365 million. This improved guidance reflects continued strength in our underlying business, supported by strong organic growth and sustained demand for our services. As we reflect on our Q2 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 continued execution of our 2026 strategic plan and look forward to providing you with further updates at the end of Q3.

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

Operator

[Operator Instructions] Our first question comes from Brian Tanquilut with Jefferies.

Question-and-Answer Session

Meghan Holtz

This is Meghan Holtz on for Brian Tanquilut. Congrats on the quarter, guys and the full year guidance raise and the California rate increase. I know it's been in the works for a while. I guess starting on your LRPs that you raised for the business segments, given that you're raising the revenue rate, should we be thinking about corresponding margin increase in those segments as well?

Jeffrey Shaner

Yes, and thank you, Meghan, and good morning. We're excited now that we've kind of 15, 16 months after the OBBBA has settled in, we have more clarity, more visibility in how our state rate setting process works. It has played through and will play through. We also have more confidence, as we talked about, in both our Home Health and our Hospice rate setting and rule-making process. As we think of the long-term revenue growth, to your comment, I think Matt and I would lead you to continue to think about wage pass-through being a key component of our story.

From a gross margin standpoint, I would think about the gross margin percentage staying pretty consistent. Clearly, gross margin dollars will increase as revenue accelerates and revenue dollars accelerate. But I think you're seeing that even in our results today. So really focused on continuing to grow the business at accelerated rates, as well as continuing our caregiver pass-through both on a government basis and a preferred payer basis. Matt, you want to add to that?

Matt Buckhalter

No, I think you said it really well, Jeff, but I think gross margins came right in line with our expectations in Q2. Obviously, 2025 had a little bit of timing-related items for PDS segment, and people are able to normalize that out and understand what that is, but we believe Q2 really does, the results represent, and specifically in the PDS business, but everywhere else, where we expect gross margins to remain going forward.

Meghan Holtz

And then on the California state rate increase, is there any additional color you guys can provide on the expected benefit as we think about 2027? I know it's a little early. And then you mentioned passing through the wages prior to the rate going into place in the back half of this year. How should we be thinking about that?

Jeffrey Shaner

Thanks, Meghan. Probably not the last California question we're going to get this morning. Really excited to your point, because if you think about the last rate increase in California was July 1st of 2018. So I mean, we're coming up on almost 9 years, 8.5 years. We've been advocating with our peers, industry peers, and the California Home Care Association now for almost 5 years. So really pleased that the legislature and the governor both saw the value in investing in the private duty nursing rate. We're in a process now that the legislature and the governor have allocated specific dollars to the Medi-Cal department. We're in the process now of the Medi-Cal department now updating its fee-for-service schedule.

And as you said, we'll have to remain a little bit patient over the next few weeks as they do their normal process. We would expect by the end of September for the Medi-Cal department to have updated 2027 rate schedule to include the updated investment from the legislators. So it'll be a few more weeks, probably a month before we see the final rates for the PDN rate increase in 2027. Matt, with that, you want to talk about the wage pass-through?

Matt Buckhalter

Yes, Meghan, we've done this in the past and we've had a lot of great success, but we'll be proactive once things settle to Jeff's point on passing through wages to really pull those patients out of the hospital. It's been, like I said, 8 years going on, 9 years since the last rate increase in the state of California, and there's so much pent-up demand for services. So we will be thoughtful on our approach to that and kind of the back half of Q3, really in Q4 about starting to pass through some of those wages proactively, even before the rate goes live, so that we can pull that census out of the hospital, get our staffing rates and percentages up, and really hire those caregivers to provide that care.

Operator

Our next question comes from Raj Kumar with Stephens.

Raj Kumar

Maybe just on 2026 guidance. I know you guys, intra-quarter, increased it for the Family First acquisition, but maybe comment kind of thinking about the new enhanced guidance. Is there any increased contributions there from Family First or should we just be all thinking about the raise being solely driven by the kind of core organic business?

Matt Buckhalter

You nailed it there, Raj, and good question. So we did previously increase our guidance for the Family First impact, kind of within the quarter itself. So that's already contemplated into our previous guidance that we provided earlier. So what you're really seeing now is just driven by strong operational performance in the core Aveanna business. So all three divisions continuing to perform at very high levels give us the confidence to increase our revenue and our EBITDA guidance for 2026.

Raj Kumar

Got it. And then as my follow up, looking at the long-term outlook, you guys also increased the contributions from M&A. And so as I kind of think about that, maybe kind of just discuss your appetite across private duty nursing and Home Health & Hospice, kind of where do you feel comfortable with the leverage profile as you kind of, think about doing these deals?

Jeffrey Shaner

Great question and great catch, Raj. Yes, I think as I said in our prepared remarks, thoughtful M&A is continuing to be where we see the opportunity to grow. And to your point, as Matt talked about, free cash flow generation, first half of the year was right around $75 million. I think Matt talked about similar expectations in the back half of the year. So the $150 million, $150-plus million of free cash flow generation, we saw with Family First, we were able to pay for Family First and its closing costs with all cash on the balance sheet, cash on hand, we're quickly regenerating that cash flow.

Matt would want me to point out that although temporary leverage went up, that the story will continue to be deleveraging between now and the end of the year. And so the ability to accelerate our model now using cash flow, cash generation and certainly being thoughtful. I know Matt wanted to talk about leverage just to hammer home that point.

Matt Buckhalter

Yes, our M&A pipeline continues to be very robust out there, but we're going to remain focused, Raj. Just acquisitions that fit our culture, of course, create long-term value for Aveanna, of course, and the shareholders at Aveanna. We're going to remain disciplined around the valuation of these acquisitions as well, though, and keeping leverage at our top of mind. So I think you could see us, like you said, increasing that a little bit, but also continuing to deleverage the organization to really get to our long-term goal of being a sub-3x leverage company.

Jeffrey Shaner

I think that's a very important point. We've had a long-term target now for a couple of years to get the company under 3x leverage. That continues to be our target. The path gets clearer and clearer every quarter. Certainly today's announcements on our growth rates gives us even more confidence on being able to achieve that in 2027. Thanks, Raj.

Operator

Our next question comes from Pito Chickering with Deutsche Bank.

Pito Chickering

Going back to that long-term guidance change in PDS and Home Health & Hospice, on the corporate level, my back of the envelope math here is about 150 basis points revenue raised to long-term guidance. So a pretty big jump from 4.6% to 6.1% assuming my math is right. But can you talk about the margin leverage you can get on the EBITDA line from this revenue raise and does it mean EBITDA should not be growing long-term in like the 7-, 8-plus percent range?

Jeffrey Shaner

First of all, kudos on your math, Pito. As always, your math is very tight. That's roughly 6% from a core organic standpoint is where we landed on a forward-looking basis. I think I want to be careful as we are touching 14%, EBITDA at this point, I think we've, kind of, guided that that 13% to 14% is where we thought we would land as a primary Medicaid-driven organization. I think I will say, as you think of our forward-looking growth rates, our geriatric business, although it's smaller in nature today, is what will be our fastest-growing business. And I think as you think of M&A, think of us leaning in deeper into the Home Health side of the M&A picture. So I do think what you'll see from our growth rates as we're leaning into the faster growing part of our business and the business where we have the most opportunity to fill in geographically across America.

With that said, we want to be crystal clear. Our job is to hire more nurses and put more caregivers to work. To do that, we've got to continue, and I think California, as Matt said, is a great example of that. Our rate increase won't begin until January 1, '27. We'll start passing wages through some point early to mid-October. And to Matt's point, we will be ramped up. So by the time we hit, at the end of December in California, we want to be running at full speed. And we'll invest those dollars ahead of time to get ahead. All of that is in the spirit of continuing to do the right thing for our families and grow our business. So I don't know that I would try to sell that our 14% EBITDA target is changing materially. Matt, any comments just on leverage?

Matt Buckhalter

No, I think, Pito, you've obviously seen it over the last few years where gross margin has been pretty consistent, but our SG&A leverage has been really, really impressive. We've done it through a lot of ways, just being more effective and efficient, filling in some automation technology as well. 14% is a pretty good spot. Maybe that sneaks up to 15% as we continue to develop and get better with some of those growth rates, but I wouldn't bank on it being much higher than that.

Pito Chickering

Yes, yes. It does much more about obviously SG&A leverage than it was about gross margin, because obviously that's a bit more of a pass-through. So the follow-up question here is looking at the spread sort of in Q2, in PDS. I guess, how should we think about that in the back half of the year? And then the hour growth was incredibly impressive in the second quarter. And as the spreads maybe compressed in the back half of the year, kind of what should we be thinking about the PDS hourly growth rate for the back half?

Matt Buckhalter

Yes, I'm going to continue to pull you back to a gross margin comment each time. So 28.9% gross margin on a PDS segment, really impressed with where it came in at, and right where we expected it to come in at. We've guided to that 26% to 28%. We said publicly that, hey, we'll be north of that here in 2026, and we expect the remainder of the year to be right in line with that 28% and change 29% gross margin. So that's our business model. As we continue to win state rate increases, assign additional preferred payers, we'll continue to pass those dollars down, but keeping that 28%, 29% gross margin a top of mind.

Operator

Our next question comes from Benjamin Rossi with JPMorgan Chase.

Benjamin Rossi

Following up on PDS preferred payer mix, you highlighted that 400 basis point sequential step up during Q2 to 64% of mix covered by these preferred payers. Do you expect that figure to remain largely flat through the remainder of the year and then step up on January 1 when the new California rates take effect? Or how are you thinking about forward cadence as we head into 2027 with that notable state set to come through?

Jeffrey Shaner

Yes, and let me separate those two, Ben, because remember the 64% is MCO volumes, and the majority of California is still Medi-Cal, Medicaid reimbursed. So we don't count that in the PDS preferred payer MCO volume. So think of 60% -- I think we talked earlier in the year, we kind of ended last year, we were mid- to high-50s percent. We thought we would kind of hit mid-60s this year. I think from where we sit today, we probably tell you we'll be a little bit north, probably still shy of 70% in 2026. So probably another couple of percentage points on the current 64%, but not a whole lot more this year

Pivoting to back that California comment. The majority of our California business is, as I mentioned, is still a Medi-Cal reimbursed. Again, it'll mimic more of what preferred payer rates look like once this rate is, we think, is applied through. We do have a small portion of our business in California, we talked about before, which is preferred payer in nature, and we're excited for those rates to remain intact.

So long story short, I think we'll end the year kind of slightly above what we said from a preferred payer PDS volume standpoint and excited clearly now with the California 2027 kind of bulkhead leading us in. We're excited about the momentum it'll take in '27.

Benjamin Rossi

Great. Appreciate that clarification. Just a follow-up on capacity within PDS. Obviously, demand seems to remain elevated there. Where are you seeing the greatest opportunity to add capacity? Do you think it's through these new preferred payer wins in existing states or entering or expanding in the new white space geographies? And do you think the California rate unlock maybe opens up some new market opportunities there?

Matt Buckhalter

Yes, Ben, California is obviously lagged the last few years. It's been pretty significant that it's been nine years since the last rate increase itself, and so the amount of our fill rate and our volumes in California has really become less significant to Aveanna over the last few years. With the implementation of it, we will be able to grow this one actively and really hire those caregivers and onboard those caregivers to provide additional care. There are some opportunities for geography that we still want to fill in, specifically in PDS, really that middle of America, the Ohios, the Kentuckys, the West Virginias.

Those are attractive markets for us to continue to grow inorganically, but still organically there's a lot of opportunity out there, whether it's in the states that we currently provide services to, or just the continued high demand for our services in every single one of our markets is there. So there's a lot of meat left on this bone. There's a lot of opportunity out there for it, but we're going to work with our state legislators and our preferred payers to continue to fill that demand.

Jeffrey Shaner

I think as Matt -- Ben, as we said in the prepared remarks, it's nice to now put California to bed to where we can really focus on cost-of-living type adjustments, inflation types. We don't want to go 9 years with California to do another rate adjustment. We want 24 months later to be in a COLA type or a cost-of-living. And that's what we're in the seven rate wins outside of California, we're seeing more cost of living type adjustments, which is great. That's the world we want to live in moving forward versus this catch-up process we've been in. So it's nice to put that part to bed. Thanks, Ben.

Operator

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

Albert Rice

Just to lean into California a little more, obviously, if you haven't had a rate increase for that long a period of time, it probably hasn't been a growth vehicle for you. So what is the percent of your business that's in California today? And when you think about the opportunity that this rate update is going to present, I know you're saying you'll lean into giving caregivers the salary increases they need to start attracting them later this year. Do you need to put any infrastructure of any sort to be able to address a state of that size fully given now it's going to become a growth area as opposed to sort of a maintenance of what you already had type of situation?

Jeffrey Shaner

Great question, A.J. I'll start with a different perspective. We've had a lot of people ask us over the last two years why we stayed in California. Like, why don't you just pack up and leave? The rates don't work. Your business has been lethargic in the state. And I think this is the reason why we don't leave states. This is the lesson that you have to learn in this business is stay focused on the long term, stay focused on the advocacy for these patients. So yes to your point, as the company has accelerated over the last three years, California has been doing, our California business has been doing the opposite. It's been lethargic, lagging, fill rates have dropped almost 30% or 1/3, meaning, our ability to fill the hours that are already authorized.

So the very first thing that we want to do is get the caregivers who are working to work more hours on the shifts, on the patients that they currently have. So the first part of our growth is just getting our caregivers who already are working more engaged by paying them more. As Matt talked about, the next two steps that get exciting is really unlocking the unnecessary hospital days. And that's where the savings come is as we start pulling through the patients that have been just sitting in hospitals waiting to come home.

And then the third group is really the families that have been doing the jobs themselves, meaning you have parents that are providing basically high-level nursing care in their home because they can't hire a nurse anywhere. And so even though they're not in a hospital today, certainly giving those families that have medically-affected children, that may be the mother and the father, neither of which work because they're providing full-time care for the patient, is just a third opportunity for us. So as you think of all of that, it will take some time to solve number two and number three, but the very first thing we want to do that we can start solving even before we get to January 1st is getting the current caregivers more engaged, filling more hours.

So the short-term and long-term growth that unlocks is very exciting for us. But the most important part is we get to actually help the families in California.

Matt Buckhalter

Yes, Jeff, I'd just add on to it and address your question out there. A.J., the infrastructure itself is already in place. We have a very robust team, a very strong team, and a team who's ready to grow and now has the ability to grow, which is the most important thing. Going through the PDS modernization a few years ago, we have our targeted operating model, in every single one of our locations and every single one of our areas. And so we live by that every single day. And so that structure and infrastructure is already set up to propel us forward.

Albert Rice

Okay. Maybe on the follow-up, you along with some others are obviously feeling a little better about adult home care and the rate updates and the just general backdrop for the segment. Can you talk a little bit about, I know you've got a lot going on with PDS, but how you might lean into growth there, new states, anything you're looking at to try to maybe go on and encourage the acceleration there?

Jeffrey Shaner

Yes, great question. I think in my comments a few minutes ago, A.J., as we think of our M&A activity, I won't call it 80-20, but we think the majority of our M&A activity moving forward will be in the adult space, primarily because we have filled in the majority of the PDS states in America. Matt talked about we still have about five or six states we want to tuck in on the PDS side, mainly that Michigan, Ohio that Matt was talking about, kind of mid-America, but the remaining part of our growth and our de novo/M&A growth will really be on the more Home Health & Hospice. We love Hospice, we just don't love the multiples of Hospice. So I think we feel we've been a big proponent of Home Health the last three years. We think we've got a best-in-class Home Health & Hospice team. And with the cash generation we're doing now, we think we can begin to grow in that business on an inorganic and organic basis.

Operator

Our next question comes from Sean Dodge with BMO Capital Markets.

Sean Dodge

Maybe just going back to the PDS preferred payer mix. Jeff, you said 64% now. Longer term, how much higher do you think you can drive that mix? And then how should we think about how that impacts your spreads over time, over the next couple of years? How additive can that be aside from any of these more margin neutral dynamics, timing and rate updates and in the subsequent pass-throughs?

Jeffrey Shaner

Yes, great question, Sean. I think as we've thought about long-term is our ultimate goal is to kind of reach the mid-80s, maybe one day the high-80s in percentage of PDS MCO volumes. That's probably still three to five years from now. So I said I, I think if you just take the last three years and think about what this year is going to most likely be, we've been adding around 4% to 6%, 4% to 7% growth in that per year. So I think that we see that continuing forward. The key thing to really think about underneath that is last week's admissions and PDS the week before, those are still like 90% to 95% preferred payer admissions. So the majority of our admissions, the majority of our nurse hires day to day in a preferred payer environment. So again, I think we're pleased where we're going to end this year in the mid to upper mid 60% and probably in that 4% to 6% per year growth. Matt, anything else on spread?

Matt Buckhalter

No, I think we'll continue to stay consistent. Our goal and objective isn't necessarily to increase that gross margin percentage, but to be able to invest those dollars to hire more caregivers and get better clinical outcomes. That's what our preferred payers are continuing to ask of us, and that's what we need to continue to deliver to ultimately reduce the total cost of care.

Sean Dodge

Okay. And then in Home Health, your episodic mix was 81%, so remains well above your 75% goal. Is there any reason that would begin to normalize back down, or do you think kind of somewhere in the neighborhood of 80% or better is kind of sustainable there going forward?

Jeffrey Shaner

It's a great point. But by the way, we have fun with that metric internally as a team, we've been at 80% now for almost, not quite a full year, but two to three quarters, and it's been pretty consistent. We would be comfortable, Sean, with that going back down to 78%, 79%, even 77% if growth continued to accelerate north of 20% year-over-year growth. We're okay with anything in the high-70s, low-80s. I think as we lap 2026 into 2027, we'll update our target from greater than 75% to something north of that. Because at this point, it really has settled in pretty comfortably in this 80% range. I'll add to that one other piece.

Where four years ago it was very hard to get a Medicare Advantage MCO payer to want to engage in an episodic agreement, that no longer is that difficult. I think the industry has done a really good job, our peers, us, and even the payers have come around to this is the best form of payment, it is the best clinical outcome, a solid financial outcome, a fair reimbursement. So it has gotten, I don't want to use the word easier, but it has just gotten more efficient for payers to work within an episodic arrangement. And I think that that will continue to help keep us around that 80% long-term episodic range. Thanks, Sean.

Operator

Our next question comes from Jared Haase with William Blair.

Jared Haase

I'll echo the congrats on all the success so far here. Obviously you guys have talked a little bit about just how the labor environment is really the gating unlock here to driving the volume. And I think you've really well articulated the strategy of getting these rate increases and using that to invest in the workforce. I guess I'm just curious, aside from wages, is there anything incremental, either strategically or operationally, that you feel like is really resonating in terms of how you're finding caregivers, onboarding them, training them up, or ultimately getting them, matched to the cases that they want to work?

Matt Buckhalter

Yes, Jared, the answer is yes. I mean, every single, our infrastructure and our size and scale has really allowed us to create that more ease than maybe some of our peers out there in the market. So whether it be your training that's put into place, your onboarding, your quickness to onboarding on top of it, your daily pay that you're being able to offer, the technology for adding in notes, all of those really add up into a benefit of the caregiver. Obviously, one of the biggest drivers and the main driver is going to continue to be wages out there, and so that's the reason we see that success with driving reimbursements and investing into our wages. But our entire infrastructure and our entire technological stack out there also makes it more beneficial for caregivers to be on our service as well, or provide services for us.

Jeffrey Shaner

And I'll point out, Jared, a great point. We have a national onboarding team led by a wonderful, wonderful clinical leader here. And I'll use Family First as a great example. Family First did a really good job of recruiting and hiring nurses. They didn't have the ability to onboard nurses seven days a week, effectively 24 hours a day, and we do, because of our size and scale, we've invested in a team of nurses that just do virtual orientation and onboarding for our nurses across all 32 states and PDS and growing.

But it's a great example of Matt's point of size and scale. We've invested into that team. They do an amazing job. And as soon as we close on Family First, we're able to offer that service to Family First. And they've been very positive on the efficiency of that team and how it helps nurses onboard quicker to families. So again, I think that to Matt's point, wage is number one, certainly wage is the most important in the decision point for most nurses, but the efficiencies and scale that do help us.

Jared Haase

Okay, yes, that's great. That's really helpful. And then maybe just as a follow up. So maybe taking a step back a little bit, but obviously with the Home Health industry becoming perhaps a little bit more appealing here with some clarity on the rate front. And if we start to see some more investment from you guys towards that segment of the market. Can you just talk a little bit about like, how do you think about potential synergies that maybe I might not be thinking about offhand between offering both PDS and Home Health?

Yes, obviously it's a little bit of a different patient population. It's a little bit of a different payer mix, Medicaid versus Medicare. But maybe just, aside from national scale, and potential corporate efficiencies, leverage, things like that, is there anything else you'd flag as far as potential synergies from expanding in that segment of the business?

Jeffrey Shaner

I'd love to sell you on something, but you hammered the three that we would think of. I mean, it's corporate efficiencies, back office efficiencies, billing collections. We use two different EMR operating systems for those businesses because they're very different. They're different leaders who lead them. I will say just the efficiencies of those great leaders partnering together, because we offer the same services in many of our same states. So people get to know us both on the Medicaid side, the Medicare side. We're branded the same, Aveanna Home Health & Hospice, Aveanna Private Duty Services.

So just using the brand, it is different payers, right? Medicare Advantage payers, even if it's the same parent company of UnitedHealthcare, it is two different total departments in the payer standpoint. So there are efficiencies, but it's not nursing efficiencies, caregiver efficiencies. It's mostly back office, as you pointed out.

Jared Haase

Okay, that's fair. And I certainly hear you that you see, elevated growth opportunities in Home Health and that maybe has a margin benefit as well. But I wanted to make sure I wasn't missing anything. But that's great. Thank you.

Operator

Our next question comes from Andrew Mok with Barclays.

Andrew Mok

Can you speak to how your government affairs team has been able to secure better rates under a difficult state funding environment? If we take a step back, state budgets still look constrained, and we're now starting to implement OBBBA. So is the view internally that PDS is benefiting from a reallocation of funding within Medicaid? And is that helped by OBBBA's efforts to curb spending in the adult Medicaid population?

Jeffrey Shaner

Andrew, good morning. Great question. Very thoughtful question. One, we have a long-term approach to our states. I think California is a great example. There were a lot of low-hanging fruit the last three years when we did not get the California rate increase that we had asked for. So it's a long-term approach to these states. Geographic diversity matters. So I think being spread out across 30 plus states does matter, being able to offset the growth in other states as we have been working through California. But staying at the table, continuing to talk about the benefits of the cost savings of our business has settled in.

And I think to the second part of your question, I hate to say that taking $1 trillion out of Medicaid actually helps PDN, but I think what we take away from it is PDN is absolutely insulated from the idea of cuts through the OBBBA legislation, and over the long term is opening some doors in some states for reallocations of dollars. And so, we don't like the idea of, diminishing Medicaid services for any family who deserves those services, but recognizing the value of PDN.

And I think as we continue to hear from our MCO payers, 10x savings per day, $6,000 or $7,000 a day in the acute care center, $600 or $700 a day at home, that is just resonating incredibly well with the MCO payers and over time our state legislator partners. So I think we're far enough in, being a year and a half into the OBBBA legislation to really be able to see that PDN is going to come out of this, primarily in very good shape.

Operator

Our next question comes from Andrew Cooper with Raymond James.

Andrew Cooper

I'll try once just to see, can you give us a little bit more of a quantitative starting point for California and PDS to think about as we head into '27? And then when you think about some other states where you've seen, bigger step function rate increases, how much have you been able to, add that labor pool and drive the volume and response based on some of your historic experience?

Matt Buckhalter

Yes, Andrew, while we don't provide specifics about any state or any payer out there, we previously said that California's impact on Aveanna has become a little bit less significant over the last few years. That's really driven by the PDN growth, the PDS growth in the other 31 states itself, and because of California's rates, therefore their wages lagging, they've been less impactful for us. Now, we are really excited about this rate increase and the impact the rate enhancement is going to have on the medically fragile patient population and our ability to recruit and retain those caregivers going forward.

Jeffrey Shaner

And the second part of your question, Andrew. Let me use Georgia as a great example. So 3 years ago, we had a, it had been 10 years in Georgia since any movement in the Medicaid rate, and we got a, I'd say in line with this increase, if not a little bit even more significant in Georgia, and it moved the market in a matter of days, weeks. We got ahead of the rate increase in Georgia by about three or four months in the wage pass-through. So it was a July 1 effective date. We started passing wage through in March and April. We saw fill rates dramatically improve. And then the most important thing is, one month or two after the rate increase went through in Georgia, the largest children's hospital is a couple miles from our office here in Atlanta.

And we heard things like, the halls have never been empty before and these beds have never been, cleared out. And truly it did, it unlocked the unnecessary days that were being spent in the hospital. And so our hospital peers really, really, really valued that step change. And, again, California is a little bit bigger than Georgia. It's got more children's hospitals than one. But we think we'll see a similar effect take place over Q1 and Q2 of next year as really the unlocking of these unnecessary hospitalizations just start to get pulled through back to the home.

Andrew Cooper

Okay, that's helpful. And then, oh, go ahead.

Jeffrey Shaner

No, you're fine. Go ahead.

Andrew Cooper

I was just going to say, maybe shifting a little bit and thinking, no, you won't guide to '27 right now. But when we think about the moving parts of kind of on plan, if not ahead of plan in the preferred payer progress across the segments, you get California giving you a bump as well. I mean, is it safe to think that '27's rate increase across the spectrum of the business is probably a little bit more than your average. And so the growth we think about, at least on the rate side, is maybe a little bit better than what the long-term framework would suggest in a more normal year?

Matt Buckhalter

No, Andrew, I think that's why we were comfortable increasing our growth rate specifically in PDS from that 3% to 5% range to that 5% to 6% range going forward. Obviously, the clarity of the OBBBA coming through, but also just our consistent engagement with governors and legislative bodies that says like hey this is a value add to the health care system, this is a cost reduction from the health care system, so between that one also with our movement from the 5% to 7% range in our Home Health & Hospice business to going 8% to 10% going forward, we've kind of built that into our long-range growth plans itself.

Yes, California might carry the water a little bit more next year, but then the following year, maybe it's Texas. Maybe the year after that, it's Florida. The year after that, it's Massachusetts. And that's really because of the diversity of the states and the 39 states that are in, the 32 specific PDS states. All that diversity allows us to really increase our growth rates going forward.

Jeffrey Shaner

And I would still underpin it with it's still more volume growth than rate. So in that 5% to 6% PDS guide, I would still think more of like a 3/4 volume, 1/4 roughly rate. So it's rate is helping drive the volume, but volume is still the biggest driver of all of our organic growth rates. Thank you, Andrew.

Operator

Our next question comes from Grayson McAlister with Truist Securities.

Grayson Joshua McAlister

Hey guys, Grayson McAlister on for Dave. I'll wrap up with just one quick one for me here. I guess, could you talk a little bit more about the Family First integration thus far? How has the integration gone versus your expectations? And then any bigger, more challenging aspects that you would expect for the second half of the year as you look to get it wrapped up?

Jeffrey Shaner

Great, great question. And I think in our remarks, we're incredibly pleased. The Thrive integration a year earlier gave us a great roadmap for PDS acquisitions. Family First is a little bit bigger, but very similar, going as well or better than expected. I'd say we're still in the front third of the integration in the next few months, a few months, intensify as we work through the back-office and EMR transitions, which are the biggest movements. The teams are doing great. They've strengthened our business in a couple key markets, including Florida. I'd say we're a better business today because of their partnership in the state of Florida.

And it's also just bolstered some of the service areas in Iowa and South Dakota that were really important. I mean, these are incredibly rural communities, rural states, so the ability to have a little bit better service distribution in those states, Illinois, South Dakota, and Iowa, really, I think, ultimately make us better.

And then, leaning forward, and your last part of your question there is, I think as we think about this moving forward, we'd like to see similar type acquisitions on the HHH side, the Home Health & Hospice side, where we start to materially move our Home Health & Hospice business from an inorganic growth standpoint. But the model is here, we have a great team. Our integration management office does a phenomenal job leading us through the integration process. So incredibly pleased. Also excited to wrap it up here later part of the year and get this done by the end of 2026.

Operator

We've reached the end of our question and answer session. I would now like to turn the floor back over to Jeff Shaner for closing comments.

Jeffrey Shaner

Thank you so much. We look forward to updating you on our continued progress at the end of Q3, and have a great day, and thanks for your continued interest in Aveanna Healthcare.

Operator

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