AMN Healthcare Services, Inc. (AMN) Q4 2020 Earnings Call Transcript

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AMN Healthcare Services, Inc. (AMN 1.17%)
Q4 2020 Earnings Call
Feb 18, 2021, 5:00 p.m. ET

Contents:

• Prepared Remarks
• Questions and Answers
• Call Participants

Prepared Remarks:

Operator

Ladies and gentlemen, thank you for standing by and welcome to the AMN Healthcare Fourth Quarter 2020 Earnings Conference Call. [Operator Instructions]

I would now like to hand the conference over to your speaker for today, Mr. Randy Reece, Director of Investor Relations. Thank you, sir. Please go ahead.

Randle Reece -- Director, Investor Relations

Good afternoon everyone. Welcome to the AMN Healthcare's fourth quarter and full year 2020 earnings call. A replay of this webcast will be available at ir.amnhealthcare.com following the conclusion of this call. Details for the audio replay of the conference call are in our earnings release issued this afternoon.

Various remarks we make during this call about future expectations, projections, trends, plans, events or circumstances, constitute forward-looking statements. These statements reflect the company's current beliefs, based upon information currently available to it. Our actual results may differ materially from those indicated by these forward-looking statements, as a result of various factors and cautionary statements, including those identified in our most recently filed Forms 10-K and 10-Q, our earnings release, and subsequent filings with the SEC.

The company does not intend to update guidance or any forward-looking statements provided today, prior to its next earnings release. This call contains certain non-GAAP financial information. Information regarding and reconciliations of these non-GAAP measures to the most directly comparable GAAP measures, are included in our earnings release and on our Financial Reports page at ir.amnhealthcare.com.

On the call today are Susan Salka, Chief Executive Officer; Brian Scott, Chief Financial Officer; Kelly Rakowski, Group President and COO of Strategic Talent Solutions; Landry Seedig, Group President and COO of Nursing and Allied Solutions; and Maureen Huber, President of Workforce Technology Solutions.

I will now turn the call over to Susan.

Susan Salka -- Chief Executive Officer

Thank you so much, Randy, and welcome everyone. We have all been affected by the events of 2020 but none more so than the people afflicted with Covid-19, their families and caregivers. Healthcare providers went through astonishing lengths putting themselves at risk to save lives. Millions of Americans fundamentally changed the way they live each day sacrificing to contain the pandemic. We must never forget those losses, but it is also essential that our efforts have focused on the future and doing all we can to help to bring an end to this crisis.

While our nation was rocked by the pandemic, we also faced the turmoil of racial and social injustice and political unrest. I feel great pride in the way our AMN team responded to a year of dramatic swings and demand for healthcare labor were also making great progress on our commitment to social responsibility, diversity, and equity. No matter how intense the storm, we never lost sight of all of our stakeholders. We didn't just respond to the crisis, we transformed our company with agility and innovation when our clients and healthcare professionals needed us most.

AMN began 2020 by taking bold steps, acquiring Stratus Video, the leader in virtual language services for healthcare and launching mobile and other digital capabilities and enhanced how we support our healthcare professionals. These and other investments gave us the ability to deploy new solutions, speeding our pace of innovation and collaboration and creating lasting benefit. To provide you with more insights on how Stratus Video and other technology investments have enabled us to respond, we've invited Maureen Huber to join us on this call.

In addition to her role as President of Stratus, Maureen has taken on broader responsibilities as the President of AMN's Workforce Technology Solutions. We are so fortunate to have her leading these teams and creating a vision for how AMN will create greater value to novel technology-based solutions.

With that introduction, I will hand the call over to my colleague, Maureen.

Maureen Huber -- President, Workforce Technology Solutions

Thank you, Susan. The Stratus team was thrilled to join the nation's leader and healthcare total talent solutions last February. And as we celebrated our one year anniversary last week, we recognized the successful melding of our purpose driven culture processes and technology.

I am pleased to say that the union has exceeded our high expectations, the importance of AMN Telehealth platform including Stratus for language interpretation, became even more essential through the last year. Our Language interpretation volumes grew about 30% year-over-year in 2020, their momentum continues with first quarter volumes expected to be up at least 35% year-over-year. We help our clients deliver meaningful access to language services provided by more than 3,300 amazing medical interpreters in 208 languages. Additionally, we've integrated our language services into the AMN Televate school platform to provide interpretation for students and clinicians.

We've added language services to several existing in the market to engage additional strategic clients who are seeking a more integrated full service total talent solutions partner. Our technology enabled talent solutions are critical part of AMN's long-term strategy and you have seen how the [Technical Issue] company has been steadily investing in these capabilities. Over the last year we've made advancements to respond the urgent market need. We quickly deployed enhanced capabilities and reinforced our AMN team with additional technology. This allowed us to do extraordinary things beyond clinical staffing including the planning and ramp-up of field hospital, deployment of an open talent marketplace, return to work in contact tracing solutions and now integrating many of our technology and services to support mass vaccine administration.

We improved our unique ability to offer a total payout solution to rapidly respond to these emerging needs at scale. We will further integrate and reimagine our technology and staffing capabilities to more efficiently and effectively deliver total talent solutions across the queue, post the queue and virtual settings.

We believe these advancements will position AMN well for the changing market needs. I look forward to sharing more with you in our Q&A session. And now I'll turn the call back over to you Susan.

Susan Salka -- Chief Executive Officer

Thank you so much. Maureen. Now, we'll share more about what occurred throughout the fourth quarter and the outlook as we begin 2021. Unfortunately, our country continue to experience higher and higher levels of COVID-19 infections during November and December. After peaking in January, we began to see some more positive trends, with vaccination efforts under way, we appear to be moving into the next phase of this pandemic and there is a light at the end of the tunnel. The AMN team is working hard to continue to fill critical positions across all of our staffing businesses and adapting our services to partner with organizations to vaccinate our communities.

Now let's turn to the financial results and outlook that we announced today. In the fourth quarter AMN produced record high consolidated revenue of $631 million and adjusted EBITDA of $89 million. The revenue increase was unusually strong as our team leaned in like never before to serve the most extraordinary level of demand we've ever seen. Our Nurse and Allied Solutions segment came in with revenue of $448 million, 6% higher year-over-year. This segment returned to growth ahead of schedule, led by our largest business Travel Nurse Staffing, which put up a 23% increase. I can't emphasize enough, how impressive this team's performance was sourcing, recruiting, credentialing, placing, and onboarding more healthcare professionals in one quarter than ever before.

We would have normally said that this type of growth was unrepeatable, however, we've already seen the first quarter eclipse the historic high fourth quarter delivery. We reached our highest ever number of assignment starts in January and in February, we now have the most nurses on assignment company history. Allied Staffing revenue was 13% lower year-over-year in the fourth quarter and all major Allied disciplines grew on a sequential basis. Our revenue cycle solutions business is still down year-over-year, so it's fourth quarter grew 8% over prior quarter with better trends heading into 2021.

For the first quarter, we expect Nurse and Allied Solutions revenue to grow approximately 40% year-over-year. We project Travel Nurse Staffing revenue to grow approximately 40% sequentially and at least 50% over prior year. Our forecast assumes Allied Staffing revenue will grow sequentially by about 30% and return to year-over-year growth in the low double digits.

Before discussing our Physician and Leadership Solutions segment, I'd like to extend a welcome to James Taylor, who recently joined us as the segment's first Group President and Chief Operating Officer. James is an outstanding leader with an excellent record of leading service providers to the healthcare industry. We are very fortunate to have James and his wonderful family join AMN and we look forward to having him participate on the next earnings call.

Physician and Leadership Solutions log fourth quarter revenue of $111 million define normal seasonality by being 2% higher than the third quarter. Within this segment Locum Tenens performed better than expected and resulted in sequentially flat revenue. The year-over-year revenue gap narrowed and was down 12%, showing great improvement since the low point earlier in the year. The higher than expected revenue came from the COVID related assignments and a rebound in the core business and our leadership also continue to improve with revenue increasing 5% sequentially.

Demand for interim leaders and placements picked up through the fourth quarter and that momentum has increased in the first part of 2021. While physician and executive searches were hit hard during the pandemic, with revenue still down 30% year-over-year in the fourth quarter, we are starting to see stabilization. Clients are turning their attention back to hiring of new leaders and physicians and our team is rebuilding its pipeline replacement. With these improving trends, we expect first quarter revenue for Physician and Leadership Solutions to grow sequentially by 17% to 19% and narrow the year-over-year gap to be down about 5%.

Our Technology and Workforce Solutions segment revenue of $72 million in the fourth quarter was up 192% year-over-year. The acquisitions of Stratus Video and b4health made another strong revenue contribution, and organic growth of our businesses in this segment was 32% above prior year, far exceeding our expectations. Our VMS business grew revenue 31% year-over-year with 19% organic growth, showing a swift rebound compared with previous quarters. This division benefited from the same trend that drove our strong Nursing and Allied performance.

In the first quarter, we expect Technology and Workforce Solutions revenue to be up about 100% year-over-year with over 60% organic growth. COVID related clinician needs should hit their peak in the first quarter, however, there will be many ongoing needs related to the pandemic such as vaccine administration, recovery of elective procedures, and other care that may have been delayed. The well deserved higher than usual compensation packages for nurses and other clinicians supporting the COVID surges should begin to subside, and this will also bring down the corresponding bill rate. It is difficult to predict exactly what the timing and trajectory of this decline will look like and if the continuing shortage of clinicians, so we believe we could experience premium rate decline starting in the second quarter.

As rates in Nursing and some Allied specialties decline, we would expect to see continued recovery of most of our businesses, which would provide a partial offset to this headwind. While we are only providing first quarter guidance at this time, we will share that we currently expect to see year-over-year revenue growth in all quarters of 2021. The workforce shortages that were already on a worsening path before the pandemic began have now been made worse by the burdens and pressures of the last year.

The importance of having a strong total talent solutions partner has never been more essential and clear for the complex and sophisticated healthcare systems up today. The AMN team feels honored and fortunate to be in such a capable position to help patients, clinicians, and healthcare organizations at such a critical time in our country.

In closing, let me emphasize that I have never been more energized and proud of the AMN team. They are working literally around the clock and their commitment to service excellence and making a positive impact is an inspiration for all. I know I speak for all of our AMN leaders when I say, we feel so fortunate to be a part of this team and wish to thank each and every one of our colleagues for their contributions. In a few minutes. Kelly, Landry and Maureen will join us for the Q&A session, but for now, I will turn the call over to Brian, who will provide more insight into our financial results.

Brian Scott -- Chief Financial Officer, Chief Accounting Officer, and Treasurer

Thank you Susan and good afternoon everyone. Fourth quarter revenue of $631 million was well above our guidance range, as we previewed last months. Consolidated revenue grew 14% sequentially and 8% year-over-year. On an organic basis, revenue grew 1% year-over-year, even with the headwind from labor disruption staffing, which was $14 million lower this year.

Gross margin for the quarter was just above the high end of our guidance range at 32.9%, 70 basis points lower than prior year and down 60 basis points sequentially. Year-over-year, the margin was lower because of the higher compensation packages and nurse staffing more than offsetting a benefit from higher average hours worked and the acquisitions of higher margin Stratus Video and b4health.

Sequentially, the higher pay packages where the biggest driver of the margin decline. Consolidated SG&A expenses were $155 million or 24.6% of revenue compared with $133 million or 22.7% of revenue in the year ago quarter, and $111 million or 20.2% of revenue in the previous quarter. As noted in our earnings press release, the quarter included a $20 million increase in legal reserves related to wage in our claim.

Adjusted SG&A, excluding this legal expense, integration related cost and stock based compensation expense was $119 million this quarter or 18.8% of revenue compared with $121 million or 20.7% of revenue in the prior year quarter. The lower SG&A margin from the prior year reflects a reduction in total headcount and traveling convention costs partly offset by $7 million of SG&A expenses added from the acquisitions of Stratus Video and b4health.

On a sequential basis, adjusted SG&A was higher by $10 million due to hiring support the strong revenue growth and other related adjustments to variable compensation and benefits for the better quarter and full year results.

In the fourth quarter, Nurse and Allied revenue was $448 million, 6% higher than prior year and up 17% sequentially. For our Travel Nurse Division, the revenue grew 23% over prior year. Although our Nurse Travelers On Assignment were down 6% year-over-year, the average nurse bill rate rose by more than 20% and average billable hours worked also increased to historically high levels.

Allied Revenue was down 13% from the prior year and grew 23% sequentially on strong placements and a record high demand. Revenue Cycle Solutions was down by about 40% for the prior year and posted 8% sequential growth. Nurse and Allied gross margin of 26.7% was 230 basis points lower than prior year and down 70 basis points sequentially. The year-over-year decline resulted in large part from the prior year including $14 million more in labor disruption revenue at an unusually high gross margin.

In addition, the margin is lower from increased clinician pay packages during this critical time. Segment EBITDA margin of 13% was 140 basis points lower than prior year on the lower gross margin. Physician and Leadership Solutions revenue in the fourth quarter was $111 million, 20% lower year-over-year and up 2% sequentially. Locum Tenens revenue was $68 million, 12% lower than prior year and flat sequentially and our Leadership Revenue declined almost 30% from the prior year and was up sequentially by 5% from improved demand and volume. Search revenue was down just over 30% from prior year and up 2% sequentially.

Gross margin for the segment was 37.1%, 10 basis points lower than the prior year and up 40 basis points sequentially. Segment EBITDA margin was 15.2%, up 150 basis points from last year and 100 basis points sequentially. The year-over-year improvement was driven mainly by reduced SG&A. Technology and Workforce Solutions revenue of $72 million in the fourth quarter, growing 192% year-over-year and 21% sequentially. Organic revenue was up 32% year-over-year by growth in VMS and a boost from a contact tracing project. This also drove the sequential increase along with 7% growth in our language interpretation business.

Gross margin was 64.5% down from the prior year margin of 92.3% as the acquisition of Stratus Video changed the revenue mix. Segment gross margin was down 160 basis points sequentially, also due to a revenue mix shift.

Segment EBITDA margin of 42% was down 140 basis points year-over-year from the Stratus acquisition and was a 100 basis points lower sequentially. Consolidated fourth quarter adjusted EBITDA of $89 million was 18% higher year-over-year driven by the acquisitions and cost reductions during the year.

Adjusted EBITDA margin of 14.1% was 120 basis points higher year-over-year and better by 20 basis points sequentially. We reported net income of $9 million and diluted earnings per share of $0.19 in the fourth quarter. Adjusted earnings per share was $1 compared with $0.85 in the year ago quarter. Days sales outstanding was 55 days, four days better than last quarter. Operating cash flow for the quarter was $40 million and capital expenditures were $10 million. Interest expense in the fourth quarter included $11.5 million of one-time expenses related to the bond financing transaction we discussed on the last earnings call.

As of December 31st, we had cash and equivalents of $29 million. During the fourth quarter, we reduced our long-term debt by $40 million, ended the year with $872 million of long-term debt and a leverage ratio of 2.6 times to 1.

Recapping some financial highlights for the full year 2020, we reported revenue of $2.4 billion, our record level for AMN, an 8% increase from prior year. Adjusted EBITDA for the year was $321 million, up 16% from prior year, with a margin of 13.4% higher by 90 basis points. 2020 adjusted earnings per share was $3.43 higher than prior year by 8%. Full year cash flow from operations was $257 million, which included $48 million for deferred payroll taxes from the CARES Act.

Now turning to first quarter guidance, we are projecting consolidated revenue to be in a range of $800 million to $820 million, up 33% to 36% over prior year. First quarter gross margin is projected to be 31.5% to 32%, down year-over-year and sequentially primarily from a segment mix change. Reported SG&A expenses are projected to be 18.3% to 18.6% of revenue. Operating margin is expected to be 10.3% to 10.7% and adjusted EBITDA margin is expected to be 14.3% to 14.7%.

Other first quarter estimates include the following, depreciation expense of $8 million, non-cash amortization expense of $15 million, stock-based compensation expense of $6 million, interest expense of $10 million, integration and other expenses of $4 million, and an adjusted tax rate of 29%.

And now we'd like to open the call for questions.

Susan Salka -- Chief Executive Officer

Operator, I believe we are ready for our first question.

Questions and Answers:

Operator

Thank you. Your first question comes from the line of Kevin Fischbeck with Bank of America.

Kevin Fischbeck -- Bank of America -- Analyst

Great, thanks. Yeah, I appreciate the directional commentary for the year about revenue growth in every quarter, is there any reason to think that doesn't translate into earnings growth every quarter or is there something that which we are factoring in and are thinking about and even the gross profit or the G&A line that could be a headwind, to reporting that?

Susan Salka -- Chief Executive Officer

Well, I'll let you go, Brian, take it.

Brian Scott -- Chief Financial Officer, Chief Accounting Officer, and Treasurer

Yeah, thanks for Kevin -- question, Kevin. Yeah, this was a very -- first quarter obviously is going to be very unique quarter for us and we don't give full year guidance, but I'm glad you asked the question. I think it would be helpful maybe to give some additional color around expectations for the year. So this should help you a little bit. We do expect revenue to decline from this Q1 high point that we've given in the guidance. As Susan noted, there was significant increase in demand from the COVID hospitalizations and that in turn led to increase in pay rates and then corresponding bill rates and that certainly was a pretty significant element of the higher guidance along with some incremental volume as well. Just from an order of magnitude, the average nurse bill rate in the first quarter of guidance is expected to be up well over 20% higher, just sequentially from Q4 to Q1. And that was really driven a lot by that COVID hospitalizations and the demand that came from that. Fortunately, well know, the demand has come down now as hospitalizations have declined. We're still at well above normalized levels for demand, but off from those highest levels and we would expect to see bill rates follow as the demand has come down off its highest levels still and pay rates. So, we would again expect not only for the second quarter, but through the year, if things continue to improve in terms of COVID hospitalizations, there would be some moderation of the bill rate through the year. And just like framing of the financial impact of that is, for example, we assume that we lose about half of that rate increase that we had in Q1 in the second quarter, that equates to about $50 million lower revenue in the second quarter, just as rates start to come down again, it is just half of that amount that we increased in Q1. We would also expect to see some COVID-related volume declines across the few of our different business lines. We would also expect at the same time if that's normalizing and that we start to see some pickup in our core business as healthcare utilization picks up and you see an improvement in elective procedures. So we take all into account, we at this point, we are thinking about the second quarter revenue, something more in the low $700 million range, and now that would be down around 10% from the Q1 guide that would still reflect our year-over-year growth of around 15% to 20%. And then in terms of how that would flow through on the margins, as I mentioned in the prepared remarks that the Q1 margin guide is lower than we've been trending. And lot of that is because of the mix change with a much higher percentage of revenue for Nurse now as well as some of these elevated clinician pay packages. As we see little more normalization and growth in our other segments, we would expect the gross margin to work back toward around 33%. And then, as it comes from that down to EBITDA margin, this Q1 margin, guidance given would be, obviously, well above our normal level. We think that will likely be the keep base, and we can see right now, and obviously work through the year. We still expect our EBITDA margins to remain above 13%, but come down from this high level that we gave in the first quarter guidance. So, a lot of moving parts, a lot of unknowns at this point, but, hopefully that gives you a little more color on what we're expecting for the year.

Kevin Fischbeck -- Bank of America -- Analyst

No, that's perfect. I guess maybe just last question. You guys sounded pretty optimistic about the supply demand imbalance persisting, or maybe even exacerbating as a result of COVID, I guess, most of these publicly traded hospital companies are talking about labor, labor outlook improving, I guess, toward the end of the year. Would just love to kind of hear how you guys are thinking about it, maybe, which segments you think post COVID are kind of seeing the biggest shortages, and if there is anything specifically that you would point to, as some segment of your business back that pretty clearly in your view got worse as a result of COVID with actually more temporary staffing?

Susan Salka -- Chief Executive Officer

Sure. Kevin. I'll start with that. This is Susan, and then, perhaps from my colleagues will want to add something in. Certainly all of different clinical disciplines, and I would say even beyond clinical disciplines, like healthcare leaders, have been affected in it's advanced retirements for many individuals who decided they didn't want to stay in the healthcare environment throughout the COVID pandemic, but also, that's perhaps changed their course going forward. So there has been a larger than usual number of retirements among target, find real-time data on that, we're certainly hearing that very clearly from our clients. And then, even with the younger workforce, many of the commissions, and I'd say nurses in particular, but also many of the female physicians, have had to make a decision to leave the workforce in order to juggle children at home and school at home. And again, maybe does not even willing to take the risk that of reentering direct patient care in this environment. So it's believed that, we've lost some subset of the nursing workforce permanently, and that will accelerate the shortage path that we were already on. It was already getting quite bad before the pandemic, and it's really just accelerated it considerably. So, nursing is probably the area where we believe, the shortages will persist at relatively difficult levels, while the demand continues to be really quite strong. In other areas, you might see some of those individuals come back, but they may not come back full-time. Physician is one example where we've been really fortunate as a country to have so many more women go into medicine. But typically, the female physicians are working less hours because they are, maybe juggling, again, families at home. And then, now some of them have made a more permanent decision that will take that less than full-time schedule, and take it even down further on a permanent basis. So there is expected to be some long-term impacts there, and truly, it's really just across the board.

So we think that those shortages that will persist, will continue to drive a relatively strong demand environment and then again, as Brian said, you've got the elective surgeries and other delayed care procedures and what not, that will start to come back. And we're already seeing that a little bit in some of the businesses. But, as we start to see COVID cases subside, we'd expect for them to come back more. We will stop there, and I don't know, Randle, if you have anything else that you want to add in regarding the nursing shortage in particular?

Randle Reece -- Director, Investor Relations

Yes. Maybe I would add in that, specific to nursing. We have been doing, an RN survey quarterly, just to look at different trends that are impacting the occupation. And our last survey that we did, we actually did it in January. So, it's very recent, and cut down a couple of things in there that I'll mention. One is that 75% of nurses felt burnt out, of the respondents said that responded to the survey. And, of course, you might think, well -- you would expect that with everything that's been going on. But the important thing here is the trend, since we have been doing the survey quarterly, and to see that number increasing every quarter, whatever we've asked it. Another thing that we learnt is that, only 66% of nurses plan to continue working as they are today, within the next year. That means that 34% of the workforce are planning some sort of change in the next year, within the next 12 months, which is again a really high number from what we've seen that we've asked that question before. So with all that, we got to do our part, to try to help the occupation out, as much as possible, to get through this. But, what it does suggest is that, we're likely to be in this high demand environment for quite some time.

Kevin Fischbeck -- Bank of America -- Analyst

Okay. That's great. Thank you.

Operator

Our next question comes from the line of A.J. Rice with Credit Suisse.

A.J. Rice -- Credit Suisse -- Analyst

Hi, everybody. Maybe a couple of questions. First of all, Brian, as you've given those numbers about what happens from first quarter to second quarter, and the $50 million potential impact on revenues from having a premium, but less premium than you had in the first quarter, where does that leave you relative to sort of a normal state? Is there still a substantial in that second quarter assumption, is there still a substantial amount of premium revenue that you're getting, or is that -- take you back to pretty much trend line?

Brian Scott -- Chief Financial Officer, Chief Accounting Officer, and Treasurer

Yes. Thanks for the question. A.J. No, that would still have us above where we stand. May be to give as a starting point, that in fourth quarter of '19 and in the first quarter of '20, kind of pre-pre-pandemic, it would still leave us reasonable amount above that level, so tha, as I mentioned, we -- it would not be surprising if we saw some further reduction in the average rate through the back half there, at least in the third quarter, assuming that we see these COVID hospitalizations come down over time. So we do expect to see some further rate reductions, but with the -- as Randle mentioned shortages we're seeing, it's going to take some time, I think, for our clients to really adapt to these changes, and give their teams their summer break as well as we get through this. So we do think, it will take a few quarters for that to unwind as we get closer to the back half of the year. If we still would expect rates to be higher than they were a couple of years ago, which is the normal inflationary rates, and probably some acceleration from the shortages, where that lands exactly, we're still determining. But we expect that they'll still be above where we were pre-pandemic.

A.J. Rice -- Credit Suisse -- Analyst

Okay. Another thing, obviously, we're talking about burn out at a high level and so forth. One metric. I guess, you can track is, when people come off of the assignment in the Nurse and Allied, are they reupping for another assignment? Are you seeing a trend there, where that percentage is going down, as your own nurses or allied professionals are sort of saying, I need to break down, I need to come off of that? And the other thing we hear from hospitals is that, there is some pressure from people seeing, how much they can make as a temporary nurse, and giving up their permanent job to do that for at least a time. Are you seeing new applicants, pick up will be the flip side to what the hospitals to dealing with. Are you presumably see new applicants in that, are you seeing much in the way of new applicants?

Susan Salka -- Chief Executive Officer

Yes, A.J. I'll have Randle pick up most of that. But I will say, our recruiting team has done a phenomenal job, and our rebook rates have actually improved since the, kind of the lower point in the middle of the year when, of course, demand dropped for a period, and so the increased demand. But also, I'd say the -- just the great work of our team in delivering so well during such a difficult environment, has helped improve our rebook rates. So we feel really quite good and confident about those. If anything, I think, that's really helped us to find ways to serve our clients and clinicians better and faster through digital capabilities and what not, and certainly, having more assignments that attract the compensation rates and what not, is helpful. But Randle, let me add to that, and then also, talk about applications which, I know, is a great story.

Randle Reece -- Director, Investor Relations

Yeah, A.J. On the the clinicians that are rebooking, extending, we're not seeing anything material there. You, of course, always have a certain percentage of them better on assignment that extend where they are today. Perhaps, some of them come off, and they take a new assignment. And then some of them -- to your point which is, it's always happened which again -- we're not see anything different, they'll take some time off. So, that's one of the benefits of traveling, is that, between contracts, you can take 2 or 3 weeks off. But, again, nothing different today than what we've seen over the years. Specific to our supply, that funnel is working really, really well right now. I'm seeing some extremely strong new applicants in some record levels that have been covenant to our business and into our database. Teams have done a really nice job, pushing a lot of the med supply through and get them on assignment. We couldn't do as much as we've been doing without some of the digital investments that we've been making. I know we've talked about some of these before, but we've got a lot of focus around our mobile initiatives and adding parts of the process, creating a lot of automation, increasing self-service and really just given -- overall given our clinicians more control, so that they can move through the process and then ultimately get on the assignment faster. So speed is a big -- big piece of it.

Those investment of course also help our internal teams, so we become more efficient, which of course has allowed us to hit some of these record numbers on assignment that we're seeing in the first quarter and then the last thing I'd mentioned that we've talked about before Passport -- AMN Passport our mobile application, we continue to see great adoption with that mobile app and as well as great increase in the number of users, and we can see that the investments really something that our clinicians want. We see a lot of the staffs on where they're spending time, how frequently they're returning to the app, how many users are going through it every single week and overall just kind of put more control in their hands and they give them one place to go to whether they are searching for a job or all the way through them being on assignment of their last day. So all of that looks really good, it helped us do what we've been able to do over the last few quarters and we'll keep on making investments in that mobile app in those digital initiatives as we look forward.

A.J. Rice -- Credit Suisse -- Analyst

Okay. Maybe one last question. When I think about, I would, it's -- it's fun to talk about the areas that are doing well in the last 12 to 15 months. There are some areas that were adversely impacted by the pandemic, certain places in Allied like rehab, tech -- therapist, I know some of them, especially in the Locums business and then things like permanent placement. Have you started to see any recovery there in demand, and anything you'd highlight there or is it still sort of early in the transition out of the pandemic, to see that.

Susan Salka -- Chief Executive Officer

Yeah A.J. it's Susan. I'll take the first couple and then have Landry comment on Allied. So regarding Locums really, really nice recovery there, part of it's been the work they've done to assist in some of the COVID activities with whether be state temporary facilities or just helping our clients overall, but even the underlying core business has seen some nice recovery. Now it's not back to pre-pandemic levels, but there are some specialties like Anesthesia, Behavioral Health that are back above pre-pandemic levels just in our core business and others that are lagging a little bit more, but we're continuing to see a steady trajectory upwards. Those should continue to grow faster, as the COVID cases subside and you see more elective procedures and more normal care start to return, and it's definitely the dynamic that we're witnessing. So that's a pretty good story now. You know search has been the hardest hit by far, I mentioned that's still over 30% down in the fourth quarter, but in the fourth quarter, we started to see searches and some placement pick up and more dialog with clients about those leadership in physician position that they want to start to fill now that dust is settling a little bit in terms of how they're managing the COVID crisis, but then also expecting more patient flow back. So the sign of quarter off pretty strong definitely going to close the year-over-year gap, but they will be the lag of it, but at least we're starting to see things move forward. And then Allied, it's been a great story so Landry, as you take that.

Landry Seedig -- Group President and Chief Operating Officer, Nursing and Allied Solutions

Yeah A.J. Allied of course went backwards quite a bit. Maybe the last year and their trajectory is probably one of the best trajectory that I've seen in our business. They had an outstanding fourth quarter and really across all their segments, kind of, outperforming what we originally thought that they were going to do in the fourth quarter, and of course respiratory and laboratory specialties have been performing well. Those specialties are closely tied to help in the pandemic, but we saw good performance across all the other parts of the business as well. So therapy performed better, imaging performed better, schools looks great for in particular speech language pathologist. So looking into the first quarter, they are experiencing the largest sequential growth that they've seen in the business, and it also includes their volume of travelers on assignment being back above prior year levels.

A.J. Rice -- Credit Suisse -- Analyst

Okay, thanks a lot. Okay.

Brian Scott -- Chief Financial Officer, Chief Accounting Officer, and Treasurer

Thank's A.J..

Operator

Your next question comes from the line of Jeff Silber with BMO Capital Markets.

Jeffrey Silber -- BMO Capital Markets Corp. -- Analyst

Thanks so much. I know we're in a unique time here, but given the kind of bill rate increases that we're seeing and you're continuing to see this quarter when we -- when we in the past when we've seen these kind of larger premium rates or bill rate increases, after the things subside, you tended to see some of your clients kind of push back on the usage of temp nurses, and can we talk a little bit about that, would things be different this time why or why not?

Susan Salka -- Chief Executive Officer

Yeah, that's not our expectation, Jeff indeed the dynamics are different here. First of all, the shortage environment and some of the factors that Landry mentioned earlier around burn out and decisions by clinicians to do something different, whether it be retire or just should change their work environment, and our clients know that. It was a real concern among the healthcare systems that we talk with, as well as nurse educators that this could put a real dent in the availability of clinicians for quite some time. And as you all know, we don't really have the capacity in nursing schools to increase new nurse graduates because we're pretty much at full capacity already. In fact, if anything I'd say the dialog we're having with clients around planning for their needs, not just now, but 2, 3, 5 years from now is increasing, and maybe it's a good time for Kelly to comment on some of the conversations, we're having with the most strategic clients and how we are helping them plan, not just for the next quarter or two, because we all know we'll get through that together, but rather how we're building our Strategic Accounts kind of for the future. So Kelly, you want to take that.

Kelly Rakowski -- Group President and Chief Operating Officer, Strategic Talent Solutions

Yeah, absolutely. Hi, Jeff. And I think you made the comment about, are they going to push back on utilization. I think it's a much more holistic view as Susan mentioned, there is -- they're certainly looking at the workforce and they're all understanding what the impact is going to be with them in the short term and the long-term and it's not just about the workforce today, what's changing in healthcare, looking at changes in the care delivery model, looking at changes in sites of service, the impact of telehealth in the future. So we're able to talk with them and help them with that planning. I think in the short term, we're seeing there is an expectation of still using a complementary workforce, but also around how can we optimize and what you have today they're looking at, how can they keep the level of flexibility and agility in their -- in their workforce that they didn't have at the outset, but they really recognized as a limitation for them to be able to move, different types of resources around to where the needs are, and so we use our advantage workforce optimization solutions to help them with that. And I would also say on the perm side, helping them back to I think very high vacancy rates, a lot of our clients are seeing above 10% in their full time clinical staff and they don't have the -- they're not resourced appropriately to help them bring that workforce back on math. So how can they be more agile and effective in backfilling some of those permanent roles as well. So we're really helping them end-to-end on all of their strategies, but we certainly see the partnership and the reliance on travel nurses, local nurses, flex nurses to continue in the future as well.

Jeffrey Silber -- BMO Capital Markets Corp. -- Analyst

Okay, that's fair enough. And based on that. I'm just curious what your own internal hiring plans are for this year and in which areas do you think you might be adding?

Susan Salka -- Chief Executive Officer

We are hiring significant resources right now as you can imagine, some of it is temporary in nature, to help support some of the projects we have going on, and we talked about the vaccine administration support work that we're doing in California, and we expect actually that there will be more opportunities and more projects going forward. But as those are admittedly a little shorter term probably most of them will occur this year. And then we've been adding across really all of our businesses because we are seeing growth in pretty much all of our businesses and so we want to make sure that we're adding the resources we have, I think 10% more recruiters or more and that we're continuing to add on top of that. So it's a time when we're adding resources in anticipation of the underlying business continuing to grow. We know that first quarter is a bit of an anomaly with the surge in COVID cases and all that ensued with that, but we also see the underlying business continuing to rebound and come back and there's no reason it shouldn't and if anything, Nurse Travelers On Assignment, as an example, volumes should continue to grow. So we need to be continuing to add resources. Now earlier, Landry mentioned the investments that we're making in digital and I will say a lot of the automation that we added over the last year has been very beneficial to create efficiency for us and not only it has treated cost savings and speed and more reliability, it has also fueled our desire to accelerate our investments and do more, which is why our Capex that you see is a bit higher than usual and we're glad to spend that money because we're getting some really nice benefits out of it. If anything, at our size and scale and in our leadership position, we need to be really advancing our digital and analytical capabilities for us, but really for the benefit of our clients, our clinicians, and even the industry. And so we're doing a lot of that, which will also help ensure that when we're hiring, it's not just to move data around, it's really more to add value.

Jeff Silber -- B of A Securities -- Analyst

All right. That's really helpful. Thanks so much.

Susan Salka -- Chief Executive Officer

Thanks, Jeff.

Operator

Your next question comes from the line of Tobey Sommer with Truist Securities.

Jasper Bibb -- Truist Securities -- Analyst

Hey, good afternoon. This is Jasper Bibb on for Tobey. I wanted to ask how you would assess your performance with MSP accounts this past year and could you update us on account retention and what the pipeline looks like there. Thanks.

Susan Salka -- Chief Executive Officer

I know Kelly is thrilled to tell you about that. So I am going to hand it over to her.

Kelly Rakowski -- Group President and Chief Operating Officer, Strategic Talent Solutions

Thanks Jasper and first as we reflect on the past year, very strong performance. We've been sharing, I think with you throughout the last few quarters. As demands became so high, we really prioritized and focused on our most strategic accounts and of course supporting the rest of the industry to the extent we could with other solutions as well. So we ended up as we look at the year, we are up about 20% over prior year in both gross spend as well as direct revenue from our MSP clients. I would say, for the most part, our relationships really strengthened throughout the year and one evidence of that is, we actually had a fair amount of large renewals in 2020. We were able to successfully renew 20 accounts out of the 21 that were up from last year and then coming into next year, we have much less of our revenue up for renewal, about 50% less than in 2021, but we're on pace to continue those relationships. And the other I think really bright spot for us is in those renewals, we're also seeing a level of extensions into different service lines and also longer-term contracts as our clients and us are both committed to those longer-term strategic partnerships that we're really encouraged and really grateful for the relationship that we have with our clients throughout the year. They, had to pivot and adjust with us so that we could collectively be successful in getting them the resources that they need. We have a healthy pipeline. I will say a lot of -- while we had actually by our strongest sales year last year in 2020. We are close to about $500 million in growth spend that we brought under contract. Some of that was through expansions, but also about two-thirds of that was from new business. And we did in the back half of the year have to do a fair amount of that through technology. client-led solutions. This year now we're starting to see much more engagement around AMN-led managed services programs in a very healthy funnel and I would say we're much stronger engagement now as they've started to be able to engage and think about their future needs. So I would say we're in a very strong position around our existing clients and pretty bullish on our ability to grow in this environment as well.

Jasper Bibb -- Truist Securities -- Analyst

Thanks. And then on the M&A front, there were some deals in the news this month as leverage comes down when you consider adding scale in Nursing or Locums or is that not as attractive to you by these valuations.

Susan Salka -- Chief Executive Officer

Yeah, Jasper, our priorities are to continue to add things that will help us be a better total talent solution partner for our clients. So at the top of that list are probably tech-enabled workforce solutions that help us to create efficiency and in some cases enable virtual care and Stratus was a fantastic example where the team have taken a traditional on-premise or maybe over-the-phone workforce solution and created a video solution that really adds so much more value and a better experience for all. So those types of things will certainly be toward the top of our list. We could add on to existing tech-enabled solutions. The language interpretation industry is pretty fragmented still even though we're the leader in virtual language interpretation there's opportunities to do other tuck-in acquisitions, Maureen and the Stratus team had actually done that before. They joined AMN and have a great track record there. So, we'd be very confident in doing that and there are other tech capabilities that might enable us to extend what we're doing into home health as an example, which we think is a really important market. It's important that we support the patient and clients where care is shifting and whether that be virtual and tele-health or homecare or just helping our existing acute care clients to be more efficient in how they use their workforce, we want to do that. So again tech enabled at the top, I would say second would be adding on to existing areas where we believe there is a lot of growth opportunity and maybe we don't have as much scale as we would like. A nice example of that would be our schools-related business. Our schools team is doing a phenomenal job right now and there again we have a wonderful virtual capability through our Televate platform. And yet the schools' part of the industry is still pretty fragmented. So we could increase our footprint and continue to build that business by additional acquisitions such as one example, but there are others throughout the company. So hopefully that's helpful.

Jasper Bibb -- Truist Securities -- Analyst

No, I appreciate the color. Thanks for taking the question.

Susan Salka -- Chief Executive Officer

Thanks.

Operator

Your next question comes from the line of Brian Tanquilut with Jefferies.

Brian Tanquilut -- Jefferies -- Analyst

Hey, good morning -- good afternoon you guys, congratulations on an obviously strong year. I guess my first question, Susan, just to follow up on that claim on Stratus. Obviously really strong results out of those guys. Is there anything you can share with us in terms of what's driving that. Are there new contract wins that you can point to and maybe taking the opposite side of that, how much more market share do you think realistically is there for Stratus to take over with low hanging fruit versus having to take from existing providers and competitors.

Susan Salka -- Chief Executive Officer

Thanks for the question, Brian. It is all of our lucky day because we have Maureen Huber here who is the expert, in not only Stratus but language interpretation so I'm going to let her take that question.

Maureen Huber -- AMN Healthcare -- President, Workforce Technology Solutions

Thank you, Susan, and that's a very generous compliment seen as I struggle with the English language at times and I am always honored and humbled to represent the Language Services team in organization. The U.S. medical interpreting market is a $1.6 billion industry and that comes in the form of onsite interpreting as well as over-the-phone and video interpretation. Video interpretation only approximately half of the hospitals in the U.S. have made a video-based decision. Most rely heavily on their staff interpreters or over-the-phone and over-the-phone, as you know, both communication -- 93% of communication is non-verbal, so the preferred modality, especially around patient safety and improved outcome, is being able to be present for the provider and the patient visually. So there's a lot of opportunity there for video, especially as the onsite interpretation from patient safety, as well as the safety of the interpreters and our providers really was reduced during COVID period and with our tech-enabled services, we actually doubled the number of call centers where we could enable the hospital systems' own staff to provide services. So, we are working in partnership with our current client to explore better opportunities for filling the gap and the needs, that aren't quite interpreted either through video or other tech-enabled services with our in-person application.

So, to answer your question, what's the opportunity in the market share, the LAP population continues to grow in the United States, and it's outpacing other areas. It's pretty significant, part of that will come from the conversion approach on the phone to video, and others will come from the continued onsite interpreting, and removing that from a patient safety perspective.

Maureen, I know, another great thing the team has really made advancement in is, integrating our language interpretation services into other telehealth platforms, and the ability to support the queue-care facilities, but also -- and into other telehealth providers. And we've really just scratched the surface in that. I think we've got 25 to 30 platforms that we've integrated in. And so, there is a lot of opportunity. A telehealth in general growth, if you have a telehealth encounter, you need an interpreter there, and most telehealth companies or technology providers aren't going to provide that network of 3,000 plus language interpreters. And so, we are a wonderful plugin to services that are already, or going to be launched.

Brian Tanquilut -- Jefferies -- Analyst

I appreciate that. And then, I guess -- and just back on the nursing side, I mean, a lot of questions that have been asked on the demand side. But, I think in the past, we've talked about how supply has been the bigger constraint. So-- and I guess, the fact that you guys have invested a lot in recruitment technology. But, as premium pay starts to come down, how are you guys thinking about the willingness of nurses who are currently employed full-time, to take breaks, and take some of these ad hoc post things where these guys are with other staffers.

Susan Salka -- Chief Executive Officer

Yes Brian. I'm sure there will be some element of the clinicians that have decided to join in the COVID fight, that will go back into permanent roles. But many of them will now have their eyes opened to the travel industry. Actually, I just talked with a nurse like that a couple of weeks ago who said, I never thought about traveling, but COVID pulled me into the industry, and now I see all the great benefits. And so, I'm going to spend the next year traveling. And this is something that is typical when someone gets introduced to the industry, they don't usually just take one assignment. And again, the rates might cause some to go back into other roles. But some will say, no, this is a career choice that I want to make for some period of time. And so, that's a really positive thing for our industry overall. It will keep more of these new candidates, and kind of new starts that we talked about, within the industry for some period of time. And Randle, I don't know. if there's anything else you want to add to that.

Randle Reece -- Director, Investor Relations

No, I think you covered it. I don't really have a whole lot more to add from the clinician side. If I was going to make one more point, it's that, our clients also like this flexibility of being able to bring clinicians on in a temporary capacity. So we're hearing that from them that -- If you went back 5 years ago, it was, I'm going to try to minimize the amount of contractors or temporary labor. And right now, the conversations are more about, how do I have the flexible staffing model for the future.

Brian Tanquilut -- Jefferies -- Analyst

Got you. And then last question for me really quickly. You obviously touched on vaccinations. In what role, or what are the niche clients, are you touching on the vaccination? Will this be the retail pharmacies will be -- will we look at the drive-throughs. And then what are, kind of the economics, or how should we be thinking about that opportunity?

Susan Salka -- Chief Executive Officer

Sure. And certainly for our clients, our healthcare clients, we are supporting them. In fact, we might have had staff on premise that was previously assisting with COVID testing, and now they shifted to vaccine administration. And that will probably ramp up over time, as more vaccine becomes available. But even beyond that, probably obvious and traditional way of staffing with our existing clients, the team's done a phenomenal job of partnering with clients in other organizations to build a more multi-disciplinary program, so that we can help staff mass vaccination sites, and I am going to ask Kelly to give you little more insight on that because her team's really led the charge on that, and we've had some great success just in the last couple of months. But really, we're just at the beginning, and I think of what the need is going to be. So, Kelly, you want to take that?

Kelly Rakowski -- Group President and Chief Operating Officer, Strategic Talent Solutions

Yes. I just take -- give a little bit more color on that. And I think Susan's right. I think we've had the opportunity to help several of our clients with more clinic like -- vaccine capabilities. But we've also been able to really scale up to help in what we're constantly mass vaccination sites. And we are partnering currently with one client to operationalize these and that multi-disciplinary nature is really critical because, the nature of these sites require both, clinical and non-clinical staff, different levels of licensure to manage the different parts of the vaccine, management and administration and we were able to tap into all of our resources truly across they amend to staffing-related in just a matter of weeks, and we've also been able to underlie those solutions with our technology, using our VMS technology, using our scheduling, optimization technology, and to support that as well. So we do know that we are very capable of standing up these sites in a matter of weeks. We're kind of at the mercy, like our clients and other organizations right now, around the supply of vaccine. But we see as that supply ramps up, we're in several conversations with other health systems, as well as potentially some state or governmental programs that are going to do these across the nation. So it could be very significant in the next couple of quarters, or it could be a little bit more moderate type of volume remains to be seen, but we are absolutely ready, and had great success being able to do it that far.

Brian Tanquilut -- Jefferies -- Analyst

Okay. Thank you guys, congrats again.

Operator

Thank you. Your next question comes from the line of Mark Marcon with Baird.

Mark Marcon -- Robert W. Baird & Co. -- Analyst

Hey, good afternoon, and congrats. I was wondering if you could talk a little bit about the Tech and Workforce Solutions. You obviously had very strong organic growth there, wondering if you can segment that between the flow through coming through MSP and VMS versus more of the monthly client ads. And then, the second question is, how do we think about Tech and Workforce Solutions on a go-forward basis beyond the first quarter? Would you expect that to continue to increase sequentially throughout the year?

Susan Salka -- Chief Executive Officer

So, I'll have Maureen take that up, since a lot of the discussion is around Stratus and VMS, and to some degree advances, which all saw within her purview. And certainly, we've had some great growth across really all of those businesses, but in particular Stratus and VMS. So Maureen, you want to take that and talk about where that growth is coming from both existing clients, as well as some of the new clients that we've been able to add through our MSP contracts?

Kelly Rakowski -- Group President and Chief Operating Officer, Strategic Talent Solutions

And I think I can take -- Susan it's Kelly. As we look at the whole segment, we -- to go back to the first part of the question, which was, how much of that was driven by the MSP and kind of COVID related volume. The business that really has impacted their the most is VMS. So we'll see the same kinds of trends in VMS in both, volume and bill rates that we're seeing in our Nurse and Allied division, and expect that to kind of moderate throughout the year. Although, as we look at our new clients, and our new business that we brought on last year in VMS, about two-third of that was COVID related. But we expect another third of that to maintain, and kind of normal business if you will. Our other businesses, Stratus in particular, we expect to see continued growth throughout the year. Maureen mentioned a lot of the dynamics there, the ability to win new business. We continue to both, bring Stratus into our AMN clients, as well as have other organic growth through a more robust sales support network, or enabling them well. So we're expecting to see steady increase for Stratus. And then the others, like our outsourced solutions, and Advantest which has been -- Advantest has been very steady throughout the year, we'll see some moderate growth from them as more and more clients are engaging us in both our consulting and our Technology Solutions and the outsource business has been a little bit lumpy. We have -- that has been buoyed by a contact tracing program, but we are -- and our core RPO business was a little bit softer, but we're starting to see that pick up as I mentioned with the higher vacancy rates and hospitals really needing additional resources and their talent acquisition function to to back fill those. We are engaged with a lot of our strategic customers helping them in that regard. So probably the biggest one that is tied to the volatility, if you will, around the contingent staffing is on the VMS side while the others are pretty steady-eddy.

Mark Marcon -- Robert W. Baird & Co. -- Analyst

And so when we factor in the VMS relative to the growth and the others, do you think that we would end up seeing sequential growth in Q2 for Tech and Workforce Solutions going forward because it does sound like things are going pretty well there.

Susan Salka -- Chief Executive Officer

Yeah. I will grab that. So I think as Kelly said VMS will have some of the same headwinds that Nursing is having as rates come down. They will experience some decline in their revenues so you'll have a decline in VMS revenue, but it will be offset by increases in Stratus and Avantas through the year. So probably a step down in Q2 and then from there, kind of a more stable positive growth trajectory, but we'll be feeling that headwind of the VMS decline probably in this -- mostly the second quarter, but maybe going into third quarter as well and so it will be either on a steady after the second quarter or maybe a little bit of growth.

Mark Marcon -- Robert W. Baird & Co. -- Analyst

Got it. And then with regards to just the bill rates for the first quarter, how much are the bill rates up in terms of the projection on Nurse and Allied relative to a normal environment.

Brian Scott -- Chief Financial Officer, Chief Accounting Officer, and Treasurer

This is Brian. Well, we're not in a normal environment. So it's very different. As I mentioned, we kind of demand the fourth quarter rates, our nurse bill rate up a little over 20% in the fourth quarter and then seeing about a 20% sequential increase into the first quarter. So it's -- we're up 40% or so on a year-over-year basis in the Q1 guide so that is far from normal and as we mentioned, we think that will start to come down as we get into the second quarter and in the third quarter as well, and we would hope that that happens because that means that we're continuing to see progress with vaccinations and now that we have been out and moving more toward a more normalized environment and we think that will be healthy for our clients of course and for the industry overall as well. So this is something we knew we would see an increase and it's obviously a bit more than we anticipated, but also have been very consistent in articulating that we expect that to come down and we would like to see that happen as well and when that does, it's we will still continue to expect to see the volume recovery that we've already had over the last couple of quarters as well. Allied has seen some pricing growth as well, far less than what we've had in nursing, and so it is a little bit of a take-up in the fourth and first quarter, do expect that to also come down a bit. If you see some of that respiratory therapy and a couple other specialties that have seen a little bit greater increase, but the more of magnitude is not nearly as significant as on nursing.

Mark Marcon -- Robert W. Baird & Co. -- Analyst

Right. And then on the vaccine administration. It doesn't sound like you're baking in a lot for that, but it could end up being significant. Is that the correct interpretation?

Brian Scott -- Chief Financial Officer, Chief Accounting Officer, and Treasurer

Yes, yes.

Mark Marcon -- Robert W. Baird & Co. -- Analyst

Great,

Brian Scott -- Chief Financial Officer, Chief Accounting Officer, and Treasurer

Well it is a a little early at this point. We have had several different things in the pipeline, but until we have a contract signed and really understand the scope of the services and the duration, it is very difficult for us to predict anything at this point.

Mark Marcon -- Robert W. Baird & Co. -- Analyst

And, Brian, can you just give us a feel for capex for the full year. What your expectation is and cash flow and how we should think about that?

Brian Scott -- Chief Financial Officer, Chief Accounting Officer, and Treasurer

Yeah, sure. As Susan mentioned, we are investing right now and we think it's really critical. The fourth quarter, Capex was about $10 million. I think that is specific baseline to start one -- start with for 2021 and I think it will be level through the year and it really, it's been -- with the pandemic, it is tough to talk about, just a full-forwarded digital and tele-medicine and so we have had a really good strategy around our digital mobile initiatives analytics. We talked about that over the last year. We really have focused on even accelerating some of those investments as we need to really match where our clients are heading and as they're moving those ways more quickly, we as the leader of the industry need to do the same thing as well. So I mean a lot of benefits for our clients, for the healthcare professionals that we put to work every day, their sufficiency as well, but we really strongly believe in these initiatives and feel like we got the best team ever and with folks like Maureen and our IT team to really drive these initiatives. We're really positive on that. So you should assume, somewhere in the $40 million to $45 million range for the year.

Mark Marcon -- Robert W. Baird & Co. -- Analyst

Great, thank you.

Operator

Our final question comes from Sam Kusswurm with William Blair.

Samuel Kusswurm -- William Blair & Company, L.L.C.. -- Analyst

Hey, everyone, congrats on the quarter. I just had a quick one relating to tele-health actually, some of the comments made on tech-enabled acquisitions. I'm wondering in the large space that virtual health is, where you see yourself able to develop internal capabilities versus where you think you need to look outside for new solutions and how are you making that decision between the two different approaches?

Susan Salka -- Chief Executive Officer

Great question. So I'll start with a couple of points and then have Maureen add on. So first, when you think about tele-health, there is more than just the tech-enabled offerings that we have to play and so we are a staffing provider for tele-health. You think about our Schools business. We have over about 300 therapists that are working on our Televate tele-health platform, about half of them are therapists that are working for the Schools and we have a lot of opportunity to expand that, both for therapists, but also in adding in school psychologists and other capabilities, so we can't forget about the opportunity that we have to combine our staffing and recruitment capabilities with the tele-health platforms that we already have and then Maureen I'll have you talk about the expansion opportunities for Stratus and where we go with that as well as Televate and then maybe other opportunities in some other categories that we might not necessarily extend Televate and Stratus into.

Maureen Huber -- AMN Healthcare -- President, Workforce Technology Solutions

Thank you, Susan. And so as we think about the hospital at home and the initiatives around hospital without walls in supporting our acute-care clients today, how we can leverage our existing technology and capability to provide tech-enabled services across that care continuum. So as we continue to support those initiatives, that takes us from the acute-care setting and into the home. And as we heard Landry say earlier, many of the nurses are looking for some type of change in the next 12 months and so a lot of that will be driven toward these virtual care environments and also following that care continuum. So we'll continue to support those initiatives, also with our Language Services. We thought about the integrations in the 23 -- integrate with more than two dozen existing tele-health platforms, but the number of clients that we've implemented with has increased ten folds in the last 12 months. So we're continuing to see that expansion, especially from the acute-care provider and the adoption of virtual care. And I think we'll continue to see those initiatives grow as they are reevaluating their virtual care strategy.

Samuel Kusswurm -- William Blair & Company, L.L.C.. -- Analyst

Great, thanks for the color.

Susan Salka -- Chief Executive Officer

Okay. Hopefully that answers your question. And I do believe that was our last question so we want to thank you all for joining us today on this earnings call and we look forward to updating you on our next call.

Operator

[Operator Closing Remarks]

Duration: 68 minutes

Call participants:

Randle Reece -- Director, Investor Relations

Susan Salka -- Chief Executive Officer

Brian Scott -- Chief Financial Officer, Chief Accounting Officer, and Treasurer

Landry Seedig -- Group President and Chief Operating Officer, Nursing and Allied Solutions

Kelly Rakowski -- Group President and Chief Operating Officer, Strategic Talent Solutions

Maureen Huber -- AMN Healthcare -- President, Workforce Technology Solutions

Kevin Fischbeck -- Bank of America -- Analyst

A.J. Rice -- Credit Suisse -- Analyst

Jeffrey Silber -- BMO Capital Markets Corp. -- Analyst

Jeff Silber -- B of A Securities -- Analyst

Jasper Bibb -- Truist Securities -- Analyst

Brian Tanquilut -- Jefferies -- Analyst

Mark Marcon -- Robert W. Baird & Co. -- Analyst

Samuel Kusswurm -- William Blair & Company, L.L.C.. -- Analyst

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