The Pennant Group, inc (PNTG) Q3 2021 Earnings Call Transcript

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The Pennant Group, inc (PNTG -0.60%)
Q3 2021 Earnings Call
Nov 12, 2021, 9:00 p.m. ET

Contents:

• Prepared Remarks
• Questions and Answers
• Call Participants

Prepared Remarks:

Operator

Good day, and thank you for standing by. Welcome to the Pennant Group Third Quarter 2021 Earnings Conference Call.

[Operator Instructions]

I would now like to hand the conference over to your speaker today, Mr. Derek Bunker. Please go ahead.

Derek J. Bunker -- Chief Investment Officer, Executive Vice President and Secretary

Thank you, Tino, and welcome everyone. Thanks all for joining us today. Here with me, today, I have Danny Walker, our CEO; Brent Guerisoli, our President; Jen Freeman, our CFO; and John Gochnour, our COO. Before we begin, I have a few housekeeping matters. We filed our press release and 10-Q yesterday for our third-quarter earnings. This announcement is available on the Investor Relations section of our website at pennantgroup.com. A replay of this call will also be available on our website until 5:00 PM Mountain Time on Friday, December 10, 2021. We want to remind anyone that may be listening to a replay of this call that all statements are made are as of today, November 9, 2021 and these statements have not been nor will they be updated subsequent to today's call. Any forward-looking statements made today are based on management's current expectations, assumptions, and beliefs about our business and the environment in which we operate. These statements are subject to risks and uncertainties that could cause our actual results to materially differ from those expressed or implied on today's call. Listeners should not place undue reliance on forward-looking statements and are encouraged to review our SEC filings for a more complete discussion of factors that could impact our results. Except as required by federal securities laws, Pennant and its affiliates do not undertake to publicly update or revise any forward-looking statements where changes arise as a result of new information, future events, changing circumstances, or for any other reason.

In addition, The Pennant Group Inc. is a holding company with no direct operating assets, employees, or revenues. Certain of our independent subsidiaries collectively referred to as the Service Center, provide accounting, payroll, HR, IT, legal, risk management, and other services to the other operating subsidiaries through contractual relationships with such subsidiaries. The words Pennant, company, we, our, and us, refer to The Pennant Group Inc. and its consolidated subsidiaries. All of our operating subsidiaries in the Service Center are operated by separate independent companies that have their own management, employees, and assets. References herein to the consolidated company and its assets and activities, as well as the use of the terms we, us, our, and similar terms used today are not meant to imply, nor should it be construed as meaning that The Pennant Group Inc. has direct operating assets, employees, or revenue or that any of the subsidiaries are operated by the Pennant Group.

Also, we supplement our GAAP reporting with non-GAAP metrics. When viewed together with our GAAP results, we believe that these measures can provide a more complete understanding of our business. They should not be relied upon to the exclusion of GAAP reports. A GAAP to non-GAAP reconciliation is available in yesterday's press release and in our 10-Q.

With that, I'll turn the call over to Danny Walker, our CEO. Danny?

Daniel H Walker -- Chairman of the Board and Chief Executive Officer

Thank you, Derek, and welcome everyone to our third quarter 2021 earnings call. Thank you for joining us today to discuss our third-quarter results and more importantly, the steps we are methodically taking to return to the healthy growth rate we've achieved over much of our history. These ongoing, multifaceted efforts will position us for a stronger 2022. We are grateful for our frontline employees and resources that continue to provide exceptional care to the 23,000 patients and residents we served during the third quarter. Our third-quarter results are sobering, given the high expectations we established for ourselves and have caused us to review our actions to identify missteps we've taken over the past two years as a public company. In general, the demands of completing the spin off successfully, the high volume of home health and hospice acquisitions, the leadership overhaul of our senior living segment, and the investment of time and resources in early stage new business ventures, all when coupled with the unique pressures of the COVID-19 pandemic have diluted our effectiveness at operating to our standards. Throughout our history, we have gone through periods of substantial growth followed by periods of retrenchment and concerted focus on our organic growth. We know that sustainable, clinical, and financial results are achieved when our investment activity is well calibrated with the health of our current operations and the bandwidth of our leaders and resources. We haven't struck this delicate balance well enough over the past 18 months. We are taking immediate actions to one, ensure that local -- each local team is executing at a high level without distractions. Two, retrench around the core opportunities across both segments. And three, reinforce the core principles of our operating model that have led to our historical success. We believe that these efforts will yield significant results in the short term and ensure long-term health.

Now, turning first to our Home Health and Hospice segment performance. We continued to produce solid results with segment revenue up $14.6 million or 22.7% and adjusted EBITDA up $0.05 million or 3.9%, both over the prior year quarter. Our third quarter results reflect both the strength of our same-store agencies and the challenges of integrating a large number of new acquisitions. The operating environment in the third quarter was impacted by the rise in COVID-19 cases in several of our key markets and the ongoing labor pressures across the platform. For example, in the third quarter, total Home Health admissions declined 5.7% from the second quarter. Nearly a quarter of which relate to the delay in elective procedures in key markets, such as Arizona, Idaho, Utah, and the Dallas-Fort Worth Metroplex, where we've recently acquired Home Health agencies. Approximately 80% of our decline in our total Home Health admissions is attributable to agencies acquired over the past 24 months.

Our Hospice business continued to produce steady results despite similar pressures related to COVID-19 and our recent acquisitions. Excluding agencies acquired within the past 12 months, our Hospice admissions increased 12% in the third quarter over the prior year quarter and average daily census increased 1.4% over the prior-year quarter. While we see a -- when we see a spike in COVID-19 cases like we saw in the latter half of the third quarter, it temporarily impacts our ability to admit and increases our cost of services as more and more staff are -- enter quarantine protocol. As COVID-19 cases normalized in our markets as we exited the third quarter, we are beginning to see traction in our Home Health business evidenced by an 8.7% increase in total admissions in October over September. The bedrock of our confidence in continued growth and our long-term health is our relentless focus on providing exceptional clinical care to our patients and residents. We continued to achieve high marks in several quality scores across our Home Health and Hospice segment, with an average Home Health star rating of 4.23 stars according to CMS and 4.4 stars according to real-time third-party analytics. Our Hospice quality composite score continues to trend well at 95% at the end of the third quarter compared to the reported national average of 90%. Our emphasis on clinical outcomes will be increasingly rewarded as the Home Health Value-Based purchase model is rolled out nationwide through the expansion of Hospice -- and through the expansion of Hospice quality reporting programs. Since 2018, 12 of our agencies have participated in the Home Health value-based purchasing model in Washington, Arizona, and Iowa, and we achieved net positive revenue adjustments each year. Just as we have successfully prepared for and navigated the implementation of the patient driven groupings model or PDGM and our reimbursement -- and prior reimbursement program changes, we look forward to the opportunity presented by the nationwide Home Health value-based purchasing model and related value-based reimbursement models to demonstrate and be rewarded for the clinical quality of care that our talented teams provide.

In our senior living segment, the ongoing effort to support our leaders and executing within our unique operating model continues. The improvement we achieved in the second quarter and believed would continue into the third quarter was disrupted by the sharp rise in COVID-19 cases, particularly in the markets where our senior living communities are concentrated. During the quarter, the spike in COVID-19 cases also amplified the labor pressures we've felt across our senior living communities for most of 2021. There are several levers we are pulling to help address these pressures directly and help offset their impact. And now that we've completed the implementation of our full suite of IT systems, the tools and analytics available are improving our sales and marketing processes, wellness delivery, and labor management. As we build stronger senior living operations, move past the worst of COVID-19 and begin serving a growing addressable senior population, our senior living segment has the potential to be a source of strength for Pennant.

As we announced in our press release yesterday, we are providing guidance for the full year of 2022. We anticipate full-year revenue in the range of $468 million to $478 million and adjusted earnings per share in the range of $0.75 to $0.82. As we consider the impact the COVID-19 has had on our businesses over the past 18 months, we believe and have assumed in our guidance some ongoing pressure, similar to what we've experienced in 2021. We also believe that the external effects we experienced in the third quarter are more transitory and likely to dissipate as cases normalize. Our guidance assumes accelerated results in our recent acquisitions more in line with our historical transition rates, continued growth in our Home Health and Hospice same store agencies, and incremental improvement in our senior living segment.

With that, I would just say that our hope remains strong in our long-term value proposition and we're deeply grateful for the team members in the field and at the Service Center that are making the important changes that need to take place for us to unlock that up -- that value and opportunity for our shareholders.

With that, I'll ask Derek to provide an update on our recent investment activity. Derek?

Derek J. Bunker -- Chief Investment Officer, Executive Vice President and Secretary

Thank you, Danny. During the third quarter, we announced the acquisition of one hospice agency in Texas, bringing the total number of new operations since the beginning of 2022 to 27. As Danny mentioned, the sheer number of new operations acquired immediately before and during the pandemic, coupled with the ongoing pressures in our senior living segment caused some short-term chop in our operating results. The complexities of the current environment, including elective procedure delays in markets in which we've acquired new agencies stretched many teams that are new to our operating model, contributing to the delays in our expected performance ramp. Much of this pressure appears temporary and we remain confident in the underlying fundamentals of our acquisitions, each of which have the potential to contribute in a meaningful way to our long-term results, just as many of our existing agencies continue to grow year after year.

Our growth strategy often leads to burst of activity when we are opportunistically deploying capital through acquisitions led by talented local leaders. Although in such periods of high activity, our priority is ensuring that these new teams transitioned into our unique operating model in a way that would lead to years of successful results. As we focus the energy of our local leadership teams -- refocus the energy of our local leadership teams, retrench around our core business opportunities, and reinforce the principles of our operating model, we will create a stronger foundation from which to pursue growth opportunities in 2022.

With that, I'll pass it to Jen for a review of the financials. Jen?

Jennifer L. Freeman -- Chief Financial Officer

Thank you, Derek. And good morning everyone. Detailed financial results for the three months ended September 30, 2021, are contained in our 10-Q and press release filed yesterday.

For the three months ended September 30, 2021, we reported total GAAP revenue of $111.9 million, an increase of $13.5 million or 13.7% over the prior-year quarter. GAAP diluted earnings per share of $0.04 and non-GAAP adjusted earnings per diluted share of $0.11. Please note, that our non-GAAP adjusted earnings per share results for the three months ended September 30, 2021, include the benefit of the Medicare sequestration holiday, as well as the effects of all COVID-related expenses and lost revenue. While difficult to perfectly capture all such expenses and lost revenue, we estimate that our third-quarter results were negatively impacted by COVID-19 in the amount of approximately $2.3 million in lost revenue, at least $0.3 million to specifically identify expenses across both segments and approximately $1.6 million increase in wages including overtime compared to the second quarter. The combined impacts on our business will likely continue to impact our results through the end of the year, which we have considered in our updated guidance released on November 1.

Key metrics for the quarter ended September 30, 2021, include $101.7 million remaining on our revolving line of credit and $3.7 million cash on hand at quarter-end. 1.31 times net debt to adjusted EBITDA and 1.75 times as Medicare Advance payments had been paid back as of the quarter-end. Automatic recoupment of the advanced payments began in April 2021, on which we have repaid $17.6 million through November 5, 2021 and we expect to repay the remaining $10.4 million over time within the payback period. Cash flows provided from operations of $1.5 million, excluding the impact of the automatic recoupment of advanced payments and the impact of the final phase-out of the request for advance or anticipated payment.

As Danny mentioned, yesterday, in our press release, we provided full-year 2022 guidance of revenue of $468 million to $478 million and adjusted earnings per share of $0.75 to $0.82. Our guidance is based on diluted weighted average shares outstanding of approximately 31.7 million and 26.1% effective tax rate. In addition, the guidance assumes among other things, anticipated reimbursement rate adjustments, no unannounced acquisitions, and the estimated ongoing effect of COVID-19 and excludes costs at start-up operations, share-based compensation, and acquisition-related costs. In our guidance development, we considered the reality of how COVID has impacted our operations. Our 2022 guidance includes incremental improvements in our segments throughout the year recognizing some revenue growth and accounting for the lingering effects of COVID on our census and occupancy, as well as costs through 2022. We have looked through the lens of the two COVID peaks that we experienced in 2021 and included moderate recovery throughout the 2022 calendar year. 2020 proved to be less challenging than 2021 and in some ways, we benefited in the early days of the pandemic. COVID impacted our markets more heavily in 2021 compared to 2020. Although predicting the impact of COVID is difficult, we have used our experience in 2021 to create a better picture of what to expect in 2022. With that in mind, we included moderate revenue growth and slight improvement over our 2021 adjusted cost of service as a percentage of revenue.

Despite the setbacks in 2021, our local leaders have proven to be adept at adjusting to challenging environments. With the focus on our core principles, retrenching the focus on our core opportunities across both segments, and emphasis on execution, I am confident the results can match our historical success.

And with that, I'll hand it over to Brent to highlight a couple of our local leaders.

Brent Guerisoli -- President

Thank you, Jen. It's great to be with all of you today. It's my pleasure to acknowledge the tremendous accomplishments of a few leaders in our organization. At Preceptor Home Health and Hospice in Milwaukee, Wisconsin, Chief Executive Officer, Sarah Martel; and Chief Clinical Officer, Shelly Darmody have built an incredible culture of success. In the early days of the pandemic, Sarah, Shelly, and the Preceptor team developed solutions tailored to the unique needs of the communities they serve, quickly increasing their reputation as the provider of choice. Their leadership has led to consistently strong financial and clinical results, including revenue growth of 36% in the third quarter over the prior year quarter and EBIT growth of 38% over the same period. They've also improved their CMS star rating to 4 stars on a real-time basis. The Preceptor team also exemplified our core value of ownership and supported the delivery of quality care at several of our senior living communities across the state of Wisconsin, building a strong continuum of care to better serve our residents, patients, and their families.

Staying in Wisconsin, Executive Director, Jeanie Brogni, Wellness Director, Suzie Car and the whole leadership team at Brenwood Park Assisted Living in Franklin, Wisconsin have shown it's possible to grow in the midst of a historically challenging operating environment. Jeanie and team have helped lead Brenwood Park to revenue growth of 16% in the third quarter over the prior year quarter and occupancy growth of 8% over the same period. This strong topline growth occurred during a period when many other communities saw significant pressure on occupancy. The Brenwood team also focused on managing their business effectively, while providing quality services to the residents, contributing to the EBIT growth of 39% through the first three quarters of 2021 over the same period of 2020. Jeanie and Susie are examples of what can be accomplished by executing in our unique operating model and achieving success even in very difficult operating environments.

With that, I'll turn it back to Danny.

Daniel H Walker -- Chairman of the Board and Chief Executive Officer

Thank you, Brent. And thank you, Derek, and Jen for your contributions today. I'd also like to just express again our gratitude for the Pennant team members throughout the organization that are fighting through the current complexities of the operating environment to ensure short-term results, improve and maintain long-term health in the process. We also want to express gratitude to our long-term-minded shareholders for their continued belief in our ability to work through these temporary headwinds and drive and unlock the long-term value proposition that we believe so deeply in. Thank you all.

Tino, can you please instruct the audience on the Q&A procedure, please?

Questions and Answers:

Operator

[Operator Instructions]

First question comes from the line of Scott Fidel from Stephens. Your line is now open.

Scott Fidel -- Stephens -- Analyst

Hi. Thanks. And hi, everyone. First question, just wanted to just drill into the 2022 guidance just as it relates to the implied margin improvement that you're targeting for next year, it works out to around and applied 150 basis points of adjusted EBITDA margin improvement in the guidance. And just interested if you can talk about the tempo of that margin improvement? Do you see this sort of playing out just ratably throughout the year or is there some seasonality that you're expecting in the sort of the tempo of that margin improvement that you're baking into the guidance?

Jennifer L. Freeman -- Chief Financial Officer

Yes. Scott. Thank you for your question. This is Jen. We are anticipating that the margins will improve throughout the year and that our seasonality would be in line with our typical seasonality. So, we do have cost pressures that occur in the third quarter. We do have some seasonality as well in the second and fourth quarter. So, we would expect that seasonality to occur with the margin improvement increasing throughout the year.

Scott Fidel -- Stephens -- Analyst

Okay. And then just a follow-up, just one on each of the segments if I could. First, just on the Home Health and Hospice business. What you're estimating the Pennant-specific home health rate increase would be. CMS had talked about a 3.2% increase for the industry. Just interested if it's -- what you're estimating with all the puts and takes for Pennant? And then any thoughts that you can give us on some of the same-store volume assumption that you may be thinking about for HHH in 2022?

Jennifer L. Freeman -- Chief Financial Officer

Yeah. So, on the rate increase, we estimated a rate increase of about 2.3%. And with that, we are also assuming in our guidance that the sequestration holiday goes away. So, that sequestration is reinstated. So sort of a flat rate year-over-year assumption is -- on that side on the rate. On the volume, we do anticipate that our volume would increase and our revenue would continue to grow, both in our same-store and our acquisitions. I think we have a lot of margin opportunity in our acquisitions, as Danny mentioned. And in our same-store, we are anticipating our normal growth that we would expect year-over-year. So, it's around about a 10% to 11% increase in the Home Health and Hospice segment on the top side.

Daniel H Walker -- Chairman of the Board and Chief Executive Officer

And I'll just add, Scott, maybe John Gochnour can comment a little bit on that. The way the operating environment has affected our same-store operation in Home Health versus the new acquisitions is fairly meaningful. So, John, do you want to?

John J. Gochnour -- Chief Operating Officer

Yeah. I'm happy to comment a little bit on that, Scott. I appreciate the question. I think our expectations and what I think our results show throughout the year is that where we've had an operation for a consistent period of time, the opportunity to develop a team, we've been able to really meet these headwinds and move through them. And you see that in some of the strengths we've shown year-over-year from the admission side. A lot of the opportunity and kind of the untapped potential in our portfolio resides in these acquisitions that we've talked about. And those are acquisitions that have occurred over the last two years, and we've talked for a long time about how that's often a nine-quarter process of moving through sort of taking an acquisition that is relatively weak from a margin standpoint, from a clinical standpoint and transforming that to operate at our level. And I think what we've experienced over the -- through some of the headwinds of COVID and the labor situation we've been facing is that's taking a little bit more time. So, the untapped potential is there and I think that's why we're very optimistic in that margin expectation. We feel like there's a lot of untapped potential that we can reach.

Daniel H Walker -- Chairman of the Board and Chief Executive Officer

Thanks, John. We've weathered the storm really well on the same-store front and we look forward to providing even more clarity on same-store versus new store in the future. Jen?

Jennifer L. Freeman -- Chief Financial Officer

Scott, I just wanted to provide a clarification. So, the rates that I was quoting about, what the impact of the rule was on us was actually on the proposed rule. Home Care and Home-based are still updating with the final rule. So, we should be able to have that estimate this week sometime.

Scott Fidel -- Stephens -- Analyst

Okay. Got it. So I would assume there's probably a tad of upside then right to that 2.3% rate changes [Indecipherable]? Okay. I'll get back in the queue and let others ask questions. Thanks.

Jennifer L. Freeman -- Chief Financial Officer

Okay.

Operator

All right. Next one on the queue is Frank Morgan. Your line is now open.

Frank Morgan -- RBC Capital Markets -- Analyst

Good morning. I guess staying on that subject of margins. Could you maybe talk about sort of the relative weight and contribution between this -- the same-store portfolio that you've had, the two years or more, or nine quarters, whatever the measure is, like what's the relative weight of that in the enterprise versus all the things that you have bought in the last two years that would be sort of in the non-same-store bucket? What's the weighting there and then what -- on a relative basis, I mean are we talking about a margin differential of 500 bps or 800 bps, or just any help there would be appreciated? And that's my first question.

Daniel H Walker -- Chairman of the Board and Chief Executive Officer

Yeah. Great question, Frank, and we appreciate it. I think what you're seeing is a pretty significant differential between those two and that's driven by a couple -- primarily by a couple of large acquisitions that we've done and that have underperformed from a margin standpoint. So our same-store -- those acquisitions that we've carried for a while, they've faced some of the same labor pressures. They've been impacted but they've managed really well through it. And when you look at a couple of these acquisitions and I'll highlight our joint venture with Scripps, which was included in this quarter's financials and you see a pretty significant revenue boost from that acquisition, about $3.4 million in the quarter, but you see a very minimal margin on that business. And I think the untapped potential that's reflected in that acquisition that we've increased -- at that acquisition, we've increased the census by 32% since we took it over. We've increased the quality outcomes. There's tremendous opportunity that exists and our direct costs have declined by about 13% during that same period. And so, we expect to see that untapped potential start to be realized really effectively both in the fourth quarter and into the first quarter of next year. And so, there's some significant impact upside in that [Phonetic] bucket, while our same-store has performed really well. Jen, do we have an exact number?

Jennifer L. Freeman -- Chief Financial Officer

Yeah. So, if you were looking at your EBITDA margin on same-store, it's 18.3% year-to-date compared to our acquirers about 6.5%.

Daniel H Walker -- Chairman of the Board and Chief Executive Officer

And then the percentage -- I think Frank was asking the percentage that are in our, what we would kind of call new store bucket versus same-store, 27 of those -- roughly about a quarter. So, Frank, that's there. And then on the margin, I guess you provided that perspective on the margin.

Frank Morgan -- RBC Capital Markets -- Analyst

And I'm sorry, the quarter -- what is the quarter? Is that the same store or the new store?

Daniel H Walker -- Chairman of the Board and Chief Executive Officer

New stores is about 25% of our total operations.

Frank Morgan -- RBC Capital Markets -- Analyst

Okay. And that's of agencies or I guess, yeah, maybe on agency or...

Daniel H Walker -- Chairman of the Board and Chief Executive Officer

Yeah.

Frank Morgan -- RBC Capital Markets -- Analyst

Okay. Got you.So it sounds like that a lot of these similar pressures, is it fair to say that it's just basically the lack of having a seasoned management team in place in all of these locations or was it just something that happened above and beyond the impact of COVID, which is obviously not insignificant. But was there anything else that happened, just some kind of unexpected integration issue?

Daniel H Walker -- Chairman of the Board and Chief Executive Officer

No. None of those kinds of unexpected integration issues. It really is the complexities of the COVID environment within a new management team. You're having to deal with quarantine, vaccination processes, and then in a number of the states that we're in, where we did new acquisitions, elective procedures were shut down for a period of time in the quarter. The combination of all of that is just our seasoned leadership teams navigate those complexities and have much better than our newer teams. But there's not been any major disruption to our normal acquisition process. We're just performing behind where we expected to. And we -- frankly, we don't like to attribute it to external factors. We're looking hard at the ways we have made missteps, things that we control and we see opportunities for improvement, we're making those changes and learning from that process. But really, that's the story is that it's like a rookie season being a little tough for somebody or a sophomore season and that's what's going on.

Frank Morgan -- RBC Capital Markets -- Analyst

Got you. Maybe just two more and I'll hop. Just curious, the rate growth in Hospice was remarkably strong up about 6.1% per day. Any color on what's driving that? And then also just on the senior living side, I appreciate the color you gave about how things are going in October on the Home Health care side. But any updated color on occupancy trends in senior living? Thanks.

Daniel H Walker -- Chairman of the Board and Chief Executive Officer

Yeah. So on the Hospice front, this Scripps acquisition that we've talked about is a joint venture and we're really excited about its overall trajectory. A lot of those patients are first-period discharges. We've seen a -- not just in that pocket of the organization but across the board, we've seen an increase of referrals from our higher acuity setting and actually a decline of referrals in that sort of mid-tier where SNFs typically reside. Most of that is just a function of what's been happening in the hospital systems and what's been happening overall in the post-acute census world. So, that's really the main story unless there's something to add from Jen or John. But -- and then on the occupancy side on senior living, I'll have Brent tackle that one.

Brent Guerisoli -- President

Yeah. So, we saw a pretty sustained growth up until the middle of September -- August-September timeframe. Then we started to see a dip partially because of COVID and there is some seasonality in that as well. So, right now that we're still being impacted by COVID and so, we anticipate that it will be -- there may be some occupancy pressures going into the end of the year. From a seasonality standpoint, November and December tend to be a little bit tougher generally, but then things will pick back up at the beginning of the year.

John J. Gochnour -- Chief Operating Officer

And Frank, I'd add one more piece of color just on the Hospice rate opportunity. And that is that as our -- as we have grown, our geographies have changed a little bit. So, our traditional business, we've been very strong for many years in Utah, Idaho, Arizona, as we've grown on the Pacific Coast, that's going to affect our rates. So we've been awarded several CONs in Washington this year. We're very excited about those. We've completed a start-up up in Everett, Washington as well as down in Olympia, Washington. And so, as those have come online, that's affecting our rates just because we receive higher reimbursement in some of those geographic areas. The same thing is true of our growth in California. And so, you'll see that fluctuate as we grow in different parts of our platform as well.

Frank Morgan -- RBC Capital Markets -- Analyst

Got you. So, the geographic wage adjustment would affect that more. Okay. That's great. What about at length of stay, just on Hospice, how are loss in medium length [Indecipherable]? Thanks.

Brent Guerisoli -- President

Yeah. It's Brent. That's a great question. We've been really pleased actually to see that our median length of stay has remained fairly constant from the second quarter to the third quarter. We have experienced a fairly -- it's been declining for throughout the pandemic. And so to see that stabilize a bit, we're very optimistic. As Danny said, some of this is driven by the percentage of our patients that are coming out of the acute setting, which is higher than it's ever been. We're excited about that. We're excited about the fact that acute systems are trusting us with their patients and we continue to work with our partners in the Enzyme Pennant Care Continuum and other facility partners to be the resource that we can be to the community which I think will stabilize those facility and their numbers.

Daniel H Walker -- Chairman of the Board and Chief Executive Officer

Thanks, Frank.

Operator

[Operator Instructions]

Next one on the queue is Tao Qiu. Your line is now open.

Tao Qiu -- Stifel -- Analyst

Hey. Good morning, guys. I just wanted to ask about the 2021 guidance. In terms of the revenue guidance $425 million to $430 million, it seems to imply kind of a decline in revenue in the fourth quarter. I'm just wondering what is driving that revenue decrease sequentially? And just a tack-on question to that. If you look at the way you guide your operations, any reason you'd prefer to guide EPS versus using EBITDA or EBITDAR at this point given the higher volatility associated with the EPS?

Jennifer L. Freeman -- Chief Financial Officer

So on the revenue side, Tao. Thank you. This is Jen. We guide to adjusted revenue. So that is going to take into account the Scripps revenue is not included in the first two quarters and will be included in the second or the third and fourth quarter. So, you'll just need to adjust for that particular piece. We're not anticipating a decline in the fourth quarter in revenue, so it actually is increasing. It's just that will probably be -- that's part of your difference if you're looking at GAAP revenue versus adjusted revenue. And then on EPS, what we've traditionally guided on EPS as looking at the various puts and takes that we have into various items of revenue and cost of service. So, we've just historically guided on EPS.

Daniel H Walker -- Chairman of the Board and Chief Executive Officer

We'll review that, though. Thanks for the question. We'll take it into consideration, we'll do a review of that.

Tao Qiu -- Stifel -- Analyst

Sounds good. And just on the acquisition front, given the strength you see on the Hospice side, I know that you guys see a bit more in position this quarter and I think you started up another Hospice agency during the quarter. How should we think about the pipeline of investment going forward? Do you guys take a breather next year on Home Health front and kind of focus more on the Hospice front?

Daniel H Walker -- Chairman of the Board and Chief Executive Officer

Yeah. I would say that's what we're trying to communicate in the script. That's a natural process for it, it's not a sign that we're sort of taking a break from acquisitions or sort of something is wrong. It's just when we see significant opportunity in our already acquired operations, it's -- we see the best return coming from continuing to transition those and ensure that that's the case. Our return to different types of acquisition opportunities will actually be fairly uneven in that -- certain markets in our portfolio make more progress more quickly, they will start deploying capital sooner than perhaps others who may have a little more prolonged lifting to do. But this is kind of a typical cycle for us where we see so much opportunity internally that it's harder to justify taking resources and deploying capital externally. So, I think it would be a little lighter in the fourth quarter, maybe into the first quarter. And then I expect we'll be in the trajectory we would want to be to make sure we're deploying more capital next year.

Tao Qiu -- Stifel -- Analyst

Sounds good. And on the Home Health value-based purchasing, you mentioned that there are 12 agencies that you guys have that are already participating in the program and getting positive revenue adjustments. Could you quantify kind of the revenue you see among the 12? And how should we think about when the program gets rolled out nationwide, what will be the impact on your total portfolio?

Daniel H Walker -- Chairman of the Board and Chief Executive Officer

That is a good question. I'm not sure we have that -- we're looking it up right now. Collectively, those agencies represent a fairly small percentage of our overall Home Health revenue but we viewed them as test cases and made sure -- while the number -- a little more concrete numbers are coming. But we've learned a lot from those experiences, right? There's a lot of data tracking and reporting that is really important on that front and we feel like those test cases have been really positive for us. But John or Jen, do you have other specifics on the numbers?

John J. Gochnour -- Chief Operating Officer

So, our total -- the impact was a positive of about $125,000 across those agencies. And again, as Danny said, some of those are very small, some of them are midsized. But we've been very pleased overall at how our local teams have taken the data around these clinical metrics, how our Service Center partners have helped to scoreboard and provide education and training, and the resulting impact has been that the majority of those agencies have been in a positive -- have had a positive impact year-over-year. And I think that's one of the reasons we really are excited about Home Health value-based purchasing rolling out across the country. We see it as a way that our model has the potential to impact our operational results because of our focus on clinical outcomes, because of the way we measure them and provide leaders with transparent data, and their ability as clusters and local leaders to address the unique opportunities in their markets. So, we're excited.

Daniel H Walker -- Chairman of the Board and Chief Executive Officer

And those agencies accounted for 16% of our Home Health revenue. What that whole dollar translates to in terms of a revenue increase is about 1%.

John J. Gochnour -- Chief Operating Officer

And that's a year-to-date number.

Daniel H Walker -- Chairman of the Board and Chief Executive Officer

And that's just our year-to-date stuff. Does that help, Tao?

Tao Qiu -- Stifel -- Analyst

That's very helpful. Yeah, obviously. And lastly, I wanted to ask about the vaccine mandate that OSHA and CMS is pushing through. I know that in certain states where they are already state mandates. What kind of turnover impact are you expecting on the vaccine mandate? What's your experience in the markets that have already gone through that?

Daniel H Walker -- Chairman of the Board and Chief Executive Officer

Yes. Thank you for that question. We have been dealing with mandates and frankly, counter forces to mandates in various states. There are some states who have gone away from that. There's been states that have done it. Now that the federal mandate process is underway, there's a lot of dynamics moving both directions depending on markets, specific issues and -- but I believe that it hasn't contributed enormously to our overall turnover situation, although there's a lot going on in the labor market right now. When we are watching it closely, we have seen a fairly high adoption in those states that have had mandates and have really very modest turnover rate driven by it. Now it's difficult for us to say how that's affecting the rest of the marketplace. It certainly is factoring into people's decision-making. But we've done careful reviews, we're reporting. We have good data systems now to report vaccine status and spending a lot of one-on-one time with individuals in their individual circumstances, reviewing the nuances that go into the decision around vaccination. We're not anticipating a significant turnover spike as a result of these mandates making their way through. We've spent a lot of time individually with our staff members in understanding where they're at, why they're in the place that they are and how we can best support them as they move forward. So, we won't see the full effects of it here for probably another several weeks. But it is -- it adds to the dynamic. We feel like our culture of high trust and local decision-making has served us well in that regard and we anticipate that we'll be able to get through that without any major disruptions to the already difficult labor environment but we don't anticipate it being something that is significantly problematic for us.

Tao Qiu -- Stifel -- Analyst

Thanks for the color. Thank you for taking my questions.

Daniel H Walker -- Chairman of the Board and Chief Executive Officer

Yeah. Thank you, Tao.

Operator

And there are no further questions on the queue. I will now turn the call over back to the presenters.

Daniel H Walker -- Chairman of the Board and Chief Executive Officer

Okay. Thank you all. Again, thank you for joining us. Thank you for your continued belief in our story and thank you to all of our leaders and stakeholders for the amazing work that you do on a daily basis. Have a great day.

Operator

[Operator Closing Remarks]

Duration: 46 minutes

Call participants:

Derek J. Bunker -- Chief Investment Officer, Executive Vice President and Secretary

Daniel H Walker -- Chairman of the Board and Chief Executive Officer

Jennifer L. Freeman -- Chief Financial Officer

Brent Guerisoli -- President

John J. Gochnour -- Chief Operating Officer

Scott Fidel -- Stephens -- Analyst

Frank Morgan -- RBC Capital Markets -- Analyst

Tao Qiu -- Stifel -- Analyst

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