Good morning, everyone. I'm Scott Fidel. I'm the Healthcare Services Analyst with Stephens, and welcome to day two of the Stephens Annual Investment Conference. We're going to have a full slate today of healthcare services companies that we're looking forward to speaking with, and we're very pleased to start out the morning with Brookdale. Here from the company, we've got Cindy Baier. She's the President and CEO. Dawn Kussow, the Executive Vice President and Chief Financial Officer, and then in the front row, Jessica Hanson, Vice President of Investor Relations, so great to see you again. Thanks for coming to the conference again. It's good to see you.
Scott, thank you so much for hosting us. We really appreciate you.
Great. Cindy, I thought maybe just to set the table here to kick things off, definitely want to address some current events. But I thought, you know, maybe give you the opportunity just to give us a quick State of the Union on sort of where Brookdale sits right now as we're looking out to 2025. The company has actually been quite active recently on the corporate front. So maybe if you want to just highlight, you know, some of the key recent actions, and obviously we'll dig into those more during the conversation.
Sure. One of the things that I'm really excited about is the fact that we are continuing our recovery from the pandemic, and so we're seeing consistent occupancy and RevPAR growth. That's important because the fees that we receive from our residents are what fund our expenses. We are improving cash flow, and we'll talk about that a little bit later in the day. We've made a lot of progress over the last year and a half on our lease portfolio. We'll talk about that as well, but we just announced at the end of the third quarter some acquisitions of portfolios that are currently leased. We'll talk about that, but that really gives us a nice return and gives us a lot of flexibility that we're excited about.
But as we look to the future, what we think about is the strong supply and demand that is going to propel our business forward when combined with the unique Brookdale differentiators. We're very excited about the future. So let's jump in.
All right, great. One topic that I just pretty much trying to start out every one of the conversations with, just given the timing, is around the elections. And obviously, in the last day or two, we're starting to see some visibility into the staffing of some of the healthcare policy positions. I thought, though, it may be helpful, maybe if you want to first just walk us through, when we, in terms of from your end markets and thinking about senior living, assisted living, memory care, what are sort of the key, you know, I guess, sort of policy items that you're focused on that you think, you know, have the potential to shift as we move from not only the Biden administration, but to the red sweep, which obviously opens up other legislative scenarios as well?
Thanks for the question. One of the things that is important to note is during the pandemic, which was the prior Trump administration, we had the opportunity to really work closely with the administration to explain the critical role that senior housing plays in the economy and for the benefit of seniors. And we were grateful for HHS prioritizing seniors as it related to receiving vaccines. And so I think it really helped everyone understand just the critical role our industry plays for the lives of seniors. As we look at the administration, we're hopeful that we can continue to focus on affordability of senior housing, whether that's using FSAs, HSAs, or potentially tax credits and programs that will continue to enhance the availability of healthcare workers, which is something that I know we all care deeply about.
That's a really interesting point, actually. And so how is, in terms of like FSAs and HSAs, is there really like no uniform, I guess, guidance, or is there right now in terms of how that can be used for senior living? Is that something that currently is allowed or not allowed? And then there's a potential for a change, or?
It's not allowed today, but we think it makes sense. If you think about the fact that 94% of senior housing is private pay, and by living in senior housing, you're actually preventing additional hospitalizations. One of the things that we talk a lot about is that our Brookdale HealthPlus communities, if you have a senior who lives in a Brookdale HealthPlus community and you compare the healthcare expenditures to the senior who has the same conditions who lives at home, our senior on average will have 80% fewer urgent care or ER visits and 66% fewer hospitalizations. To us, it only makes sense that you should allow a taxpayer who has set aside funding for healthcare to use those dollars to support their healthcare needs through assisted living or memory care. That's why we'd love to see a policy change in that regard.
We think ultimately it's good for taxpayers and certainly good for our residents.
Yeah, I think it just makes sense to me just on the policy side. Has Brookdale or your trade groups, have there been any studies that have been put out in terms of, you know, what type of incremental demand? Obviously, we have a lot of underlying demand anyway, but in terms of, I guess, addressing sort of eclipsing certain affordability, you know, inflection points around opening up those accounts, any analysis out there that's been done?
So there's a study out of NORC, which basically shows that a person who moves into senior living is less frail and lives longer than a person who stays outside of senior living. That's the most relevant study that I've seen. But as I've indicated, Brookdale has had for three years straight an independent third party come in and look at the outcomes of the residents who live with us and compare those to other outcomes, which is why we think it makes sense.
Okay. Well, I know you're very actively involved on the advocacy side for the industry, so I'm sure that's something that you'll all be trying to communicate.
We absolutely will.
Yeah. Okay. That's interesting, and then more from, you know, another sort of second derivative or unintended consequences. You know, we all always have these sort of one or two or three hot button, you know, sort of items that we're all sort of focused on. Right now it's things like the enhanced subsidies in the exchanges, Medicaid supplemental payments just for the broader industry, but obviously these policies have a lot of other, you know, potential implications just from the more economic perspective. You know, one, you know, that I'm curious about is just thinking about labor market impacts, you know, if the administration does move forward with mass deportations, I guess that's what they're calling it, right?
So, you know, not that it may affect your direct workforce, but just does that sort of create, you know, reduce the labor supply overall and create maybe a little more pressure, you know, in the labor market? That's one thing. And then just from the tax policy and economic policies, growth initiatives, anything else that you would, you're sort of thinking about from either the tax or inflationary sides?
I think workforce is a critically important issue, and it's important for us to make sure that we have the availability of qualified workers within our communities, and it's really important at Brookdale because we try to make sure that people who work with us have a path to a better life. Now, to work with us, you've got to have a green card and all those sorts of things, so I'm not sure that the deportation comments would necessarily have a big impact on us, but we are very proud of the fact that we are willing to advance fees if one of our associates wants to apply for citizenship. That's a way that we can help people get a path to a better life. We're also very focused on upskilling our workforce.
So if someone comes in and they start with us, maybe as a high schooler in our dining room, we want to give them the skills that they can lead a better life by advancing their skills, getting a higher position. If they're interested in becoming a certified nursing assistant or a med tech, we'll advance those fees and help them grow into those roles. So we're very focused on creating a vibrant workforce. And one of our top priorities really is to attract, engage, develop, and retain the best associates. So everything that we do is really focused on making sure that we've got the right workforce for our residents.
Okay. Great. Well, I know you're, I'm sure, deep into your strategic planning process now for 2025. Maybe if you want to just give us sort of a broad sort of outline, you know, of how at this vantage point you're looking at 2025 and walk us through some of the key headwinds and tailwinds that you see ahead.
Yep. Thank you, Scott, and thank you for having us here today. You're exactly right. We're in the middle of our budgeting process for 2025, kind of wrapping that up. But what I would say about 2025 is we would expect what we saw in 2024, kind of starting through Q3, is we saw 15% adjusted EBITDA growth and 39%, excuse me, 31% adjusted free cash flow growth through the third quarter. And as Cindy said, you know, we've been focusing a lot on top line sustainable RevPAR growth, kind of balancing that occupancy with that rate. And so what we would expect for 2025, although not giving guidance, is just the continuation of that growth, both our organic growth and looking at, you know, how we can manage to get to, we're dedicated to getting to adjusted free cash flow positive.
Just as we're looking at kind of headwinds and tailwinds, I would say from a headwinds perspective, the macroeconomic environment is starting to settle down. The labor markets are starting to moderate, but we're still seeing some higher insurance costs, whether that's general liability or property insurance. Maybe some of our health insurance costs are still a little bit higher than what we would like. From a tailwinds perspective, Cindy mentioned the demographic tailwinds that we would expect to continue to see in 2025. Also, we have been focusing a lot on retention and turnover of our associates. So with that retention and turnover focus, we would expect our occupancy to continue to grow because that's the one way that we can grow occupancy that we know where you keep your associates in your communities. We would expect that occupancy to grow.
And then as our occupancy gets higher, our flow through because of the high fixed cost of our business margin is going to get higher as well. And then, of course, not to ignore the interest rate environment. So about a 1% change in interest rate is about $13 million to us with our variable rate debt. And so as those interest rate environments start to settle down, that should help our adjusted free cash flow.
Okay, great. Do you have a particular projection on where you think rates land, or is it a little preliminary at this point?
I think we're following the 10-year. We follow the 10-year curve. And so I think, you know, what is out there is we would expect another rate cut coming through the end of this year and then multiple rate cuts coming through 2024. But I think, you know, not thinking about the higher for longer, but I think that's moderated just a little bit.
It's important to know that if you look at interest rates over time, there's always a lot more volatility than you maybe expect. We do expect that our looking at the forward rate curve, it may change.
For sure, especially as we see the policy proposals start to sort of see how they're going to sequence those. Okay, let's move on, and why don't we dig in? Oh, yeah, go ahead.
You mentioned retention turnover of associates. Can you just talk about what is your retention rate and how does that compare to industry? And then what specific steps are you taking to improve it?
Yeah, let me take that. So we look at our key three community leadership, which is our Executive Director, our Health and Wellness Director , and our Sales Director . And we look at that in terms of retention because the leadership in the community is one of the most important factors in terms of making sure that you have the reputation as the best in the marketplace. Now, ideally, we want our Executive Directors to be at least 70%, and we'd like to have our key three to be close to that. And that's a 70% retention rate. And that is something that we have made great progress on. Our EDs are currently right around there right now. When you look at our hourly associate turnover, it is a mix of different positions, right? So if you look at your cooks and your servers, we would compare those to restaurant staff.
And quite honestly, our turnover rates are better than sort of comparable restaurant positions. If you look at housekeepers, we would compare those to hospitality, and our turnover rates are better. And then obviously you look at caregivers and CNAs and med techs and nurses, and that is an area where we consider relative to the healthcare system. I will say the one thing that has been challenging for us is the turnover of our nurses. And as you know, nurses are in short supply. And one of the things that we have been working on is how do we solve for the nursing challenges when hospital systems are starting to hire more LPNs, which is the predominant portion of our nursing staff.
So the things that we do, I mentioned earlier how we basically have development programs where we're trying to make sure that if someone comes with us, they don't need to leave to get a better job. We can help them get the skills and the training and the proficiency necessary to get that better job. That's one of the biggest things that we do. The second thing that we do is the first 90 days that you are an employee is critical. And so we want to make sure that you're successfully onboarded, you're trained, you get a friend at work, you have a supervisor who's having career discussions with you to find out what do you want to do next so that you can see your future beyond the job that you're in today. Those are some of the things that we focus on.
It's also focusing on hiring the right people to begin with. One of the things that is true about our industry is the people who are most successful in our industry really have a heart for the business that we do. They want to join us because they have a passion for serving the residents that we help every day. If you find people that truly are aligned with that culture, you tend to find they do stay a lot longer.
Any other questions right now? All right. Well, please raise your hand if you've got any. Let's move on and dig in a bit to the recent transactions and have a few questions there, and we can maybe just fold it into a theme here. I guess maybe to start with, maybe we'll just sort of frame it as some of the real estate dynamics. You've talked about how the recent actions should drive around an incremental $33 million in adjusted EBITDA and then $15 million of adjusted free cash flow in 2025. Maybe can you start with just giving us an update on the remaining lease maturity structure and any opportunities that may be ahead, particularly when looking at the Ventas lease, which is set to expire on 12/31/2025?
Sure. Let me go back before I go forwards. So over the last 18 months, we have negotiated successful lease extensions with Welltower, with LTC, and with Omega. And if you look at these three leases together, they are cash flow positive in the third quarter. So I think it's important because we've always said that our goal is to improve the returns to our shareholders as measured by cash flow when there's a lease renewal. Now, if you look at our total portfolio, we only have 126 communities that will expire under their lease in the next five years. 120 of those assets are Ventas assets, and the lease runs through the end of next year. So if I think about that optionality, when you get to a lease expiration, you basically have the ability to improve the benefit to your shareholders.
We look at the cash flow both in the short term and the long term. We look at that cash flow relative to the risks and opportunities of operating the communities. We're excited about the optionality that the lease expiration provides.
Okay, great. And then let's sort of stay on sort of this topic. And then I guess as you think about the current sort of mix of your debt and you've got a greater than 60% of the debt structure is currently fixed and all the variable debt is covered by caps and swaps. But I guess any other incremental benefits that you'd want to call out or highlight relative to free cash flow, just given the further reduction in interest rates? I know, Dawn, we already sort of touched on that to a degree, but sort of even incremental, you know, for the recent rate cut.
Yeah, I would say, as you pointed out, 62% of our debt is fixed rate debt, and we are very happy that if you look over the last year, we have refinanced two very large loans with agency debt, and so we have very good relationships with both Fannie and Freddie. If you look back just as recently as last quarter, you know, one of those loans was an approximate $200 million loan. It had a variable and a fixed rate mix, and so it was just under a 7% weighted average rate, and we went and refinanced at a 5.7% fixed rate debt, and so just kind of an example of, you know, how that environment is turning, and as I said before, 1% of a change in the rates that we're getting is about $13 million.
I think if you take a further step back, if you look at our interest expense and what the environment has been doing, it added a $50 million headwind to our interest expense when you look at our adjusted free cash flow . So as I said, very much looking forward to the continuation of the environment changing.
Okay, great. And then keeping on the topic of rates, supply growth traditionally has generally lagged as a factor of this and then increased cost to build relative to pre-pandemic levels. Of course, building these communities takes time. But have you seen any signs of new builds moving along the process in your markets?
So let me start by looking at the macro. And if you look at the National Investment Center for Seniors Housing and Care, there's always a little bit of quarterly variability in the seniors housing starts. But if you look at the last several years, the trend is very clearly down and it's very significant. If you look within 20 minutes of a Brookdale community, which is what's most directly competitive to us, the starts are down 86% since the peak. And just to give you some perspective, looking at that same statistic a year ago, they would have been down 78% a year ago. So even better this year than it was last year. Now, if I look at the cost of construction and even with interest rates starting to come down, it is still incredibly difficult to build a community to compete with Brookdale at our price points.
And the reason for that is that you've seen escalating cost to build, higher interest costs, and a tightened credit environment. And it's going to take a while before that starts to unwind. I think best case is 10 years, but if it's the shortest period, I would think is more likely to be five years before there's really a material change in competition within our markets. And the fact that there's such constrained supply is outstanding for Brookdale because we have the ability to serve more seniors in our communities. And when we do, the cash flow from those recurring resident revenue will drop to the bottom line at a very high percentage.
I think that certainly has been also validated in some of the broader NIC studies at least through 2026 on the positive supply demand equation. Okay, excuse me. When thinking about the restructured balance sheet, providing additional funding for high return strategic acquisitions, how should we be thinking about that comment that you had made in relation to capital spending when thinking about allocating towards real estate assets versus senior living operations?
Yeah, what I would say is, you know, we're always looking at our capital spend and we are always looking to make sure that we are appropriately spending capital in our communities to serve our residents. That's our number one priority. When I think about, you know, we also are thinking about shareholder value as well. And when you say, okay, so what is the best way for us to spend capital, you know, it might be an investment in a CapEx project, improving a current community. Of course, it was, you know, we just announced the 41 community acquisitions. So it might be capturing that NOI and spending our capital to get out of a high and escalating lease payment with lower rate debt. And so our number one priority is taking care of the resident and then looking at how we can increase shareholder value.
And then, just to add on what Dawn said, the acquisition that we just did—we acquired those assets at a mid-8% cap rate, just on sort of the basics of the transaction, replacing a high and escalating lease payment with a lower fixed cost interest payment. But what is really above and beyond that is it gives us great strategic flexibility. And so, by owning the assets rather than lease them, we have the opportunity to go look at communities that may not fit our strategic framework or may not be performing as well as we might like. And if they're not value accretive, then we can recycle the capital. And that's something that will increase the return for our shareholders. And so, we'll constantly assess assets to make sure that they make sense to operate given the market conditions, the performance, the specific location.
We'll try to make sure that we're always putting our capital to the best use of our shareholders.
Looking at the environment for operational acquisitions, how would you say valuations are trending at this point out in the market relative to, let's say, pre-pandemic levels?
Yeah, I think instead of talking more broadly, just maybe like just touching on exactly what Cindy just talked about is, you know, the best experience we have is we just closed or we, excuse me, we just entered into agreements to close.
Right. You're probably setting the market.
Yeah, we're setting our market. Yeah. So exactly what Cindy said, you know, when we look at the NOI of the communities as opposed to the purchase price of getting or buying that NOI, it was a mid -8% cap rate, which we think is very attractive on top of the fact that you mentioned before $33 million of adjusted EBITDA immediate impact and an estimated $15 million of adjusted free cash flow. And so that along with the strategic flexibility is just going to further enhance the value of that acquisition. So, you know, that mid -8%.
Where would you say that sort of stands relative to sort of historical averages, that mid -8%?
Yeah, I would say it's higher. It is certainly asset dependent when you're thinking about cap rates, but I think that it is certainly higher than what it has been historically.
I think the important thing when you're thinking about cap rates is we're very grateful that our assets on a per unit basis are performing better than they were pre-pandemic when it relates to the net operating income of the community. There's still so much opportunity built into the assets that we're acquiring to return to pre-pandemic occupancy and historical high occupancy. When you think about cap rates, it's important to just think about is it a stabilized property that's operating at peak capacity or is there still a lot of runway ahead of it? We're excited about the cap rate, the opportunity to improve returns through capital recycling, and then also just the built-in upside that's there when you're buying assets that are not at their historical occupancies and they're acquired at a discount to replacement cost.
Great. Actually, that's a great lead into the next question I wanted to ask, which was about looking at the rest of the existing portfolio, and I'm sure you're always evaluating sort of relative performance across your different communities. Can you talk about how much sort of variability, you know, you see in the performance across your communities, and as you look to, you know, continue to improve returns overall, how much opportunity there may be in terms of, you know, potentially focusing on certain communities, whether it's divestitures or sales or other actions to offset some of the new acquisitions you're doing too?
There's always a lot of variability between communities. And to go back to one of the earlier questions, the associates and the leaders in the community are one of the single most important factors about how a community performs. So if you've got an Executive Director who builds the right culture, who makes residents' lives easier, who creates a team that is excited and engaged to serve the residents that we serve, those communities will perform better. Now, certainly market conditions are a factor. If there's a new competitor opening up across the street, that's going to impact your community regardless of sort of the quality of the experience in your community. But that'll occur for a year or so, and then that impact will abate.
But there is just a wide amount of variability, and there's a lot of opportunity left, which is why we're so excited about the positive supply and demand characteristics, which will allow us to continue to build on a consistent operational improvement that drives value for our shareholders.
Okay. And then putting all those pieces together and just think about how it affects the leverage ratio, think in the near term from some of these transactions, you're going to see a bit of a hiccup, right? So maybe talk about in the near term where you see leverage going. And then at this point, have you established any sort of formal longer term targets? How are you thinking about, you know, managing leverage, let's say over the next, you know, 18 to 36 months?
Yeah, that's a great question, Scott. Thank you. We are heavily focused on our leverage, and there's no doubt that the pandemic impacted our leverage significantly. As a matter of fact, if you look at our net debt today, we're within about 5% of our net debt back from 2019. And with the adjusted EBITDA growth that I talked about a little bit earlier, if you take our third quarter leverage and annualize it, we're actually under our 2019 leverage. And so that's about 9.4 turns. And any 10% increase in our adjusted EBITDA is about a turn on our leverage.
And so if you think about, you know, just the fact that the acquisitions over the shorter term, there's going to be a little bit of noise in our leverage just because we'll bring that debt on as we close those acquisitions, but we won't get the benefit of that reduced lease payment until in our T12 adjusted EBITDA until 12 months. And so there will be a little bit of noise, but if you normalize that, we don't expect these acquisitions to have a material impact. It's going to be less than half a turn. And so, you know, as we think about long term and short term, it's really our biggest opportunity of increasing our leverage is increasing our adjusted EBITDA with the demographic tailwinds that Cindy's been talking about, the retention of our associates and the increasing of our occupancy.
That's where we remain focused and think that, you know, our leverage is we have the opportunity to improve our leverage over the short and long term.
The other point that I would make is just remember that the vast majority of our debt is non-recourse, very low cost financing, and so when you think about leverage and you think about the underlying real estate in the business, I think it's important to consider that when you're thinking about how to think about the capital structure for a business like ours, which sits at the intersection of healthcare, hospitality, and real estate.
Okay, great. Let me just pause here and see anybody got one?
How do you think about where you want to move that leverage ratio to ultimately sit at a more low?
Yeah, I would say we haven't come out and said, here's our leverage target. But just as Cindy said, as we sit at this intersection of three different industries, I don't think our leverage expectations would be aligning with any one of those industries. And so I think, again, the best way for us to bring our leverage down is to grow our adjusted EBITDA. And, you know, as Cindy said, we also look at our debt with it being the non-recourse debt. It's a little bit more like the real estate industry where that debt is non-recourse and at a low rate.
But I think over time you'll definitely see our leverage rates come down as our operational performance continues to improve.
Okay, maybe we can talk a bit about just the January 1, 2025 book of business. You've probably got pretty decent visibility, you know, into that. And also maybe it would be helpful to just like what the typical schedule is, you know, around sort of how your rates, you know, in particular sort of maybe we could start with that, like how do those typically trend over the course of the year in terms of the percentage of when you're updating your block?
Sure, so when you think about rate increases, there's two types of rate increases. One is for your in-place residents, and all of our in-place residents get their rate increase on January 1st unless they move in in the fourth quarter because then they've essentially already gotten a market interest rate, and then throughout the quarter and throughout the year, we're constantly adjusting market rates based on competition and things like that, so if you move into one of our communities, that's going to be more dependent on what the individual market conditions are, the time an individual resident moves in. Now, what we try to do is we try to balance affordability for our residents with the costs that it takes to provide high quality care and personalized services.
I think what you'll see in 2025 is rates that are not quite as high as last year, but sort of generally higher than pre-pandemic. You'll see that there's a spread between the cost increase and the rate increase that our residents receive. We would expect there to be a margin that's positive in the rate that we just passed along to our residents, which will take effect January 1st.
Okay. And then maybe give us some insight into, and maybe we'll just sort of use this also. We'll touch on the third party referral dynamic that you talked about on the third quarter call. But even before that, sort of more generally sort of talking about sort of the move in, you know, versus the move out, I guess to sort of what the underlying sort of net resident trend would be and sort of what you're seeing currently and expecting into that 1/1/2025 book of business around each of those two components.
Yeah, let me start with our current residents. One of the things that we look at is controllable move-outs. We look at controllable move-outs because they are representative of the value that our residents see in our product as well as resident satisfaction. We're very grateful that our controllable move-outs on a year-to-date basis through September are 9% better than they were last year. I think what that represents is the fact that we focused very intently on improving resident satisfaction. Our rate increase for in-place residents was lower in 2024 than it was in 2023. That helped with the perception of value. That really did make a big difference in sort of our resident retention rates.
If I transition to move-ins, one of the things that I can say about move-ins is we have been able to continue to grow occupancy faster than we did pre-pandemic because of the difference between move-ins and move-outs, and I will say that we've talked publicly both in our second and third quarter call about the fact that our move-ins were impacted by third party paid referral sources this year. And we did not get as many move-ins from that source as we have historically, so we responded by increasing sort of our internal marketing spend because our goal is to serve as many residents as we can.
And so if we're not getting the traditional volume from the third party paid referral sources, then we want to make sure that we're marketing a little bit more so that Brookdale name is available to residents who need help or potential residents who need help. And what I can say is in the third quarter, we saw softness in the third parties, but in the month of October, we did see growth year over year in our paid third party referral sources, and we saw overall growth in move-ins in our overall move-ins. Now that's one month, and so we're going to continue to focus on it, but I'm very happy with the decision that we made to increase our internal marketing spend because it is generating value for our shareholders.
And maybe can you just, for those of us that may not be as familiar with the presence or prominence, I guess, of the third party referrals in terms of sales and marketing and customer engagement effectively, is there an estimate for like what percentage of volume, you know, effectively has driven through that channel historically? And then do you have a target as you increase your internal sales capabilities where you think you can bring that over time?
The majority of our move-ins come from our internal marketing sources, right? Whether it is a referral from a family member or a resident who wants their friend to live with them so they can live as neighbors, whether it's medical professionals, whether it's our own digital marketing or direct mail, the majority come from internal sources. The minority is external sources, but I will say that the impact has been hundreds of move-ins for us in 2024 as it relates to the weakness in that particular channel.
So within that channel, the percentage impact just within it, it's been material?
It's been a material impact in the overall channel, yes.
Okay, understood. Any questions on this or other topics? Okay, move on. We got a couple more minutes here. So then when looking at sort of those overall trends and sort of to the extent that you're able to evaluate your market share, you know, in your markets and these different dynamics, how would you sort of say that you estimate that your market share has been trending, you know, let's say year to date?
Yeah, I would say that we really haven't been focused on kind of capturing market share. Really, the focus has been on capturing or getting to adjusted free cash flow positive. And so we've been heavily focused on the operations of the business, our three strategic priorities. And I think we mentioned earlier, our adjust, excuse me, our NOI on a per unit basis today is greater than it was back pre-pandemic. And so why that's important and exciting all at the same time is because pre-pandemic, we have a lower occupancy today than our 84.5% pre-pandemic occupancy. And so with that continued occupancy growth, there will be more that flows into the bottom line, into our NOI, increasing our adjusted free cash flow.
Understood. And even, I guess, sort of looking at the 84.5%, is that still something you think that ultimately you should be able to get back to? And do you have any sort of, you know, view on timing to potentially eclipse that point?
Absolutely. I think we've been focused on kind of growing occupancy that's profitable occupancy, so our RevPAR growth. But we certainly think that the 84.5% and beyond is something that is very realistic for the industry. Now, we think it's a walk and not a run, and it will take time, but we've been showing kind of that steady and sustainable forward progress and would expect that to continue.
Is it still reasonable to think that if you can get back to that level, that that could potentially be over an incremental $200 million of an EBITDA opportunity?
Absolutely. And the one thing that I would point out about that $200 million of its revenue growth. The $210 million is revenue growth. And so we would largely expect that to flow through into adjusted EBITDA, as we've been talking about, that flow through gets a little bit higher as your occupancy gets higher. But the one thing about that math is that that is at current RevPAR rates or our current rates. And as Cindy mentioned earlier, we typically are increasing our rates higher than our costs. And so we would think that there would be incremental opportunity there as well. We just kind of wanted to make the math a little bit easy and understandable there.
Based on what you would think would be a sort of a prudent, sort of but reasonable sort of rate increase, and how would you sort of frame, just so we don't, you know, overestimate or underestimate, you know, what would the incremental margin, I guess, be on that, you know, incremental revenue?
Yeah, we would not talk publicly about, you know, the flow through and then rates, of course. We go through a rate setting process every year. It's pretty extensive and it's based upon our cost structure. So not leaning forward too much into that.
Okay. So that means that was actually a good question then.
Yes.
Any questions out there? Okay. So let's talk a bit about basically the clinical, you know, strategy that you've been having underway and the HealthPlus, you know, I think let's sort of call it under that umbrella. I guess, you know, maybe give us an update on maybe sort of keeping it around that sort of controllable near term, you know, opportunity and on the 1/1/2025 and maybe sort of talk about, you know, year to date, what type of traction you've been getting on HealthPlus sort of and even, you know, the key KPIs that we should be tracking that you'd want to talk about and then what you see ahead in 2025 on that.
I am delighted about HealthPlus. And just for those of you who don't know the program, it is really a proactive care coordination program that's designed to minimize care gaps for the seniors that we serve. And so we change all of the operations of our senior living communities. We put in a new electronic medical record. We put an extra RN care coordinator above the community to help residents better manage their chronic conditions and to make sure that they're getting preventive care and help them to take care of the chronic conditions that they do have. And we've rolled that out to 50 additional communities in the last quarter, and we're now up to 129 communities.
What's exciting about Brookdale HealthPlus is, as we mentioned earlier, from the resident perspective, if you're in a HealthPlus community and you're an average resident compared to the same resident characteristics living outside of our community, there's 80% fewer ER or urgent care visits and 60% fewer hospitalizations, 66% fewer hospitalizations. So really that better quality healthcare is so important. If you think about it, it also helps us with retention of our associates because everyone wants to work in something that is a state-of-the-art healthcare system. We do see lower turnover of our associates who are working in that population. We do see longer retention of the residents who live in those communities. What I would say is look for continued rollout.
We'll roll it out to additional communities in 2025. It can't go into independent living because that's where we're not providing care. We're providing more services. But we will roll it out to more assisted living communities. And it's something that is very attractive. And our results just get better and better every year. This is the third year we've gotten independent third-party validation of our results. And every year the results have gotten better.
Is there a way when just thinking about the RevPAR increases and we were just having a chat with the kind of group on this as well, they call it their sort of clinical initiative as well. They call it the cares charges. So yesterday we were chatting on that. And sort of can you break out sort of when you think about your increases in room and board versus then the incremental kicker that you think you can get for HealthPlus and the clinical initiatives?
Yeah, so I would say we don't add anything to the residents' charges for HealthPlus. Largely, our HealthPlus costs have been covered by payments that we get from Medicare Advantage partners for the quality outcomes that we provide for their members who live in our communities, but when you think about care, our goal is to really provide high quality personalized care, so we don't discount that. We try to make sure that we're paying attention to local market conditions as it relates to rent, and sort of the balance between rent and care is always going to change sort of like every time a new resident moves in because it depends on the acuity of the resident, what their care charges are, and the market conditions for the rent.
But we're excited about the opportunity from closing care gaps and providing a very high quality product to residents that makes us an attractive destination.
All right, great. Well, we're pretty much out of time. I guess, Cindy, just anything I missed or any closing comments or you think we covered everything?
Scott, you had really good questions, so I want to thank you all for taking the time with us this morning. Take a look at Brookdale. We are really doing amazing work for the seniors that we serve, and we are at the beginning of some incredible industry tailwinds from the increasing senior demographic as well as the tightly constrained supply. Thanks very much.
Okay, thank you.