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Document and Entity Information - USD ($)	12 Months Ended
Document and Entity Information - USD ($)	Dec. 31, 2018	Feb. 22, 2019	Jun. 30, 2018
Document Documentand Entity Information [Abstract]
Document Type	10-K
Amendment Flag	false
Document Period End Date	Dec. 31, 2018
Document Fiscal Year Focus	2018
Document Fiscal Period Focus	FY
Trading Symbol	CCRN
Entity Registrant Name	CROSS COUNTRY HEALTHCARE INC
Entity Central Index Key	0001141103
Current Fiscal Year End Date	--12-31
Entity Well-known Seasoned Issuer	No
Entity Shell Company	false
Entity Small Business	false
Entity Emerging Growth Company	false
Entity Current Reporting Status	Yes
Entity Voluntary Filers	No
Entity Filer Category	Accelerated Filer
Entity Common Stock, Shares Outstanding		36,139,876
Entity Public Float			$ 395,272,643

CONSOLIDATED BALANCE SHEETS - USD ($) $ in Thousands	Dec. 31, 2018	Dec. 31, 2017
Current assets:
Cash and cash equivalents	$ 16,019	$ 25,537
Accounts receivable, net of allowances of $3,705 in 2018 and $3,688 in 2017	166,128	173,603
Prepaid expenses	6,208	5,287
Insurance recovery receivable	4,186	3,497
Other current assets	2,364	963
Total current assets	194,905	208,887
Property and equipment, net	13,628	14,086
Goodwill	101,060	117,589
Trade names	20,402	26,702
Other intangible assets, net	55,182	60,976
Non-current deferred tax assets	23,750	20,219
Other non-current assets	18,076	19,228
Total assets	427,003	467,687
Current liabilities:
Accounts payable and accrued expenses	43,744	50,597
Accrued compensation and benefits	33,332	34,271
Current portion of long-term debt	5,235	6,875
Other current liabilities	3,075	2,845
Total current liabilities	85,386	94,588
Long-term debt, less current portion	77,944	92,259
Long-term accrued claims	29,299	28,757
Contingent consideration	7,409	5,088
Other long-term liabilities	8,767	9,276
Total liabilities	208,805	229,968
Commitments and contingencies
Stockholders' equity:
Common stock—$0.0001 par value; 100,000,000 shares authorized; 35,625,692 and 35,838,108 shares issued and outstanding at December 31, 2018 and 2017, respectively	4	4
Additional paid-in capital	303,048	305,362
Accumulated other comprehensive loss	(1,462)	(1,166)
Accumulated deficit	(84,062)	(67,111)
Total Cross Country Healthcare, Inc. stockholders' equity	217,528	237,089
Noncontrolling interest in subsidiary	670	630
Total stockholders' equity	218,198	237,719
Total liabilities and stockholders' equity	$ 427,003	$ 467,687

CONSOLIDATED BALANCE SHEETS (Parenthetical) - USD ($) $ in Thousands	Dec. 31, 2018	Dec. 31, 2017
Statement of Financial Position [Abstract]
Accounts receivable, allowance for doubtful accounts	$ 3,705	$ 3,688
Common stock, par value (usd per share)	$ 0.0001	$ 0.0001
Common stock, shares authorized	100,000,000	100,000,000
Common stock, shares issued	35,625,692	35,838,108
Common stock, shares outstanding	35,625,692	35,838,108

CONSOLIDATED STATEMENTS OF OPERATIONS - USD ($) shares in Thousands, $ in Thousands	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017	Dec. 31, 2016
Income Statement [Abstract]
Revenue from services	$ 816,484	$ 865,048	$ 833,537
Operating expenses:
Direct operating expenses	606,921	636,462	611,802
Selling, general, and administrative expenses	180,230	187,435	179,820
Bad debt expense	2,204	1,828	593
Depreciation and amortization	11,780	10,174	9,182
Acquisition-related contingent consideration	2,557	44	814
Acquisition and integration costs	491	1,975	78
Restructuring costs	2,758	1,026	753
Impairment charges	22,423	14,356	24,311
Total operating expenses	829,364	853,300	827,353
(Loss) income from operations	(12,880)	11,748	6,184
Other expenses (income):
Interest expense	5,654	4,214	6,106
Gain on derivative liability	0	(1,581)	(5,805)
Loss on early extinguishment of debt	79	4,969	1,568
Other income, net	(418)	(155)	(230)
(Loss) income before income taxes	(18,195)	4,301	4,545
Income tax benefit	(2,478)	(34,501)	(4,186)
Consolidated net (loss) income	(15,717)	38,802	8,731
Less: Net income attributable to noncontrolling interest in subsidiary	1,234	1,289	764
Net (loss) income attributable to common shareholders	$ (16,951)	$ 37,513	$ 7,967
Net (loss) income per share attributable to common shareholders - Basic (usd per share)	$ (0.48)	$ 1.07	$ 0.25
Net (loss) income per share attributable to common shareholders - Diluted (usd per share)	$ (0.48)	$ 1.01	$ 0.15
Weighted average common shares outstanding—basic (shares)	35,657	35,018	32,132
Weighted average common shares outstanding—diluted (shares)	35,657	36,166	36,246

CONSOLIDATED STATEMENTS OF COMPREHENSIVE INCOME - USD ($) $ in Thousands	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017	Dec. 31, 2016
Statement of Comprehensive Income [Abstract]
Consolidated net (loss) income	$ (15,717)	$ 38,802	$ 8,731
Other comprehensive (loss) income, before income tax:
Unrealized foreign currency translation (loss) gain	(153)	75	(34)
Unrealized loss on interest rate contracts	(420)	0	0
Reclassification adjustment to interest expense	186	0	0
Other comprehensive (loss) income, before income tax:	(387)	75	(34)
Other Comprehensive Income (Loss), Tax1 [Abstract]
Income tax benefit related to foreign currency translation adjustments	(31)	0	0
Income tax benefit related to unrealized loss on interest rate contracts	(107)	0	0
Income tax expense related to reclassification adjustment to interest expense	48	0	0
Taxes on other comprehensive (loss) income:	(90)	0	0
Other comprehensive (loss) income, net of tax	(297)	75	(34)
Comprehensive (loss) income	(16,014)	38,877	8,697
Less: Net income attributable to noncontrolling interest in subsidiary	1,234	1,289	764
Comprehensive (loss) income attributable to common shareholders	$ (17,248)	$ 37,588	$ 7,933

CONSOLIDATED STATEMENTS OF STOCKHOLDERS' EQUITY - USD ($) $ in Thousands	Total	Common Stock	Additional Paid-In Capital	Accumulated Other Total Comprehensive Loss, net	(Accumulated Deficit) Retained Earnings	Noncontrolling Interest in Subsidiary
Beginning Balance (in shares) at Dec. 31, 2015		31,952,000
Beginning Balance at Dec. 31, 2015	$ 141,344	$ 3	$ 254,108	$ (1,207)	$ (112,056)	$ 496
Increase (Decrease) in Stockholders' Equity [Roll Forward]
Exercise of share options (in shares)		103,000
Vesting of restricted stock and performance stock awards (in shares)		284,000
Vesting of restricted stock and performance stock awards	(917)		(917)
Equity compensation	$ 3,379		3,379
Stock repurchase and retirement (in shares)	0
Foreign currency translation adjustment, net of taxes	$ (34)			(34)
Distribution to noncontrolling shareholder	(701)					(701)
Net (loss) income	8,731				7,967	764
Ending Balance (in shares) at Dec. 31, 2016		32,339,000
Ending Balance at Dec. 31, 2016	151,802	$ 3	256,570	(1,241)	(104,089)	559
Increase (Decrease) in Stockholders' Equity [Roll Forward]
Exercise of share options (in shares)		41,000
Vesting of restricted stock and performance stock awards (in shares)		282,000
Vesting of restricted stock and performance stock awards	(1,774)		(1,774)
Shares issued for Convertible Notes (in shares)		3,176,000
Shares issued for Convertible Notes	45,952	$ 1	45,951
Equity compensation	$ 4,080		4,080
Stock repurchase and retirement (in shares)	0
Cumulative-effect adjustment - share-based compensation			535		(535)
Foreign currency translation adjustment, net of taxes	$ 75			75
Distribution to noncontrolling shareholder	(1,218)					(1,218)
Net (loss) income	38,802				37,513	1,289
Ending Balance (in shares) at Dec. 31, 2017		35,838,000
Ending Balance at Dec. 31, 2017	$ 237,719	$ 4	305,362	(1,166)	(67,111)	630
Increase (Decrease) in Stockholders' Equity [Roll Forward]
Exercise of share options (in shares)	40,500	21,000
Vesting of restricted stock and performance stock awards (in shares)		199,000
Vesting of restricted stock and performance stock awards	$ (889)		(889)
Equity compensation	3,575		3,575
Stock repurchase and retirement (in shares)		(432,439)
Stock repurchase and retirement	(5,000)	$ (5,000)	(5,000)
Foreign currency translation adjustment, net of taxes	(121)			(121)
Net change in hedging transaction, net of taxes	(175)			(175)
Distribution to noncontrolling shareholder	(1,194)					(1,194)
Net (loss) income	(15,717)				(16,951)	1,234
Ending Balance (in shares) at Dec. 31, 2018		35,626,000
Ending Balance at Dec. 31, 2018	$ 218,198	$ 4	$ 303,048	$ (1,462)	$ (84,062)	$ 670

CONSOLIDATED STATEMENTS OF CASH FLOWS - USD ($) $ in Thousands	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017	Dec. 31, 2016
Cash flows from operating activities
Consolidated net (loss) income	$ (15,717)	$ 38,802	$ 8,731
Adjustments to reconcile net (loss) income to net cash provided by operating activities:
Depreciation and amortization	11,780	10,174	9,182
Amortization of debt discount and debt issuance costs	448	651	1,728
Provision for allowances	5,974	4,705	4,034
Deferred income tax benefit	(3,410)	(33,812)	(5,322)
Gain on derivative liability	0	(1,581)	(5,805)
Impairment charges	22,423	14,356	24,311
Loss on early extinguishment of debt	79	4,969	1,568
Equity compensation	3,575	4,080	3,379
Other non-cash costs	3,231	68	775
Changes in operating assets and liabilities:
Accounts receivable	2,820	9,708	(30,781)
Prepaid expenses and other assets	(2,514)	1,816	(1,882)
Accounts payable and accrued expenses	(7,095)	(9,275)	20,370
Other liabilities	(597)	847	(143)
Net cash provided by operating activities	20,997	45,508	30,145
Cash flows from investing activities
Proceeds from sale of business	0	0	500
Acquisitions, net of cash acquired	(1,930)	(85,977)	(1,900)
Acquisition-related settlements	(151)	(292)	(1,858)
Purchases of property and equipment	(4,597)	(5,111)	(6,522)
Net cash used in investing activities	(6,678)	(91,380)	(9,780)
Cash flows from financing activities
Proceeds from Term Loans	0	62,000	40,000
Principal payments on Term Loans	(16,124)	(1,500)	(30,500)
Convertible Note cash payment	0	(5,000)	0
Borrowings on revolving credit facility	0	39,000	59,800
Repayments on revolving credit facility	0	(39,000)	(67,800)
Debt issuance costs	(308)	(901)	(1,182)
Extinguishment fees	0	(578)	(641)
Stock repurchase and retirement	(5,000)	0	0
Other	(2,335)	(3,265)	(1,841)
Net cash (used in) provided by financing activities	(23,767)	50,756	(2,164)
Effect of exchange rate changes on cash	(70)	23	(24)
Change in cash and cash equivalents	(9,518)	4,907	18,177
Cash and cash equivalents at beginning of year	25,537	20,630	2,453
Cash and cash equivalents at end of year	16,019	25,537	20,630
Supplemental disclosure of cash flow information:
Interest paid	6,340	3,408	3,893
Income taxes paid	$ 1,043	$ 697	$ 1,773

Organization and Basis of Presentation	12 Months Ended
Organization and Basis of Presentation	Dec. 31, 2018
Organization, Consolidation and Presentation of Financial Statements [Abstract]
Organization and Basis of Presentation	Organization and Basis of Presentation Nature of Business Cross Country Healthcare, Inc. (the Company) was incorporated in Delaware on July 29, 1999 as a business providing travel nurse and allied health staffing services. As of December 31, 2018, the Company is a leading national provider of nurse and allied staffing, recruiting, and value-added workforce solution services, multi-specialty locum tenens (temporary physician staffing) services, as well as a provider of other human capital management services focused on healthcare. The consolidated financial statements include the accounts of the Company and its direct and indirect wholly-owned subsidiaries. The consolidated financial statements include all assets, liabilities, revenue, and expenses of Cross Country Talent Acquisition Group, LLC (formerly InteliStaf of Oklahoma, LLC), which is controlled by the Company but not wholly owned. The Company records the ownership interest of the noncontrolling shareholder as noncontrolling interest in subsidiary. All intercompany transactions and balances have been eliminated in consolidation. Certain prior year amounts have been reclassified to conform to the current year presentation. See consolidated balance sheets and consolidated statements of cash flows. Liquidity and Operations Based upon current projections, the Company will not satisfy the required leverage ratio under its Credit Agreement as of March 31, 2019. As a result, a debt prepayment of between $10 million and $12 million would be required to remain in compliance. The Company believes such prepayment will be sufficient to maintain compliance with the leverage ratio covenant and meet its obligations for the next twelve months. In the event actual results differ significantly from current projections, the Company may be required to make additional debt prepayments. Further, the Company may be able to amend its Credit Agreement, and as a result, would not be required to make any debt prepayments.

Summary of Significant Accounting Policies

12 Months Ended

Dec. 31, 2018

Accounting Policies [Abstract]

Summary of Significant Accounting Policies

Use of Estimates

The preparation of consolidated financial statements in conformity with United States generally accepted accounting principles (U.S. GAAP), requires management to make estimates and assumptions that affect the reported amounts in the consolidated financial statements and accompanying notes. Significant estimates and assumptions are used for, but not limited to: (1) the valuation of accounts receivable; (2) goodwill, trade names, and other intangible assets; (3) other long-lived assets; (4) share-based compensation; (5) accruals for health, workers’ compensation, and professional liability claims; (6) valuation of deferred tax assets; (7) purchase price allocation; (8) fair value of interest rate swap agreement; (9) legal contingencies; (10) contingent considerations; (11) income taxes; and (12) sales and other non-income tax liabilities. Accrued insurance claims and reserves include estimated settlements from known claims and actuarial estimates for claims incurred but not reported. Actual results could differ from those estimates.

Cash and Cash Equivalents

The Company considers all investments with original maturities of three months or less to be cash and cash equivalents. The Company invests its excess cash in highly rated overnight funds and other highly rated liquid accounts. The Company is exposed to credit risk associated with these investments. The Company minimizes its credit risk relating to these positions by monitoring the financial condition of the financial institutions involved and by primarily conducting business with large, well established financial institutions, and diversifying its counterparties. The Company does not currently anticipate nonperformance by any of its significant counterparties.

Interest income on cash and cash equivalents of $0.4 million for the year ended December 31, 2018, and $0.1 million for the years ended December 31, 2017 and 2016, is included in other income, net, on the Company’s consolidated statements of operations.

Accounts Receivable, Allowance for Doubtful Accounts, and Concentration of Credit Risk

Accounts receivable potentially subject the Company to concentrations of credit risk. The Company’s customers are primarily healthcare providers, and accounts receivable represent amounts due from them. The Company generally does not require collateral and mitigates its credit risk by performing credit evaluations and monitoring at-risk accounts. The allowance for doubtful accounts represents the Company’s estimate of uncollectible receivables resulting from the inability of its customers to make required payments, which results in a provision for bad debt expense. The adequacy of this allowance is determined by continually evaluating individual customer receivables, considering the customer's financial condition, credit history, and current economic conditions. The Company writes off specific accounts based on an ongoing review of collectability as well as past experience with the customer. In addition, the Company maintains a sales allowance for customer disputes which may arise in the ordinary course, which is recorded as contra-revenue. Historically, losses on uncollectible accounts and sales allowances have not exceeded our allowances.

The Company’s contract terms typically require payment between 15 to 60 days from the date of invoice and are considered past due based on the particular negotiated contract terms. The majority of the Company's business activity is with hospitals located throughout the United States. No single customer accounted for more than 10% of the Company’s accounts receivable balance as of December 31, 2018 and 2017, or revenue for the years ended December 31, 2018, 2017, and 2016.

Prepaid Rent and Deposits

The Company leases apartments for eligible field employees under short-term agreements (typically three to six months), which generally coincide with each employee’s staffing contract. Costs relating to these leases are included in direct operating expenses on the accompanying consolidated statements of operations. As a condition of these agreements, the Company may place security deposits on the leased apartments. Deposits on field employees’ apartments related to these short-term agreements are included in other current assets on the accompanying consolidated balance sheets.

Property and Equipment

Property and equipment are stated at cost, less accumulated depreciation. Depreciation is determined on a straight-line basis over the estimated useful lives of the assets, which generally range from three to seven years. Leasehold improvements are depreciated over the shorter of their estimated useful life or the term of the individual lease. On an annual basis, the Company reviews its property and equipment listings and disposes of assets that are no longer in use.

Certain software development costs have been capitalized in accordance with the provisions of the Intangibles-Goodwill and Other/Internal-Use Software Topic of the Financial Accounting Standards Board (FASB) Accounting Standards Codification (ASC). Such costs include charges for consulting services and costs for Company personnel associated with programming, coding, and testing such software. Amortization of capitalized software costs begins when the software is ready for use and is included in depreciation expense in the accompanying consolidated statements of operations. Software development costs are being amortized using the straight-line method over three to five years.

Business Combinations

The Company applies accounting in accordance with the Business Combinations Topic of the FASB ASC when it acquires control over a business. Business combinations are accounted for at fair value. The associated acquisition costs are expensed as incurred and recorded as acquisition and integration costs; noncontrolling interests, if any, are reflected at fair value at the acquisition date; restructuring costs associated with a business combination are expensed; contingent consideration is measured at fair value at the acquisition date, with changes in the fair value after the acquisition date affecting earnings; and goodwill is determined as the excess of the fair value of the consideration conveyed in the acquisition over the fair value of the net assets acquired. The accounting for business combinations requires estimates and judgments as to expectations for future cash flows of the acquired business, and the allocation of those cash flows to identifiable intangible assets, in determining the estimated fair value for assets and liabilities acquired. The fair values assigned to tangible and intangible assets acquired and liabilities assumed are based on management's estimates and assumptions, including valuations that utilize customary valuation procedures and techniques. If the actual results differ from the estimates and judgments used in these estimates, the amounts recorded in the financial statements could result in a possible impairment of the intangible assets and goodwill, or require acceleration of the amortization expense of finite-lived intangible assets. The results of the acquired businesses' operations are included in the consolidated statements of operations of the combined entity beginning on the date of acquisition. See Note 4 - Acquisitions.

Goodwill, Trade Names, and Other Intangible Assets

Goodwill represents the excess of purchase price and related costs over the fair value assigned to the net tangible and identifiable intangible assets of businesses acquired. Other identifiable intangible assets with definite lives are being amortized using the straight-line method over their estimated useful lives which range from 1 to 16 years. Goodwill and certain intangible assets with indefinite lives are not amortized. Instead, in accordance with the Intangibles-Goodwill and Other Topic of the FASB ASC, these assets are reviewed for impairment annually at the beginning of the fourth quarter, and whenever circumstances change that would more likely than not reduce the fair value of a reporting unit below its carrying amount.

When reviewed, the Company has the option to first assess qualitative factors to determine whether it is more likely than not that the fair value of a reporting unit is less than its carrying amount, as a basis for determining whether it is necessary to perform the quantitative testing. If it is determined that a quantitative test is necessary or more efficient than a qualitative approach, the Company generally measures the fair value of its reporting units using a combination of income and market approaches.

For the periods prior to the fourth quarter of 2017, the performance of the quantitative impairment test involved a two-step process. The first step required the Company to determine the fair value of each of its reporting units and compare it to the reporting unit’s carrying amount. If the reporting unit's fair value was less than its carrying amount, the Company was required to perform a second step to calculate the implied value of goodwill. The implied value was then compared to its carrying amount to calculate the impairment charge, if any.

Beginning in the fourth quarter of 2017, for its annual review on October, 1, 2017, the Company early adopted the provisions of Accounting Standards Update (ASU) 2017-04, Intangibles-Goodwill and Other (Topic 350): Simplifying the Test for Goodwill Impairment. Under ASU 2017-04, the second step of the quantitative assessment is eliminated, and, if the reporting unit’s carrying value exceeds its fair value, an impairment charge is recognized for the amount by which the carrying amount exceeds the reporting unit’s fair value not to exceed the total amount of goodwill allocated to that reporting unit. Additionally, income tax effects from any tax deductible goodwill on the carrying amount of the reporting unit when measuring the goodwill impairment loss is considered, if applicable.

The Company determines its reporting units by identifying its operating segments and any component businesses and aggregates the components businesses if they have similar economic characteristics. The Company had the following reporting units that it reviewed for impairment: 1) Nurse and Allied Staffing; 2) Physician Staffing; and 3) Search.

Management considers historical experience and all available information at the time the fair values of its reporting units are estimated. However, fair values that could be realized in an actual transaction may have differed from those used to evaluate the potential impairment of goodwill.

Long-lived assets and identifiable intangible assets with definite lives are evaluated for impairment in accordance with the Property, Plant, and Equipment Topic of the FASB ASC. In accordance with this Topic, long-lived assets and definite-lived intangible assets are reviewed for impairment whenever events or changes in circumstances indicate the carrying amount may not be recoverable.

Recoverability of long-lived assets is measured by a comparison of the carrying amount of the asset group to the future undiscounted net cash flow that is expected to be generated by those assets. If such assets are considered to be impaired, the impairment charge recognized is the amount by which the carrying amount of the assets exceeds the fair value of the assets.

Any related impairment losses are recognized in earnings and included in the caption impairment charges on the consolidated statements of operations. See Note 5 - Goodwill, Trade Names, and Other Intangible Assets.

Debt Discount and Debt Issuance Costs

Stated discounts on proceeds, and other fees reimbursed to lender, as well as the initial value of any embedded derivative features of the Convertible Notes and Term Loans, as defined in Note 8 - Debt, are treated as a discount associated with the respective debt instrument and presented in the balance sheet as an offset to the carrying amount of the debt. Discounts are amortized to interest expense using the effective interest rate method, or a method that approximates the effective interest rate method, over the expected life of the debt.

Deferred costs related to the issuance of the Convertible Notes and the Term Loans were capitalized and are presented in the balance sheet as a direct deduction from the carrying amount of the debt liability. Deferred costs are amortized using the effective interest method. Deferred costs related to the Convertible Notes were written off in connection with the repayment of such Convertible Notes. See Note 8 - Debt.

Deferred costs related to the issuance of the Company’s Revolving Credit Facilities, as defined in Note 8 - Debt, have been capitalized and included in other assets on the consolidated balance sheets, and amortized using the straight line method over the term of the related credit agreement.

Derivative Financial Instruments

The Company is exposed to interest rate risk due to its outstanding senior secured term loan entered into on August 1, 2017 with a variable interest rate. As a result, the Company has entered into an interest rate swap agreement to effectively convert a portion of its variable interest payments to a fixed rate. The principal objective of the interest rate swap is to eliminate or reduce the variability of the cash flows in those interest payments associated with the Company’s long-term debt, thus reducing the impact of interest rate changes on future interest payment cash flows. The Company has determined that the interest rate swap qualifies as a cash flow hedge in accordance with ASC 815, Derivatives and Hedging. As the critical terms of the hedging instrument and the hedged forecasted transaction are the same, the Company has concluded that changes in the cash flows attributable to the risk being hedged are expected to completely offset at inception and on an ongoing basis. Changes in the fair value of an interest rate swap agreement designated as a cash flow hedge are recorded as a component of accumulated other comprehensive income (loss), net of deferred taxes, within stockholders’ equity and are amortized to interest expense over the term of the related debt as the interest payments are made. Interest rate swap payments are included in net cash provided by operating activities on the Company’s consolidated statement of cash flows.

In conjunction with entering into the interest rate swap agreement, the Company early adopted ASU 2017-12, Derivative and Hedging (Topic 815) to simplify the application of hedge accounting. See Note 9 - Derivatives.

The Company evaluates embedded conversion features within its convertible debt in accordance with the Derivatives and Hedging Topic of the FASB ASC to determine whether the embedded conversion feature should be bifurcated from the host instrument and accounted for as a derivative at fair value. Changes in the fair value of these derivatives during each reporting period were reported in other expenses (income) on the consolidated statements of operations. The fair value at inception had been recorded as debt discount and was being amortized to interest expense over the term of the note using the effective interest method. On March 17, 2017, the Company paid in full its Convertible Notes and, as a result, derecognized the derivative liability. See Note 8 - Debt.

Sales and Other State Non-income Tax Liabilities

The Company accrues sales and other state non-income tax liabilities based on the Company’s best estimate of its probable liability utilizing currently available information and interpretation of relevant tax regulations. Given the nature of the Company’s business, significant subjectivity exists as to both whether sales and other state non-income taxes can be assessed on its activity and how the sales tax will ultimately be measured by the relevant jurisdictions. The Company makes a determination for each reporting period whether the estimates for sales and other non-income taxes in certain states should be revised.

Insurance Claims

The Company provides workers’ compensation insurance coverage, professional liability coverage, and healthcare benefits for eligible employees. The Company records its estimate of the ultimate cost of, and reserves for, workers' compensation and professional liability benefits based on actuarial models prepared or reviewed by an independent actuary using the Company’s loss history as well as industry statistics. The healthcare insurance accrual is for estimated claims that have occurred but have not been reported and is based on the Company’s historical claim submission patterns. Furthermore, in determining its reserves, the Company includes reserves for estimated claims incurred but not reported as well as unfavorable claims development.

The Other Expenses/Insurance Costs Topic of the FASB ASC previously issued authoritative accounting guidance in the area of insurance contracts and related activity thereto. This topic concluded that, under circumstances such as in the Company’s insured professional liability and workers' compensation policies, since a right of legal offset does not exist due to the fact that there are three parties to an incurred claim, the insured, the insurer, and the claimant, the related liability to the claimant should be classified separately on a gross basis with a separate related receivable from the insurer recognized as being due from insurance carriers. Accordingly, the Company’s consolidated balance sheets as of December 31, 2018 and 2017 reflect the related short-term liabilities in accrued compensation and benefits and the related long-term liabilities as long-term accrued claims, and the short-term receivable portion as insurance recovery receivable and the long-term portion as non-current insurance recovery receivable. See Note 7 - Balance Sheet Details. The ultimate cost of workers’ compensation, professional liability, and health insurance claims will depend on actual amounts incurred to settle those claims and may differ from the amounts reserved by the Company for those claims.

Workers’ compensation benefits are provided under a partially self-insured plan. The Company has letters of credit to guarantee payments of claims. At December 31, 2018 and 2017, the Company had outstanding approximately $18.8 million and $19.6 million, respectively, of standby letters of credit as collateral to secure the self-insured portion of this plan.

The Company has occurrence-based primary professional liability policies that provide the Company and each working professional in its nurse and allied healthcare business with coverage. Effective January 1, 2016, the Company has a claims-made professional liability policy for its physicians and advanced practitioners, with a $0.5 million self-insured retention per claim. Prior to January 1, 2016, the Company had an occurrence-based professional liability policy for its independent contractor physicians and advanced practitioners which was insured by a wholly-owned subsidiary, Jamestown Indemnity, Ltd., a wholly-owned Cayman Island captive company (the Captive), until its voluntary liquidation in the third quarter of 2015. Beginning in March 2015, the Company's Physician subsidiary self-insured $0.5 million for each of its professional liability claims. Under the terms of the Captive’s reinsurance policy there was a requirement to guarantee the payment of claims to its insured party’s primary medical malpractice insurance carrier via a letter of credit. As a result of the Captive's liquidation, the letter of credit was reduced. As of December 31, 2018 and 2017, the value of the letter of credit was $1.8 million and $2.0 million, respectively.

Subject to certain limitations, the Company also has umbrella liability coverage for its working nurses and allied healthcare professionals. While this umbrella coverage does not extend to professional liability claims against its independent contractor physicians and advanced practitioners, it does cover claims brought against all of the Company’s subsidiaries for non-patient general liability.

Revenue Recognition

In the first quarter of 2018, the Company adopted ASU No. 2014-09, Revenue from Contracts with Customers (Topic 606). ASU 2014-09 introduces a new five-step revenue recognition model in which an entity recognizes revenue when its customer obtains control of promised goods or services, in an amount that reflects the consideration to which the entity expects to be entitled in exchange for those goods or services. The new standard also requires additional disclosures about the nature, amount, timing, and uncertainty of revenue and cash flows arising from customer contracts. See Note 3 - Revenue Recognition for additional accounting policy and related disclosures. The Company elected to adopt the standard using a modified retrospective method, which only impacts contracts not completed as of December 31, 2017.

Revenue from the Company’s services is recognized when control of the promised services are transferred to the Company’s customers, in an amount that reflects the consideration it expects to receive in exchange for the service. The Company has concluded that transfer of control of its staffing services, which represents the majority of its revenues, occurs over time as the services are provided, which is consistent with revenue recognition under the prior guidance.

The following is a description of the nature, amount, timing, and uncertainty of revenue and cash flows from which the Company generates revenue.

Temporary Staffing Revenue

Revenue from temporary staffing is recognized as control of the services is transferred over time, and is based on hours worked by the Company’s field staff. The Company recognizes the majority of its revenue at the contractual amount the Company has the right to invoice for services completed to date. Generally, billing to customers occurs weekly, bi-weekly, or monthly and is aligned with the payment of services to the temporary staff, with payment terms of 15 to 60 days. Accounts receivable includes estimated revenue for employees’ and independent contractors’ time worked but not yet invoiced. At December 31, 2018 and December 31, 2017, the Company's estimate of amounts that had been worked but had not been billed totaled $44.1 million and $41.8 million, respectively, and are included in accounts receivable on the consolidated balance sheets.

Other Service Revenue

The Company offers other optional services to its customers that are transferred over time including: managed service programs (MSP) providing agency services (as further described below in Gross versus Net Policies), recruitment process outsourcing (RPO), other outsourcing services, and retained search services, which is less than 5% of its consolidated revenue for the years ended December 31, 2018, 2017, and 2016. Generally, billing and payment terms for MSP agency services is consistent with temporary staffing as the customers are similar or the same. Revenue from these services are recognized based on the contractual amount for services completed to date which best depicts the transfer of control of services.

For the Company’s RPO, other outsourcing, and retained search services, revenue is generally recognized in the amount to which the entity has a right to invoice which corresponds directly with the value to the customer. The Company does not, in the ordinary course of business, offer warranties or refunds.

Gross Versus Net Policies

The Company records revenue on a gross basis as a principal or on a net basis as an agent depending on the contracted arrangement, as follows:

Managed Service Programs

The Company has certain contracts with healthcare facilities to provide comprehensive services through its MSPs. Under these contractual arrangements, the customer’s orders are filled with either one of the Company's healthcare professionals or a third party's healthcare professionals (subcontractors).

When its healthcare professional is staffed, the Company determined that it acts as a principal in the arrangement, as it is considered the employer of record. Accordingly, revenue is reported on a gross basis on the consolidated statements of operations.

Alternatively, the Company determined that it acts as an agent in the arrangement when a subcontracted healthcare professional is staffed, as the Company does not control the services before they are transferred to the customer. Accordingly, revenue is reported on a net basis on the consolidated statements of operations. The customer is invoiced for the hours worked by the subcontracted healthcare professional multiplied by the hourly bill rate. A subcontractor liability, which is recognized as a reduction of revenue, is established in accrued expenses for the invoiced amount, net of an administrative fee, and is generally payable after the Company has received payment from its customer. The Company’s administrative fee is calculated as a percentage of the customer’s invoice and is recognized over time as the services are rendered by the subcontracted healthcare professional. The Company does not collect or recognize an upfront placement fee.

Physician Staffing

The Physician Staffing business has contracts with its healthcare customers to provide temporary staffing services. The Company uses independent contractors for these services. The Company determined that it acts as a principal in these arrangements and, therefore, revenue is reported on a gross basis on the consolidated statements of operations.

See Note 3 - Revenue Recognition for the Company's revenues disaggregated by revenue source. Sales and usage-based taxes are excluded from revenue.

Contract Costs

All contract fulfillment costs are expensed as incurred to direct operating expenses. With respect to FASB ASC 606, Revenue from Contracts with Customers, there were no contract assets or material contract liabilities as of December 31, 2018 and 2017.

Practical Expedients and Exemptions

For the Company’s contracts that have an original duration of one year or less, the Company uses the practical expedients and has elected to recognize any incremental costs of obtaining these contracts as expensed when incurred. Further, the Company does not disclose the value of unsatisfied performance obligations for: (i) contracts with an original expected length of one year or less, and (ii) contracts for which it recognizes revenue at the amount to which it has the right to invoice for services performed.

Share-Based Compensation

The Company has, from time to time, granted stock options, stock appreciation rights, performance-based stock awards, and restricted stock for a fixed number of common shares to employees. In accordance with the Compensation-Stock-Compensation Topic of the FASB ASC, companies may choose from alternative valuation models. The Company used the Black-Scholes method of valuing its options and stock appreciation rights. The Company has elected to recognize compensation expense on a straight-line basis over the requisite service period of the entire award. The Company values its restricted stock awards and the fair value of its performance-based stock awards by reference to its stock price on the date of grant.

The Company granted performance-based stock awards to certain key personnel pursuant to its 2014 Omnibus Incentive Plan, amended and restated on May 23, 2017 (2017 Plan) as described in Note 14 - Stockholders' Equity. Pursuant to the plan, the number of target shares that vest are determined based on the level of attainment of the targets. If a minimum level of performance is attained for the awards, restricted stock is issued based on the level of attainment. The Company recognizes performance-based restricted stock as compensation expense based on the most likely probability of attaining the prescribed performance and over the requisite service period beginning at its grant date and through the date the restricted stock vests.

Compensation expense related to share-based payments is included in selling, general and administrative expenses in the consolidated statements of operations, and totaled $3.6 million, $4.1 million, and $3.4 million, during the years ended December 31, 2018, 2017, and 2016, respectively. See Note 14 - Stockholders’ Equity.

Advertising

The Company’s advertising expense consists primarily of online advertising, internet direct marketing, print media, and promotional material. Advertising costs are expensed as incurred and totaled $6.7 million, $7.6 million, and $10.2 million, for the years ended December 31, 2018, 2017, and 2016, respectively.

Restructuring Costs

The Company considers restructuring activities to be programs whereby it fundamentally changes its operations, such as closing and consolidating facilities, reducing headcount, and realigning operations in response to changing market conditions. As a result, restructuring costs on the consolidated statements of operations include on-going benefit costs for its employees, exit costs, and other costs including write-offs related to abandoned locations.

Reconciliations of the beginning and ending total restructuring liability balances are presented below:



	Year Ended December 31,
	2018						2017						2016
	(amounts in thousands)
	On-Going Benefit Costs			Exit Costs			On-Going Benefit Costs			Exit Costs			On-Going Benefit Costs			Exit Costs
Balance at beginning of period	$	87		$	441		$	325		$	273		$	44		$	338
Charged to restructuring costs (a)	1,600			184			522			504			563			190
Payments	(1,131		)	(235		)	(760		)	(336		)	(282		)	(255		)
Balance at end of period	$	556		$	390		$	87		$	441		$	325		$	273

________________

(a) The restructuring costs on the consolidated statements of operations include direct write-offs of $0.4 million related to abandoned locations, as well as other costs of $0.5 million.

Deferred Rent

Deferred rent consists of free rent, rent escalation, tenant improvement allowances, and other incentives received from landlords related to the operating leases for our facilities. Rent escalation represents the difference between actual operating lease payments due and straight-line rent expense, which we record over the term of the lease. The excess is recorded as a deferred credit in the early periods of the lease, when cash payments are generally lower than straight-line rent expense, and is reduced in the later periods of the lease when payments begin to exceed the straight-line expense. Tenant allowances from landlords for tenant improvements are generally comprised of cash received from the landlord or paid on our behalf as part of the negotiated terms of the lease. These tenant improvement allowances and other leasehold incentives are recorded when realizable as deferred rent and are amortized as a reduction of periodic rent expense, over the term of the applicable lease. See Note 12 - Commitments and Contingencies.

Income Taxes

The Company accounts for income taxes under the Income Taxes Topic of the FASB ASC. Deferred income tax assets and liabilities are determined based upon differences between the financial reporting and tax basis of assets and liabilities, and are measured using the enacted tax rates and laws that will be in effect when the differences are expected to reverse.

The Company recognizes in its financial statements the impact of a tax position if that position is more likely than not of being sustained on audit, based on the technical merits of the position. The Company recognizes interest and penalties related to unrecognized tax benefits in the provision for income taxes.

The Company maintains valuation allowances when it is more likely than not that all or a portion of a deferred tax asset will not be realized. In determining whether a valuation allowance is warranted, the Company evaluates factors such as prior earnings history, expected future earnings, carryback and carryforward periods, and tax strategies. The Company considers all positive and negative evidence to estimate if sufficient future taxable income will be generated to realize the deferred tax asset. It considers cumulative losses in recent years as well as the impact of one-time events in assessing its pre-tax earnings. Assumptions regarding future taxable income require significant judgment. The Company's assumptions are consistent with estimates and plans used to manage its business, which includes restructuring and other initiatives.

In the event that actual results differ from these estimates, or the Company adjusts these estimates in future periods for current trends or changes in its estimating assumptions, it may modify the level of the valuation allowance which could materially impact its business, financial condition and results of operations. The Company will continue to assess the realizability of its deferred tax assets. See Note 13 - Income Taxes.

Comprehensive Income (Loss)

Total comprehensive income (loss) includes net income or loss, foreign currency translation adjustments, and net change in derivative transactions, net of any related deferred taxes. Certain of the Company’s foreign subsidiaries use their respective local currency as their functional currency. In accordance with the Foreign Currency Matters Topic of the FASB ASC, assets and liabilities of these operations are translated at the exchange rates in effect on the balance sheet date. Income statement items are translated at the average exchange rates for the period. The cumulative impact of currency fluctuations related to the balance sheet translation is included in accumulated other comprehensive loss in the accompanying consolidated balance sheets and was an unrealized loss of $1.3 million at December 31, 2018 and $1.2 million at December 31, 2017. The cumulative impact of net changes in derivative instruments included in other comprehensive loss in the consolidated balance sheets was an unrealized loss of $0.2 million at December 31, 2018. See Note 9 - Derivatives.

The income tax impact related to components of other comprehensive income for the period ended December 31, 2018 is reflected on the consolidated statements of comprehensive income. During the period ended December 31, 2017, $0.2 million of income tax expense was included in the consolidated statements of operations due to the impact of a change in federal tax rate on the deferred tax asset related to foreign currency cumulative translation. See Note 13 - Income Taxes. There was no income tax impact related to foreign currency translation adjustments for the period ended December 31, 2016.

Fair Value Measurements

The Company complies with the provisions of the Fair Value Measurements and Disclosures Topic of the FASB ASC, which defines fair value, establishes a framework for measuring fair value under U.S. GAAP, and expands disclosures about fair value measurements. As of December 31, 2018 and 2017, the Company’s financial assets and liabilities required to be measured on a recurring basis were its deferred compensation liability, its interest rate swap agreements, and its contingent consideration liabilities. See Note 10 - Fair Value Measurements.

Earnings Per Share

In accordance with the requirements of the Earnings Per Share Topic of the FASB ASC, basic earnings per share is computed by dividing net income available to common shareholders (numerator) by the weighted average number of vested unrestricted common shares outstanding during the period (denominator). Diluted earnings per share gives effect to all dilutive potential common shares outstanding during the period including stock appreciation rights and options and unvested restricted stock, as calculated utilizing the treasury stock method, and Convertible Notes using the if-converted method prior to their payment in full in the first quarter of 2017.

Recent Accounting Pronouncements

In August 2018, the FASB issued ASU No. 2018-15, Intangibles - Goodwill and Other - Internal-Use Software (Subtopic 350-40), Customer's Accounting for Implementation Costs Incurred in a Cloud Computing Arrangement That is a Service Contract. The amendments in this update align the requirements for capitalizing implementation costs incurred in a hosting arrangement that is a service contract with the requirements for capitalizing implementation costs incurred to develop or obtain internal-use software (and hosting arrangements that include an internal use software license). The amendments in this update are effective for public business entities for fiscal years beginning after December 15, 2019, and interim periods within those fiscal years, and should be applied either retrospectively or prospectively to all implementation costs incurred after the date of adoption. Early adoption is permitted for all entities, including adoption in an interim period. The Company is currently in the process of evaluating the potential impact the adoption of this standard may have and expects to adopt this standard in its first quarter of 2020.

In August 2018, the FASB issued ASU No. 2018-13, Fair Value Measurement (Topic 820), Disclosure Framework - Changes to the Disclosure Requirements for Fair Value Measurement. The amendments in this update modify the disclosure requirements on fair value measurements in Topic 820, Fair Value Measurement, based on the concepts in the Concepts Statement, including the consideration of costs and benefits. The amendments in this update are effective for all entities for fiscal years, and interim periods within those fiscal years, beginning after December 15, 2019, and should be applied either prospectively or retrospectively depending on the nature of the disclosure. An entity is permitted to early adopt any removed or modified disclosures upon issuance of this update and delay adoption of the additional disclosures until their effective date. The Company is currently in the process of evaluating this standard and expects to adopt the full provisions in its first quarter of 2020.

In July 2017, the FASB issued ASU No. 2017-11, Earnings Per Share (Topic 260); Distinguishing Liabilities from Equity (Topic 480); and Derivatives and Hedging (Topic 815): I. Accounting for Certain Financial Instruments with Down Round Features, and II. Replacement of the Indefinite Deferral for Mandatorily Redeemable Financial Instruments of Certain Nonpublic Entities and Certain Mandatorily Redeemable Noncontrolling Interests with a Scope Exception. The amendments in Part I of this Update change the classification analysis of certain equity-linked financial instruments (or embedded features) with down round features. When determining whether certain financial instruments should be classified as liabilities or equity instruments, a down round feature no longer precludes equity classification when assessing whether the instrument is indexed to an entity’s own stock. The amendments in Part II of this Update recharacterize the indefinite deferral of certain provisions of Topic 480 that now are presented as pending content in the Codification, to a scope exception. Those amendments do not have an accounting effect. For public business entities, the amendments in Part I of this Update are effective for fiscal years, and interim periods within those fiscal years, beginning after December 15, 2018, and should be applied retrospectively to outstanding financial instruments with a down round feature by means of either a cumulative-effect adjustment or for each prior reporting period presented. Early adoption is permitted for all entities, including adoption in an interim period. The Company expects to adopt this standard in its first quarter of 2019, and does not expect this guidance to have a material impact on its consolidated financial statements.

In February 2016, the FASB issued ASU No. 2016-02, Leases (Topic 842), which will require, among other items, lessees to recognize most leases as assets and liabilities on the balance sheet. Qualitative and quantitative disclosures will be enhanced to better understand the amount, timing and uncertainty of cash flows arising from leases. The FASB has issued several other subsequent updates including the following: 1) ASU No. 2018-10, Codification Improvements to Topic 842, Leases, which includes sixteen separate narrow-scope amendments to clarify the codification and to correct unintended application of guidance; and 2) ASU No. 2018-11, Leases (Topic 842): Targeted Improvements, which provides entities with relief from the costs of implementing certain aspects of the new leasing standard by allowing them to elect not to recast the comparative periods presented when transitioning to ASC 842. The new lease standard, and the subsequent ASUs that modified Topic 842, are effective for fiscal years beginning after December 15, 2018, and interim periods within those fiscal years, with early adoption permitted.

With respect to the adoption of the new standard, as of December 31, 2018, the Company had $34.6 million of undiscounted future lease payments, primarily related to real estate, that is expected to be included in its initial measurement of its lease liabilities and corresponding right of use asset, and $7.2 million of accrued rent that is expected to be reclassified from liability accounts to reduce its beginning right of use asset balance. The Company does not expect the adoption of ASU 2016-02 to have a material impact on its consolidated statements of operations and statements of cash flows.

Acquisitions

12 Months Ended

Dec. 31, 2018

Business Combinations [Abstract]

Acquisitions

American Personnel, Inc.

On December 1, 2018, the Company completed the acquisition of American Personnel, Inc. (AP Staffing) for a total purchase price of $2.0 million, subject to a net working capital adjustment. Based in Boston, AP Staffing offers a range of talent management solutions to its healthcare clients primarily in Massachusetts, including permanent placement, consultative staffing solutions, and traditional staffing.

The Company assigned a total of $0.4 million to definite life intangible assets with a weighted average estimated useful life of 10 years. The remaining excess purchase price over the fair value of net assets acquired of $0.7 million was recorded as goodwill, which is not deductible for tax purposes since this was a stock acquisition. Associated acquisition-related costs incurred were $0.2 million and have been included in acquisition and integration costs on the Company's consolidated statement of operations for the year ended December 31, 2018.

The acquisition was deemed immaterial and has been accounted for in accordance with the Business Combinations Topic of the FASB ASC, using the acquisition method of accounting. AP Staffing's results of operations are included in the consolidated statements of operations from December 1, 2018 and have been included in the Company's Nurse and Allied Staffing business segment. See Note 5 - Goodwill, Trade Names, and Other Intangible Assets.

Advantage RN

Effective July 1, 2017, the Company acquired all of the assets of Advantage RN, LLC and its subsidiaries (collectively, Advantage) for cash consideration of $86.6 million, net of cash acquired. The total purchase price of $88.0 million was subject to a net working capital reduction of $0.6 million at the closing and an additional $0.8 million was received during the third quarter of 2017 as the final adjustment for net working capital. Additionally, $0.6 million of the purchase price was deferred as of the closing and is due the seller within 20 months, less any COBRA and healthcare payments incurred by the Company on behalf of the seller. As of December 31, 2018, approximately $0.5 million has been paid for claims and the remaining $0.1 million liability is included in other current liabilities on the Company’s balance sheets.

Included in the amount paid at closing were two escrow accounts, the first was $14.5 million which related to tax liabilities and the second was $7.5 million which was to cover any post-close liabilities. On July 28, 2017, $7.3 million related to the tax liabilities was released from escrow, leaving a balance of $7.2 million. In the first quarter of 2019, $7.0 million related to the post-close liabilities was released from escrow, leaving a balance of $0.5 million to cover pending post-close liabilities.

The Company financed the purchase using $19.9 million in available cash and $66.9 million in borrowing under its Credit Facility, including a $40.0 million incremental term loan, which was subsequently refinanced on August 1, 2017. See Note 8 - Debt for further information. The transaction was treated as a purchase of assets for income tax purposes.

Advantage is primarily a travel nurse staffing company that deploys many of its nurses through MSPs and Vendor Management Systems, and Advantage maintains direct relationships with many hospitals throughout the United States. This was a strategic acquisition to help the Company fill its recent MSP contract wins and for revenue growth.

The acquisition has been accounted for in accordance with the Business Combinations Topic of the FASB ASC, using the acquisition method of accounting. As such, the amounts of revenue and contribution income included in the Company's consolidated income statement from the acquisition date to the period ended December 31, 2017 were $47.0 million and $3.8 million, respectively. The acquisition results have been substantially aggregated with the Company's Nurse and Allied Staffing business segment. See Note 17 - Segment Data.

The following is the estimated fair value of the purchase price for Advantage on July 1, 2017:



	(amounts in thousands)
Purchase price	$	88,000
Net working capital adjustments	(1,438		)
Cash consideration	86,562
Cash acquired	2,833
Total consideration	$	89,395

The purchase price was allocated to the assets acquired and the liabilities assumed based on the estimated fair value at the date of acquisition. The Company used a third-party appraiser to assist with the determination of the fair value and estimated useful lives of certain acquired assets and liabilities.

The following table is an estimate of the fair value of the assets acquired and liabilities assumed on July 1, 2017.



	(amounts in thousands)
Cash and cash equivalents	$	2,833
Accounts receivable	14,396
Other current assets	392
Property and equipment	333
Goodwill	43,596
Other intangible assets	29,900
Total assets acquired	91,450
Accounts payable and accrued expenses	368
Accrued employee compensation and benefits	1,685
Other current liabilities	2
Total liabilities assumed	2,055
Net assets acquired	$	89,395

The Company assigned the following values to other identifiable intangible assets: $4.5 million to trade names with a weighted average estimated useful life of 10 years, $13.8 million to customer relationships with a weighted average estimated useful life of 10 years, $11.3 million to a database, consisting of healthcare professionals, with a weighted average estimated useful life of 10 years, and $0.3 million to non-compete agreements with a weighted average estimated useful life of 5 years, for a total of $29.9 million in definite life intangible assets with a weighted average estimated useful life of 10 years.

The remaining excess purchase price over the fair value of net assets acquired of $43.6 million was recorded as goodwill, which is deductible for tax purposes. Associated acquisition-related costs incurred were $2.0 million and have been included in acquisition and integration costs on the Company's consolidated statements of operations for the year ended December 31, 2017.

Pro Forma Financial Information

The following unaudited pro forma financial information approximates the consolidated results of operations of the Company as if the Advantage acquisition had occurred as of January 1, 2016, after giving effect to certain adjustments, including additional interest expense on the amount the Company borrowed on the date of the transaction, the amortization of acquired intangible assets, and the elimination of certain expenses that will not be recurring in post-acquisition periods, net of an estimated income tax impact. These adjustments include removing transaction-related expenses of approximately $2.0 million for the year ended December 31, 2017. These results are not necessarily indicative of future results as they do not include incremental investments in support functions, elimination of costs for integration or operating synergies, or an estimate of any impact on interest expense resulting from the operating cash flow of the acquired businesses, among other adjustments that could be made in the future but are not factually supportable on the date of the transaction.



	Year Ended December 31,
	2017		2016
	(unaudited, amounts in thousands except per share data)
Revenue from services	$	916,149	$	934,904

Net income attributable to common shareholders	$	40,255	$	11,391

Net income per common share attributable to common shareholders - basic	$	1.16	$	0.35

Net income per common share attributable to common shareholders - diluted	$	1.09	$	0.25

US Resources Healthcare

On December 1, 2016, the Company completed the acquisition of a recruitment process outsourcing business, US Resources Healthcare, LLC (USR). This acquisition expands the Company's workforce solutions offerings to deliver financial and operating efficiencies through labor optimization services while enhancing the quality of care.

The agreement specified that the sellers were eligible to receive additional purchase price consideration of $4.5 million, with a maximum of $1.0 million for 2017, $2.0 million for 2018, and $1.5 million for 2019, based on attainment of specific performance criteria achieved in each of those years. In the fourth quarter of 2017, the Company recognized a decrease in the fair value of the liability of $1.3 million included as acquisition-related contingent consideration on its consolidated statements of operations. The adjustment was driven by the decrease in the projected USR 2018 and 2019 revenue and EBITDA amounts. The earnout for 2017 was not achieved. In the third quarter of 2018, the Company determined that the contingent consideration earnout related to the USR acquisition would not be achieved for 2018 and 2019 and, as a result, the entire liability was reversed. See Note 10 - Fair Value Measurements.

The acquisition was deemed immaterial and has been accounted for in accordance with the Business Combinations Topic of the FASB ASC, using the acquisition method of accounting. USR's results of operations are included in the consolidated statements of operations from December 1, 2016 and have been included in the Company's Nurse and Allied Staffing business segment. See Note 5 - Goodwill, Trade Names, and Other Intangible Assets and Note 10 - Fair Value Measurements.

Mediscan

On October 30, 2015, the Company completed the acquisition of all of the membership interests of New Mediscan II, LLC, Mediscan Diagnostic Services, LLC, and Mediscan Nursing Staffing, LLC (collectively Mediscan) for a purchase price of $29.9 million in cash ($28.0 million plus working capital estimate) and $4.7 million in shares (or 349,871 shares) of the Company's Common Stock, and a net working capital adjustment of $0.3 million was settled in the first quarter of 2016. Additionally, an amount of $5.0 million of the purchase price that was held in escrow to cover any post-closing liabilities, was released to the sellers on May 3, 2017.

The agreement also specified that the sellers were eligible to receive additional purchase price consideration of $7.0 million, with $3.5 million per year based on attainment of specific performance criteria in 2016 and 2017. As of December 31, 2016, the Company determined that the first year earnout was not achieved for 2016 and, as of September 30, 2017, the Company

determined that the second year earnout would not be achieved for 2017.

In connection with the Mediscan acquisition, the Company also assumed additional contingent purchase price liabilities for a previously acquired business that are payable annually based on specific performance criteria for the 2016 through 2019 years. Payments related to the 2016 through 2018 years are limited to $0.3 million per year and 2019 is uncapped. As of December 31, 2018, the fair value of the remaining obligations was estimated at $7.7 million and is included in other current liabilities and contingent consideration on the consolidated balance sheets. See Note 10 - Fair Value Measurements.

Medical Staffing Network

On June 30, 2014, the Company acquired substantially all of the assets and certain liabilities of Medical Staffing Network Healthcare, LLC (MSN). Of the purchase price, $2.5 million was deferred and due to the seller 21 months from the acquisition date, less any COBRA expenses incurred by the Company on behalf of former MSN employees over that period. The Company incurred $0.4 million in COBRA expenses since the MSN acquisition and, on April 1, 2016, released to the seller the remaining liability of $2.1 million.

Revenue Recognition

12 Months Ended

Dec. 31, 2018

Revenue from Contract with Customer [Abstract]

Revenue Recognition

The Company has determined that its revenues are generated from temporary staffing services and other services, as disaggregated in the following table. See Note 2 - Summary of Significant Accounting Policies.



	For the year ended December 31, 2018
	Nurse And Allied Staffing Segment		Physician Staffing Segment		Other Human Capital Management Services Segment		Total
	(amounts in thousands)
Temporary Staffing Services	$	705,435	$	76,979	$	—	$	782,414
Other Services	14,867		5,326		13,877		34,070
Total	$	720,302	$	82,305	$	13,877	$	816,484

Goodwill, Trade Names, and Other Intangible Assets

12 Months Ended

Dec. 31, 2018

Goodwill and Intangible Assets Disclosure [Abstract]

Goodwill, Trade Names, and Other Intangible Assets

The Company had the following acquired intangible assets:



	December 31, 2018						December 31, 2017
	Gross Carrying Amount		Accumulated Amortization		Net Carrying Amount		Gross Carrying Amount		Accumulated Amortization		Net Carrying Amount
	(amounts in thousands)
Intangible assets subject to amortization:
Databases	$	30,530	$	9,216	$	21,314	$	42,909	$	18,702	$	24,207
Customer relationships	49,758		23,296		26,462		55,524		25,912		29,612
Non-compete agreements	320		97		223		3,919		3,600		319
Trade names	8,879		1,696		7,183		7,716		878		6,838
Other intangible assets, net	$	89,487	$	34,305	55,182		$	110,068	$	49,092	60,976
Intangible assets not subject to amortization:
Trade names					20,402						26,702
					$	75,584					$	87,678

In 2018, fully amortized intangible assets, along with the related accumulated amortization, were removed from the table above. As of December 31, 2018, estimated annual amortization expense is as follows:



Years Ending December 31:	(amounts in thousands)
2019	$	7,535
2020	7,431
2021	7,131
2022	6,780
2023	6,677
Thereafter	19,628
	$	55,182

The changes in the carrying amount of goodwill by segment are as follows:



	Nurse and Allied Staffing Segment			Physician Staffing Segment			Other Human Capital Management Services Segment			Total
	(amounts in thousands)
Balances as of December 31, 2017
Aggregate goodwill acquired	$	347,873		$	43,405		$	19,307		$	410,585
Sale of business	—			—			(9,889		)	(9,889		)
Accumulated impairment loss	(259,732		)	(23,375		)	—			(283,107		)
Goodwill, net of impairment loss	88,141			20,030			9,418			117,589

Changes to aggregate goodwill in 2018
Goodwill acquired (a)	694			—			—			694
Impairment charge	—			(17,223		)	—			(17,223		)

Balances as of December 31, 2018
Aggregate goodwill acquired	348,567			43,405			19,307			411,279
Sale of business	—			—			(9,889		)	(9,889		)
Accumulated impairment loss	(259,732		)	(40,598		)	—			(300,330		)
Goodwill, net of impairment loss	$	88,835		$	2,807		$	9,418		$	101,060

_______________


(a)	Goodwill acquired from the acquisition of AP Staffing. See Note 4 - Acquisitions.

2018 and 2017 Impairment Charges

The Company performed its annual quantitative impairment test of goodwill and other indefinite-lived intangible assets as of October 1, 2018 and 2017. Upon completion of the impairment testing for both years, it was determined that the estimated fair value of the Physician Staffing reporting unit’s trade name was less than its carrying amount resulting in impairment. For its goodwill impairment testing, with the exception of its Physician Staffing reporting unit, the estimated fair value of its reporting units exceeded their respective carrying values.

Projections of revenue, operating costs, and expected cash flows of each reporting unit are inputs into the quantitative testing for goodwill and intangible assets. The Company reduced its long-term revenue forecast for the Physician Staffing business segment in the fourth quarter of 2018 and 2017. The lower than expected revenue was driven by lower booking volumes, partly due to the loss of customers. In addition, margins of the reporting unit were negatively impacted from continued investments in the business. As a result, during the fourth quarter of 2018 and 2017 the Company recorded non-cash impairment charges of $5.2 million and $8.7 million, respectively, related to its trade name and $17.2 million and $5.7 million, respectively, related to goodwill during the fourth quarter.

During the impairment testing as of October 1, 2018, the Company reassessed the Physician Staffing brand's indefinite-life classification and determined it had characteristics that indicated a definite-life assignment was more appropriate. Effective October 1, 2018, the trade name, with a carrying value of $1.1 million after impairment charges, that was previously assigned an indefinite life was assigned a finite life of 3 years. During the three months ended December 31, 2018, the amortization expense related to this trade name was approximately $0.1 million.

2016 Impairment Charges

The Company performed its annual impairment test as of October 1, 2016. Upon completion of the impairment testing, the Company determined that no impairment of goodwill, trade names, or other intangible assets was warranted.

During an evaluation of goodwill, trade names, and other intangible assets at June 30, 2016, the Company determined that indicators were present in the Physician Staffing reporting unit which would suggest the fair value of the reporting unit may have declined below its carrying value. The Physician Staffing reporting unit was under-performing relative to management’s expectations. The lower than expected revenue was driven by lower booking volumes partly due to the loss of customers, and margins were negatively impacted from continued investments in the business all through the first half of 2016. The Company considered these factors to be impairment indicators that warranted impairment testing of goodwill, trade names, and other intangible assets. The interim impairment testing resulted in the carrying values of goodwill, trade names, and other intangible assets for Physician Staffing to exceed their estimated fair values. As a result, the interim impairment testing was performed which resulted in the carrying values of goodwill, trade names, and other intangible assets for Physician Staffing to exceed their estimated fair values. As a result, the Company recorded a non-cash impairment charge totaling $24.3 million: $17.7 million related to goodwill, $0.6 million related to trade names, and $6.0 million related to customer relationships.

Quantitative Methods and Assumptions

Trade Names

The Relief From Royalty methodology was utilized to value the Physician Staffing trade names using projected cash flows of an estimated royalty fee. The royalty rate was determined by a blended rate using the Market Royalty Rate Method and the Apportionment of Profit Method.

Goodwill

The discounted cash flows serve as the primary basis for the income approach and are based on the Company’s discrete financial forecast of revenue, gross profit margins, operating costs and cash flows. The forecast considers historical and estimated future results, general economic and market conditions, as well as the impact of planned business and operational strategies. For its 2018 testing, the assumptions used in the income approach included discount rates of 12.0% to 15.0% and a terminal value growth rate of 1.0% to 3.0% for cash flows beyond the discrete forecast period of ten years. Assumptions used in the market approach testing included valuation multiples based on an analysis of multiples for comparable public companies. The Company utilized total enterprise value/Earnings Before Interest, Taxes, Depreciation, and Amortization (EBITDA) multiples ranging from 3.0 to 10.5. The concluded fair value was based on a weighting of 75% applied to the income approach and 25% to the market approach for its Physician Staffing and Search reporting units and a 50% weighting was applied to the components of each approach to estimate the total fair value of goodwill for its Nurse and Allied Staffing reporting unit. This weighting was an estimate by management and was developed based on the specific characteristics, risks and uncertainties of the reporting units.

Customer Relationships

The Multi-Period Excess Earnings Method (MPEEM) methodology was utilized for valuing the Physician Staffing customer relationships in its interim impairment testing for the second quarter of 2016. The MPEEM estimates the fair value based on the present value of the allocated future economic benefits. The inputs include the projected revenue and associated expenses from the customers, an estimated attrition rate, and a discount rate of 13.5%.

Although management believes that the Company's current estimates and assumptions are reasonable and supportable, there can be no assurance that the estimates and assumptions made for purposes of the impairment testing will prove to be accurate predictions of future performance.

Property and Equipment

12 Months Ended

Dec. 31, 2018

Property, Plant and Equipment [Abstract]

Property and Equipment

The Company's property and equipment consists of the following:



		December 31,
	Useful Lives	2018			2017
		(amounts in thousands)

Computer equipment	3-5 years	$	6,257		$	6,432
Computer software	3-5 years	26,651			24,933
Office equipment	5-7 years	1,514			1,379
Furniture and fixtures	5-7 years	4,966			4,680
Leasehold improvements	(a)	7,716			7,340
		47,104			44,764
Less accumulated depreciation and amortization		(33,476		)	(30,678		)
		$	13,628		$	14,086

_______________


(a)	See Note 2 – Summary of Significant Accounting Policies.

Balance Sheet Details

12 Months Ended

Dec. 31, 2018

Balance Sheet Related Disclosures [Abstract]

Balance Sheet Details



	December 31,
	2018		2017
	(amounts in thousands)
Insurance recovery receivable:
Insurance recovery for workers’ compensation	$	2,295	$	1,623
Insurance recovery for professional liability	1,891		1,874
	$	4,186	$	3,497

Other non-current assets:
Insurance recovery for workers’ compensation claims	$	5,280	$	6,093
Insurance recovery for professional liability claims	9,924		10,011
Non-current security deposits	982		1,095
Non-current income tax receivable	522		1,044
Deferred compensation assets	433		—
Net debt issuance costs	935		985
	$	18,076	$	19,228

Accrued compensation and benefits:
Salaries and payroll taxes	$	15,884	$	16,342
Bonuses	1,476		2,067
Accrual for workers’ compensation claims	6,454		5,957
Accrual for professional liability claims	2,786		2,683
Accrual for healthcare benefits	5,158		5,105
Accrual for vacation	1,574		2,117
	$	33,332	$	34,271

Long-term accrued claims:
Accrual for workers’ compensation claims	$	12,997	$	13,160
Accrual for professional liability claims	16,302		15,597
	$	29,299	$	28,757

Other long-term liabilities:
Non-current deferred tax liabilities	$	95	$	105
Deferred compensation	1,725		1,467
Deferred rent	6,039		6,875
Long-term unrecognized tax benefits	590		485
Other	318		344
	$	8,767	$	9,276

Debt

12 Months Ended

Dec. 31, 2018

Debt Disclosure [Abstract]

Debt

The Company's long-term debt consists of the following:



	December 31, 2018						December 31, 2017
	Principal			Debt Issuance Costs			Principal			Debt Issuance Costs
	(amounts in thousands)

Term Loan, interest of 4.80% and 3.61% at December 31, 2018 and 2017, respectively	$	83,876		$	(697	)	$	100,000		$	(866	)
Less current portion	(5,235		)	—			(6,875		)	—
Long-term debt	$	78,641		$	(697	)	$	93,125		$	(866	)

Amended and Restated Senior Credit Facility

On August 1, 2017, the Company entered into an Amendment and Restatement of its Credit Agreement dated June 22, 2016 (Amended and Restated Credit Agreement), to refinance and increase the current aggregate committed size of the facility to $215.0 million, including a term loan of $100.0 million (Amended Term Loan) and a $115.0 million revolving credit facility (Amended Revolving Credit Facility) (together with the Amended Term Loan, the Amended Credit Facilities). The Amended Revolving Credit Facility includes a subfacility for swingline loans up to an amount not to exceed $15.0 million, and a $35.0 million sublimit for the issuance of standby letters of credit. The proceeds of $106.5 million from this refinancing included $6.5 million under the new revolving credit facility and were used to repay borrowings under the Company’s 2016 Senior Credit Facilities (defined below), as well as to pay related interest, fees, and expenses of the transaction.

In addition to increasing the size of the facilities, the maturity date was extended to August 1, 2022. The Amended and Restated Credit Agreement also includes an accordion feature permitting the Company, subject to certain conditions, to increase the aggregate amount of the commitments under the Amended Revolving Credit Facility or establish one or more additional term loans in an aggregate amount not to exceed $50.0 million with optional additional commitments from existing lenders or new commitments from additional lenders. Other terms and pricing are substantially similar to the 2016 Credit Agreement (defined below).

Borrowings under the Amended Term Loan are payable in quarterly installments, which commenced January 2, 2018, provided that, to the extent not previously paid, the aggregate unpaid principal balance would be due and payable on the maturity date. In addition to its scheduled payments, in both the third and fourth quarters of 2018, the Company made optional prepayments of $5.0 million each as permitted by the Amended and Restated Credit Agreement. The Company has the right at any time and from time to time to prepay any borrowing, in whole or in part, without premium or penalty, by giving written notice (or telephonic notice promptly confirmed in writing). The Company is required to prepay the Amended Credit Facilities under certain circumstances including from net cash proceeds from asset sales or dispositions in excess of certain thresholds, as well as from net cash proceeds from the issuance of certain debt by the Company.

As of December 31, 2018, the aggregate scheduled maturities of debt are as follows:



	Term Loan
	(amounts in thousands)
Through Years Ending December 31:
2019	$	5,235
2020	5,671
2021	6,980
2022	65,990
2023	—
Total	$	83,876

Subject to the Amended and Restated Credit Agreement, the Company pays interest on: (i) each Base Rate Loan at the Base Rate (as defined therein) plus the Applicable Margin in effect from time to time; (ii) each LIBOR Index Rate Loan at the One Month LIBOR Index Rate (as defined therein) plus the Applicable Margin in effect from time to time; and (iii) each Eurodollar Loan at the Adjusted LIBOR for the applicable Interest Period (as defined therein) in effect for such Loan plus the Applicable Margin in effect from time to time. The Applicable Margin, as of any date, is a percentage per annum determined by reference to the applicable Consolidated Net Leverage Ratio (as defined by the agreement) in effect on such date as set forth in the table below.



Level	Consolidated Net Leverage Ratio	Eurodollar Loans, LIBOR Index Rate Loans and Letter of Credit Fee	Base Rate Loans	Commitment Fee
I	Less than 1.50:1.00	1.75%	0.75%	0.25%
II	Greater than or equal to 1.50:1.00 but less than 2.00:1.00	2.00%	1.00%	0.30%
III	Greater than or equal to 2.00:1.00 but less than 2.50:1.00	2.25%	1.25%	0.30%
IV	Greater than or equal to 2.50:1.00 but less than 3.00:1.00	2.50%	1.50%	0.35%
V	Greater than or equal to 3.00:1.00	2.75%	1.75%	0.40%

As of December 31, 2018, the Amended Term Loan and Amended Revolving Credit Facility bore interest at a rate equal to One Month LIBOR plus 2.50%. The interest rate is subject to an increase of 2.00% if an event of default exists under the Amended and Restated Credit Agreement. The Company is required to pay a commitment fee on the average daily unused portion of the Amended Revolving Credit Facility, based on the Applicable Margin which is 0.35% as of December 31, 2018. During the three months ended March 31, 2018, the Company entered into an interest rate swap to reduce its exposure to fluctuations in the interest rates associated with its debt, which was effective April 2, 2018. See Note 9 - Derivatives.

The Amended and Restated Credit Agreement contains customary representations, warranties, and affirmative covenants. The Amended and Restated Credit Agreement also contains customary negative covenants, subject to some exceptions, on: (i) indebtedness and preferred equity; (ii) liens; (iii) fundamental changes; (iv) investments; (v) restricted payments; and (vi) sale of assets and certain other restrictive agreements. The Amended and Restated Credit Agreement also contains customary events of default, such as payment defaults, cross-defaults to other material indebtedness, bankruptcy and insolvency, the occurrence of a defined change in control and the failure to observe the negative covenants and other covenants related to the operation of the Company’s business.

The Amended and Restated Credit Agreement also includes two financial covenants: (i) a maximum Consolidated Total Leverage ratio (as defined therein); and (ii) a minimum Consolidated Fixed Charge Coverage ratio (as defined therein) as of the end of each fiscal quarter of 1.50:1.00. As of December 31, 2018, the Company was in compliance with the financial covenants and other covenants contained in the Credit Agreement.

On October 30, 2018, the Company entered into a First Amendment (First Amendment) to its Amended and Restated Credit Agreement that, among other administrative and clarifying changes, modified the following: (1) the definition utilized in its financial covenants of Consolidated EBITDA to allow for exclusion of charges related to the Company’s initiative to replace its front-end system supporting its legacy travel nurse operations, subject to a basket of addbacks, of which the basket dollar amount was also increased; (2) increased the maximum Consolidated Total Leverage Ratio to 3.75:1.00 from 3.25:1:00 for the periods of September 30, 2018 through June 30, 2019, to 3.50:1:00 from 3.00:1.00 for the period ended September 30, 2019, to 3.25:1.00 from 3.00:1:00 for the period ended December 31, 2019, and maintained 3.00:1:00 for the periods thereafter and as adjusted pursuant to a Qualified Permitted Acquisition (as defined therein); and (3) increased the pro forma Consolidated Total Leverage Ratio threshold for allowing restricted payments. In connection with the First Amendment, the Company paid $0.3 million in fees to its lenders, of which a portion has been included in other noncurrent assets as deferred issuance costs related to the revolving credit facility and a portion has been treated as a deduction to long-term debt related to its Term Loan.

The foregoing description of the amendment is qualified in its entirety by reference to the full terms and provisions of the Amended and Restated Credit Agreement.

The obligations under the Amended and Restated Credit Agreement are guaranteed by all of the Company’s domestic wholly-owned subsidiaries and are secured by a first-priority security interest in the Collateral (as defined therein).

As of December 31, 2018, the Company has $20.6 million letters of credit outstanding, which relate to the Company’s workers’ compensation and professional liability insurance policies.

2016 Senior Credit Facilities

On June 22, 2016, the Company entered into a senior credit agreement (2016 Credit Agreement), which provided for an initial term loan of $40.0 million (Term Loan) and a revolving credit facility of up to $100.0 million (Revolving Credit Facility) (together with the Term Loan, the 2016 Senior Credit Facilities) both of which would have matured on June 22, 2021. The Revolving Credit Facility included a subfacility for swingline loans up to an amount not to exceed $15.0 million, and a $35.0 million sublimit for the issuance of standby letters of credit. Proceeds of the Senior Credit Facilities were used primarily to refinance the Company’s prior senior secured asset-based credit facility and $30.0 million Second Lien Term Loan and to pay related transaction fees and expenses, including a redemption premium of $0.6 million. The repayment of the Second Lien Term Loan was treated as extinguishment of debt and, as a result, the Company recognized a loss on extinguishment of debt of approximately $1.6 million in the second quarter of 2016, related to the write-off of unamortized net debt discount and issuance costs as well as transaction fees and expenses.

On July 5, 2017, the Company entered into a Second Amendment to its 2016 Credit Agreement primarily to allow for the acquisition of Advantage including a reset of the Applicable Margin to Level III, based on the incremental borrowings and consistent with the prior pricing grid (or 2.25% for Eurodollar Loans and LIBOR Index Rate Loans, 1.25% for Base Rate Loans and a 0.30% commitment fee). Also, on July 5, 2017, the Company entered into an Incremental Term Loan Agreement for $40.0 million with SunTrust as Lender and Administrative Agent to pay for part of the consideration of the acquisition of Advantage. The Incremental Term Loan maturity date was June 22, 2021 and was prepayable at any time without penalty.

Borrowings under the Incremental Term Loan were payable in quarterly installments, commencing September 30, 2017, with each such installment being in the aggregate principal amount (subject to adjustment as a result of prepayments) for the first eight installments equal to 1.875% and 2.5% of the principal amount of the Incremental Term Loan for the remaining installments; provided that, to the extent not previously paid, the aggregate unpaid principal balance would be due and payable on the maturity date. As of July 5, 2017 the Applicable Margin for Eurodollar Loans and LIBOR Index Rate Loans was 2.25% and the Applicable Margin for Base Rate Loans was 1.25%.

Convertible Notes

The Company and certain of its domestic subsidiaries entered into a Convertible Note Purchase Agreement (the Note Purchase Agreement), with certain note holders (collectively, the Noteholders) on June 30, 2014. Pursuant to the Note Purchase Agreement, the Company sold to the Noteholders an aggregate of $25.0 million of convertible notes (the Convertible Notes). On March 17, 2017, the Company paid in full the Convertible Notes. In connection with the repayment, the Company issued to the Noteholders an aggregate of 3,175,584 shares of Common Stock, par value $0.0001, and cash in the aggregate amount of $5.6 million (of which $5.0 million is included in repayment of debt and $0.6 million is presented as extinguishment fees, both within financing activities on the consolidated statements of cash flows). Upon derecognition of the net carrying amounts of the Convertible Notes (the remaining $20.0 million after the $5.0 million cash payment) and derivative liability ($26.0 million), the Company recognized a non-cash charge of $5.0 million as loss on early extinguishment and a non-cash addition to additional paid-in capital of $46.0 million for the fair value of the shares, which is not presented on the consolidated statements of cash flows. The loss on early extinguishment of debt includes the write-off of unamortized loan fees and remaining interest due through the Forced Conversion date (defined below) of June 30, 2017.

The Convertible Notes were convertible at the option of the holders thereof at any time into shares of the Common Stock at a conversion price of $7.10 per share, or 3,521,126 shares of Common Stock. After three years from the issuance date, the Company had the right to force a conversion of the Convertible Notes if the volume-weighted average price (VWAP) per share of its Common Stock exceeded 125% of the then conversion price for 20 days of a 30 day trading period (Forced Conversion date).

The Convertible Notes bore interest at a rate of 8.00% per annum, payable in quarterly cash installments. The Convertible Notes would have matured on June 30, 2020, unless earlier repurchased, redeemed or converted. Subject to certain exceptions, the Company was not permitted to redeem the Convertible Notes until June 30, 2017.

Derivatives	12 Months Ended
Derivatives	Dec. 31, 2018
Derivative Instruments and Hedging Activities Disclosure [Abstract]
Derivatives	Derivatives Interest Rate Swap In March 2018, the Company entered into an interest rate swap agreement, with an effective date of April 2, 2018 and termination date of August 1, 2022. No initial investments were made to enter into the agreement. The interest rate swap agreement requires the Company to pay a fixed rate to the respective counterparty of 2.627% per annum on an amortizing notional amount beginning at $48.8 million (corresponding with the initial term loan payment schedule), and to receive from the respective counterparty, interest payments based on the applicable notional amounts and 1 month USD LIBOR, with no exchanges of notional amounts. At initiation, the interest rate swap effectively fixed the interest rate on 50% of the amortizing balance of the Company’s term debt, exclusive of the credit spread on the debt. As of December 31, 2018, the interest rate swap is treated as a cash flow hedge and its fair value of a $0.2 million liability is included in current and noncurrent liabilities on the consolidated balance sheets. See Note 2 - Summary of Significant Accounting Policies and Note 10 - Fair Value Measurements. Convertible Notes Derivative Liability The Company issued Convertible Notes with features that were either (i) not afforded equity classification, (ii) embody risks not clearly and closely related to host contracts, or (iii) may be net-cash settled by the counterparty. As required by the Accounting for Derivative Financial Instruments and Hedging Activities Topic of the FASB ASC, in certain instances, these instruments were required to be carried as derivative liabilities, at fair value, in the financial statements. On March 17, 2017, the Company paid in full its Convertible Notes and, as a result, derecognized the derivative liability. See Note 8 - Debt. The fair value of the derivative liability was primarily determined by fluctuations in the Company's stock price. In addition, changes in the Company's credit risk profile impacted the fair value determination. These fluctuations resulted in a current period gain that was presented on the Company's consolidated statements of operations as gain on derivative liability in 2017 and 2016 related to its Convertible Notes.

Fair Value Measurements

12 Months Ended

Dec. 31, 2018

Fair Value Disclosures [Abstract]

Fair Value Measurements

The Fair Value Measurements and Disclosures Topic of the FASB ASC defines fair value as the exchange price that would be received for an asset or paid to transfer a liability (an exit price) in the principal or most advantageous market for the asset or liability in an orderly transaction between market participants on the measurement date. This topic also establishes a fair value hierarchy which requires an entity to maximize the use of observable inputs and minimize the use of unobservable inputs when measuring fair value. The standard describes three levels of inputs that may be used to measure fair value:

Level 1—Quoted prices in active markets for identical assets or liabilities.

Level 2—Observable inputs other than Level 1 prices such as quoted prices for similar assets or liabilities; quoted prices in markets that are not active; or other inputs that are observable or can be corroborated by observable market data for substantially the full term of the assets or liabilities.

Level 3—Unobservable inputs that are supported by little or no market activity and that are significant to the fair value of the assets or liabilities.

Items Measured at Fair Value on a Recurring Basis

The Company’s financial assets/liabilities required to be measured on a recurring basis were its: deferred compensation liability included in other long-term liabilities, interest rate swap agreement included in other current and noncurrent liabilities, Convertible Notes derivative liability included in long-term debt and capital lease obligations, and contingent consideration liabilities.

Deferred compensation—The Company utilizes Level 1 inputs to value its deferred compensation liability. The Company’s deferred compensation liabilities are measured using publicly available indices that define the liability amounts, as per the plan documents.

Interest rate swap agreement—The Company utilized Level 2 inputs to value its interest rate swap agreement. See Note 8 - Debt and Note 9 - Derivatives.

Convertible notes derivative liability—The Company utilized Level 3 inputs to value its Convertible Notes derivative liability. On March 17, 2017, the Company paid in full its Convertible Notes and, as a result, derecognized the derivative liability.

Contingent consideration liabilities—Potential earnout payments related to the acquisition of Mediscan and USR are contingent upon meeting certain performance requirements through 2019. The long-term portion of these liabilities has been included in contingent consideration, and the short-term portion is included in other current liabilities on the consolidated balance sheets. The Company utilized Level 3 inputs to value these contingent consideration liabilities as significant unobservable inputs were used in the calculation of their fair value. Both of the Mediscan contingent consideration liabilities have been measured at fair value using a discounted cash flow model in a Monte Carlo simulation setting, utilizing significant unobservable inputs, including the expected volatility of the acquisitions' gross profits and an estimated discount rate commensurate with the risks of the expected gross profit stream. In the third quarter of 2017, the Company determined that one of the contingent consideration earnouts related to the Mediscan acquisition would not be achieved for 2017 and, as a result, the entire earnout was reversed. The contingent consideration related to the Company's acquisition of USR was recorded as a liability and measured at fair value using a discounted cash flow model utilizing significant unobservable inputs, including the probability of achieving each of the potential milestones and an estimated discount rate commensurate with the risks of the expected cash flows attributable to the milestones. In the third quarter of 2018, the Company determined that the contingent consideration earnout related to the USR acquisition would not be achieved for 2018 and 2019 and, as a result, the entire liability was reversed. See Note 4 - Acquisitions.

The fair value of contingent consideration and the associated liabilities will be adjusted to fair value at each reporting date until actual settlement occurs, with the changes in fair value and related accretion reflected as acquisition-related contingent consideration on the consolidated statements of operations. Significant increases (decreases) in the volatility or in any of the probabilities of success, or decreases (increases) in the discount rate would result in a significantly higher (lower) fair value, respectively, and commensurate changes to these liabilities.

The table which follows summarizes the estimated fair value of the Company’s financial assets and liabilities measured on a recurring basis:

Fair Value Measurements



	December 31, 2018		December 31, 2017
Financial Liabilities:	(amounts in thousands)
(Level 1)
Deferred compensation	$	1,725	$	1,467
(Level 2)
Interest rate swaps	$	234	$	—
(Level 3)
Contingent consideration liabilities	$	7,689	$	5,368

The opening balances of contingent consideration and Convertible Notes derivative liabilities are reconciled to the closing balances for fair value measurements of these liabilities categorized within Level 3 of the fair value hierarchy as follows:



	Contingent Consideration			Convertible Notes
	Liabilities			Derivative Liability
	(amounts in thousands)

December 31, 2016	$	5,603		$	27,532
Payments/Settlements	(280		)	(25,951		)
Accretion expense	967			—
Valuation gain for the period	(922		)	(1,581		)
December 31, 2017	5,368			—
Payments	(280		)	—
Accretion expense	903			—
Valuation loss for the period	1,698			—
December 31, 2018	$	7,689		$	—

Items Measured at Fair Value on a Non-recurring Basis

The Company's non-financial assets, such as goodwill, trade names, other intangible assets, and property and equipment, are measured at fair value when there is an indicator of impairment and are recorded at fair value only when an impairment charge is recognized. During an evaluation of goodwill, trade names, and other intangible assets during the years ended December 31, 2018, 2017, and 2016, the carrying value of goodwill, trade names, and other intangible assets in the Physician Staffing reporting unit exceeded their fair values. As a result, the Company recorded impairment charges that incorporates fair value measurements based on Level 3 inputs. For further discussion on measuring the Company's non-financial assets, specifically goodwill, trade names, and customer relationships, see Note 5 - Goodwill, Trade Names, and Other Intangible Assets.

Other Fair Value Disclosures

Financial instruments not measured or recorded at fair value in the accompanying consolidated balance sheets consist of cash and cash equivalents, accounts receivable, accounts payable and accrued expenses, and short and long-term debt. The estimated fair value of accounts receivable, accounts payable, and accrued expenses approximate their carrying amount due to the short-term nature of these instruments. The estimated fair value of the Company’s debt was calculated using a discounted cash flow analysis and appropriate valuation methodologies using Level 2 inputs from available market information.

The carrying amounts and estimated fair value of the Company’s significant financial instruments that were not measured at fair value are as follows:



	December 31, 2018				December 31, 2017
	Carrying Amount		Fair Value		Carrying Amount		Fair Value
	(amounts in thousands)
Financial Liabilities:
(Level 2)
Term Loan, net	$	83,179	$	81,800	$	99,134	$	100,500

Concentration of Risk

The Company has invested its excess cash in highly-rated overnight funds and other highly-rated liquid accounts. The Company is exposed to credit risk associated with these investments, as the cash balances typically exceed the current Federal Deposit Insurance Corporation (FDIC) limit of $250,000. The Company minimizes its credit risk relating to these positions by monitoring the financial condition of the financial institutions involved and by primarily conducting business with large, well established financial institutions and diversifying its counterparties.

The Company generally does not require collateral and mitigates its credit risk by performing credit evaluations and monitoring at-risk accounts. The allowance for doubtful accounts represents the Company’s estimate of uncollectible receivables based on a review of specific accounts and the Company’s historical collection experience. The Company writes off specific accounts based on an ongoing review of collectability as well as past experience with the customer. The Company’s contract terms typically require payment between 15 to 60 days from the date of invoice and are considered past due based on the particular negotiated contract terms. Overall, based on the large number of customers in differing geographic areas, primarily throughout the United States and its territories, the Company believes the concentration of credit risk is limited.

- Definition

The entire disclosure for the fair value of financial instruments (as defined), including financial assets and financial liabilities (collectively, as defined), and the measurements of those instruments as well as disclosures related to the fair value of non-financial assets and liabilities. Such disclosures about the financial instruments, assets, and liabilities would include: (1) the fair value of the required items together with their carrying amounts (as appropriate); (2) for items for which it is not practicable to estimate fair value, disclosure would include: (a) information pertinent to estimating fair value (including, carrying amount, effective interest rate, and maturity, and (b) the reasons why it is not practicable to estimate fair value; (3) significant concentrations of credit risk including: (a) information about the activity, region, or economic characteristics identifying a concentration, (b) the maximum amount of loss the entity is exposed to based on the gross fair value of the related item, (c) policy for requiring collateral or other security and information as to accessing such collateral or security, and (d) the nature and brief description of such collateral or security; (4) quantitative information about market risks and how such risks are managed; (5) for items measured on both a recurring and nonrecurring basis information regarding the inputs used to develop the fair value measurement; and (6) for items presented in the financial statement for which fair value measurement is elected: (a) information necessary to understand the reasons for the election, (b) discussion of the effect of fair value changes on earnings, (c) a description of [similar groups] items for which the election is made and the relation thereof to the balance sheet, the aggregate carrying value of items included in the balance sheet that are not eligible for the election; (7) all other required (as defined) and desired information.

+ References + Details

Employee Benefit Plans	12 Months Ended
Employee Benefit Plans	Dec. 31, 2018
Retirement Benefits [Abstract]
Employee Benefit Plans	Employee Benefit Plans The Company maintains a voluntary defined contribution 401(k) profit-sharing plan covering all eligible employees as defined in the plan documents. The plan provides for a discretionary matching contribution, which is equal to a percentage of each eligible contributing participant’s elective deferral, which the Company, at its sole discretion, determines from year to year. Contributions by the Company, net of forfeitures, under this plan amounted to $0.8 million, $0.7 million, and $0.8 million for the years ended December 31, 2018, 2017, and 2016, respectively. Eligible employees who elect to participate in the plan are generally vested in any existing matching contribution after three years of service with the Company. The Company offers a non-qualified deferred compensation program to certain key employees whereby they may defer a portion of annual compensation for payment upon retirement. The program is unfunded for tax purposes and for purposes of Title I of the Employee Retirement Income Security Act of 1974. The liability for the deferred compensation is included in other long-term liabilities on the consolidated balance sheets and amounted to $1.7 million and $1.5 million at December 31, 2018 and 2017, respectively.

Commitments and Contingencies

12 Months Ended

Dec. 31, 2018

Commitments and Contingencies Disclosure [Abstract]

Commitments and Contingencies

Commitments

Operating Leases

The Company has entered into non-cancelable operating lease agreements for the rental of office space and equipment. Certain of these leases include options to renew as well as rent escalation clauses and in certain cases, incentives from the landlord for rent-free months and premises reductions, and allowances for tenant improvements. The rent escalations and incentives have been reflected in the table below.

Future minimum lease payments, as of December 31, 2018, associated with these agreements with terms of one year or more are as follows:



Years Ending December 31:	(amounts in thousands)
2019	$	7,451
2020	6,287
2021	5,407
2022	4,857
2023	4,700
Thereafter	5,893
	$	34,595

Total operating lease expense included in selling, general, and administrative expenses was approximately $9.3 million, $9.4 million, and $8.4 million for the years ending December 31, 2018, 2017, and 2016, respectively.

Contingencies

Sales and Other State Non-income Tax Liabilities

The Company's sales and other state non-income tax filings are subject to routine audits by authorities in the jurisdictions where it conducts business in the United States which may result in assessments of additional taxes. The Company accrues sales and other non-income tax liabilities based on the Company's best estimate of its probable liability utilizing currently available information and interpretation of relevant tax regulations. Non-income tax expense is included in selling, general and administrative expenses on its consolidated statements of operations and the liability is reflected in sales tax payable within other current liabilities as of December 31, 2018 and 2017, on its consolidated balance sheets.

Legal Proceedings

From time to time, the Company is involved in various litigation, claims, investigations, and other proceedings that arise in the ordinary course of its business. These matters primarily relate to employee-related matters that include individual and collective claims, professional liability, tax, and payroll practices. The Company establishes reserves when available information indicates that a loss is probable and an amount, or range of loss can be reasonably estimated. These assessments are performed at least quarterly and are based on the information available to management at the time and involve a significant management judgment to determine the probability and estimated amount of potential losses, if any. Based on the available information considered in its reviews, the Company adjusts its loss contingency accruals and its disclosures as may be required. Actual outcomes or losses may differ materially from those estimated by the Company's current assessments including available insurance recoveries, which would impact its profitability. Adverse developments in existing litigation claims or legal proceedings involving the Company or new claims could require it to establish or increase litigation reserves or enter into unfavorable settlements or satisfy judgments for monetary damages for amounts in excess of current reserves, which could adversely affect its financial results. With regard to the outstanding contingencies as of December 31, 2018, the Company believes the outcome of these matters will not have a material adverse effect on its business, financial condition, results of operations or cash flows.

Income Taxes

12 Months Ended

Dec. 31, 2018

Income Tax Disclosure [Abstract]

Income Taxes

he components of the Company's (loss) income before income taxes are as follows:



	Year Ended December 31,
	2018			2017		2016
	(amounts in thousands)
United States	$	(18,619	)	$	3,826	$	3,309
Foreign	424			475		1,236
(Loss) income before income taxes	$	(18,195	)	$	4,301	$	4,545

The components of the Company’s income tax benefit are as follows:



	Year Ended December 31,
	2018			2017			2016
	(amounts in thousands)
Current:
Federal	$	43		$	(555	)	$	227
State	620			(273		)	587
Foreign	269			139			322
Total	932			(689		)	1,136
Deferred:
Federal	(2,137		)	(23,245		)	(4,114		)
State	(1,277		)	(10,684		)	(866		)
Foreign	4			117			(342		)
Total	(3,410		)	(33,812		)	(5,322		)
Income tax benefit	$	(2,478	)	$	(34,501	)	$	(4,186	)

Deferred income taxes reflect the net tax effect of temporary differences between the carrying amount of assets and liabilities for financial reporting purposes and the amounts used for income tax purposes.

Significant components of the Company’s deferred tax assets and liabilities are as follows:



	December 31,
	2018			2017
	(amounts in thousands)
Deferred Tax Assets:
Accrued other and prepaid expenses	$	2,734		$	2,955
Allowance for doubtful accounts	607			624
Intangible Assets	11,300			7,776
Net operating loss carryforwards	15,717			14,718
Accrued professional liability claims	1,952			1,709
Accrued workers’ compensation claims	2,729			2,512
Share-based compensation	646			734
Credit carryforwards	188			189
Other	542			444
Gross deferred tax assets	36,415			31,661
Valuation allowance	(1,189		)	(1,076		)
	35,226			30,585
Deferred Tax Liabilities:
Depreciation	(52		)	(41		)
Indefinite intangibles	(11,136		)	(9,964		)
Tax on unrepatriated earnings	(383		)	(466		)
	(11,571		)	(10,471		)
Net deferred taxes	$	23,655		$	20,114

On December 22, 2017, the 2017 Tax Act was signed into legislation which, among other changes, reduced the corporate federal income tax rate from 35% to 21% effective for the Company's year ended December 31, 2018. The Company recorded income tax expense of $8.0 million, primarily due to a re-measurement of its deferred tax assets and liabilities in the fourth quarter of 2017. The impact of the Global Intangible Low-Taxed Income provision, the transition tax on the deemed repatriation of deferred foreign income, and any future tax impact associated with basis differences on foreign subsidiaries were immaterial.

In December 2017, the Securities and Exchange Commission (SEC) staff issued Staff Accounting Bulletin No. 118 (SAB 118), which provided guidance on accounting for the tax effects of the 2017 Tax Act. SAB 118 provided a measurement period that should not extend beyond one year from the enactment date for companies to complete the accounting required under the Income Taxes Topic of the FASB ASC. In accordance with SAB 118, the Company provided a provisional amount with regard to certain foreign tax provisions in 2017. In 2018, the Company revised its estimate with regard to the 2017 Tax Act and recorded $0.1 million of tax expense.

As of December 31, 2016, the Company determined that it could not sustain a conclusion that it was more likely than not that it would realize any of its deferred tax assets resulting from recent losses, the difficulty of forecasting future taxable income, and other factors, and as a result, the Company had a valuation allowance on its deferred tax assets, exclusive of indefinite-lived intangible deferred tax liabilities.

For the year ended December 31, 2017, predominantly on the basis of a reassessment of the amount of its deferred tax assets that are more likely than not to be realized, the Company reduced its valuation allowance by $45.4 million (comprised of $15.7 million related to U.S. net operating losses, $4.4 million related to state net operating losses, and $25.3 million related to other net deferred tax assets). The valuation allowance on a portion of state net operating losses not more likely than not realizable was not released after analysis of respective expiration periods and specific state taxable income projections.

As of December 31, 2018, the Company continues to maintain a valuation allowance of $1.2 million on a portion of state net operating losses not more likely than not realizable.

As of December 31, 2018 and 2017, respectively, the Company had approximately $185.1 million and $166.1 million of federal, state, and foreign net operating loss carryforwards. The carryforwards will expire as follows: federal between 2032 and 2037, state between 2019 and 2038, and foreign between 2019 and 2023.

The reconciliation of income tax computed at the U.S. federal statutory rate to income tax benefit is as follows:



	Year Ended December 31,
	2018			2017			2016
	(amounts in thousands)
Tax at U.S. statutory rate	$	(3,821	)	$	1,506		$	1,591
State taxes, net of federal benefit	(543		)	(1,374		)	344
Noncontrolling interest	(252		)	(455		)	(260		)
Non-deductible items (a)	625			2,676			1,546
Foreign tax expense	180			175			(5		)
Valuation allowances	—			(45,354		)	(8,379		)
Uncertain tax positions	1,629			1,145			1,090
Return to provision	(458		)	—			—
Federal rate change	—			8,011			—
Other	162			(831		)	(113		)
Income tax benefit	$	(2,478	)	$	(34,501	)	$	(4,186	)

________________

(a) Includes non-deductible meals and incidentals, miscellaneous non-deductible items, and beginning in 2018, non-deductible stock-based compensation.

The tax years 2008 and 2010 through 2017 remain open to examination by certain taxing jurisdictions to which the Company is subject to tax. During 2018, the Company accrued $0.1 million of India tax on earnings of approximately $0.5 million. India withholding taxes on a dividend of India earnings are not affected by the calculation of U.S. taxes due and continue to be accrued.

A reconciliation of the beginning and ending amounts of unrecognized tax benefits is as follows:



	2018		2017			2016
	(amounts in thousands)
Balance at January 1	$	3,807	$	5,180		$	4,071
Additions based on tax positions related to the current year	1,401		1,145			1,054
Additions based on tax positions related to prior years	204		—			55
Reductions based on settlements of tax positions related to prior years	—		(439		)	—
2017 Tax Act federal tax rate change	—		(1,859		)	—
Other	—		(220		)	—
Balance at December 31	$	5,412	$	3,807		$	5,180

Short-term unrecognized tax benefits are included in other current liabilities on the consolidated balance sheets and were $0.1 million as of December 31, 2018, 2017, and 2016. Long-term unrecognized tax benefits are included in other long-term liabilities on the consolidated balance sheets and were $0.6 million, $0.5 million, and $0.9 million as of December 31, 2018, 2017, and 2016, respectively. See Note 7 - Balance Sheet Details. As of December 31, 2018, 2017, and 2016, the Company had unrecognized tax benefits, which would affect the effective tax rate if recognized, of $5.6 million, $4.0 million, and $4.9 million, respectively. During 2018, the Company had gross increases of $1.6 million to its current year unrecognized tax benefits, related to federal and state tax positions.

The Company recognizes interest and penalties related to unrecognized tax benefits in the provision for income taxes. During the year ended December 31, 2017, the Company recognized a decrease in interest and penalties of $0.2 million, related to statute expirations. The Company has accrued $0.3 million, $0.2 million, and $0.5 million for the payment of interest and penalties at December 31, 2018, 2017, and 2016, respectively.

Stockholders' Equity

12 Months Ended

Dec. 31, 2018

Equity [Abstract]

Stockholders' Equity

Stockholders’ Equity

Stock Repurchase Programs

Under an authorized share repurchase program, during the year ended December 31, 2018, the Company repurchased and retired 432,439 shares of its Common Stock for $5.0 million, at an average market price of $11.54 per share. During the years ended December 31, 2017 and 2016, the Company did not repurchase any shares of its Common Stock under this program.

As of December 31, 2018, the Company has 510,004 shares of Common Stock under the current share repurchase program available to repurchase, subject to certain conditions in the Company's Amended and Restated Credit Agreement.

Shares Issued

On March 17, 2017, the Company issued 3,175,584 shares to its prior Convertible Notes noteholders. See Note 8 - Debt.

Share-Based Payments

2014 Omnibus Incentive Plan

The Company's 2014 Omnibus Incentive Plan (2014 Plan) provides for the issuance of stock options, stock appreciation rights, restricted stock, performance shares, and performance-based cash awards that may be granted with the intent to comply with the “performance-based compensation” exception under Section 162(m) of the Internal Revenue Code, and other stock-based awards, all as defined by the 2014 Plan, to eligible employees, consultants and non-employee Directors. On May 23, 2017, the Company's shareholders approved an amendment and restatement of its 2014 Plan (2017 Plan) which, among others, included the following modifications: (i) a 2,000,000 share increase of the aggregate share reserve to 6,100,000 shares, (2) extension of the 2014 Plan until May 23, 2027, and (3) re-approval of the Section 162(m) performance goals so that certain incentive awards granted to certain executive officers of the Company may qualify as exempt performance-based compensation.

Under the 2017 Plan, the Compensation Committee of the Company’s Board of Directors (the Committee), has the discretion to determine the terms of the awards at the time of the grant provided, however, that in the case of stock options and stock appreciation rights (share options): 1) the exercise price per share of the award is not less than 100% (or, in the case of 10% or more stockholders, the exercise price of the incentive stock options (ISOs) granted may not be less than 110%) of the fair market value of the common stock at the time of the grant; and 2) the term of the award will be no more than 10 years after the date the option is granted (or, shall not exceed five years, in the case of a 10% or more stockholder). In the case of restricted stock, the purchase price may be zero to the extent permitted by applicable law.

Restricted stock awards granted under the Company’s 2017 Plan entitle the holder to receive, at the end of a vesting period, a specified number of shares of the Company’s common stock. Share-based compensation expense is measured by the market value of the Company’s stock on the date of grant. The shares vest ratably over a three year period ending on the anniversary date of the grant, and vesting is subject to the employee's continuing employment. There is no partial vesting and any unvested portion is forfeited. Pursuant to the 2017 Plan, the number of target shares that are issued for performance-based stock awards are determined based on the level of attainment of the targets.

The following table summarizes restricted stock awards and performance stock awards activity issued under the 2017 Plan for the year ended December 31, 2018:



	Restricted Stock Awards				Performance Stock Awards
	Number of Shares		Weighted Average Grant Date Fair Value		Number of Target Shares		Weighted Average Grant Date Fair Value
Unvested restricted stock awards, January 1, 2018	515,601		$	13.03	257,575		$	13.49
Granted	391,108		$	10.96	238,328		$	11.11
Vested	(219,881	)	$	12.64	(66,692	)	$	11.63
Forfeited	(97,708	)	$	13.18	(64,062	)	$	13.03
Unvested restricted stock awards, December 31, 2018	589,120		$	12.00	365,149		$	12.35

On March 31, 2018 and 2017, the Company awarded performance stock awards totaling 238,328 and 181,067, respectively. If the minimum level of performance is attained for the 2018 and 2017 awards, restricted stock will be issued with a vesting date of March 31, 2021 and 2020, respectively. The level of attainment will be certified within 30 days of the vest date. During the first quarter of 2017, the Company's Compensation Committee of the Board of Directors approved a 48% level of attainment for the 2016 performance-based share awards, resulting in the issuance of 66,692 performance shares that vested on December 31, 2018.

As of December 31, 2018, the Company had approximately $3.8 million pre-tax of total unrecognized compensation cost related to non-vested restricted stock awards which may be adjusted for future changes in forfeitures. The Company expects to recognize such cost over a weighted average period of 1.45 years. The fair value of shares vested was approximately $2.5 million, $3.7 million, and $4.3 million for the years ended December 31, 2018, 2017, and 2016, respectively.

As of December 31, 2018, the Company had approximately $0.3 million pre-tax of total unrecognized compensation cost related to performance stock awards which may be adjusted for future changes in forfeitures. The Company expects to recognize such cost over a weighted average period of 1.87 years, the remaining service period. The fair value of shares vested was approximately $0.5 million, $1.6 million, and $1.2 million for the years ended December 31, 2018, 2017, and 2016, respectively.

During the years ended December 31, 2018, 2017, and 2016, the Company did not issue stock options or stock appreciation rights. The following table represents information about stock options and stock appreciation rights exercised in each year.



	Year Ended December 31,
	2018		2017		2016
	(amounts in thousands)
Total intrinsic value of options exercised	$	234	$	516	$	1,323

The stock appreciation rights can only be settled with stock or cash, at the discretion of the Committee. The stock appreciation rights vest 25% per year over a 4 year period and expire after 7 years. The Company’s policy is to issue new shares from its authorized but unissued balance of common stock outstanding or shares of common stock reacquired by the Company if stock appreciation rights are settled with stock.

The Company recorded compensation expense for stock options based on the estimated fair value of the options on the date of grant using the Black-Scholes option-pricing model. Due to the adoption of the 2014 Plan (previously titled the 2007 Stock Incentive Plan), no further grants have been issued under the Company’s 1999 Plans referred to below.

1999 Stock Option Plan and Equity Participation Plan

On December 16, 1999, the Company’s Board of Directors approved the 1999 Stock Option Plan and Equity Participation Plan (collectively, the 1999 Plans), which was amended and restated on October 25, 2001 and provided for the issuance of ISOs and non-qualified stock options to eligible employees and non-employee directors for the purchase of up to 4,398,001 shares of common stock.

The following table summarizes the Company’s activities with respect to all of its share option plans (issued under the 2014 Plan and the 1999 Plan) for the year ended December 31, 2018:



	Number of Shares		Option Price	Weighted Average Exercise Price	Weighted- Average Remaining Contractual Life (in years)	Aggregate Intrinsic Value (amounts in thousands)
Share options outstanding, January 1, 2018	94,500		$4.16-$7.44	$5.19
Granted	—		—	—
Exercised	(40,500	)	$4.16-$7.44	$5.46
Forfeited/expired	(2,500	)	$7.44	$7.44
Share options outstanding and exercisable, December 31, 2018	51,500		$4.35-$5.21	$4.87	1.02	$	127

As of December 31, 2018, the Company had 51,500 share options outstanding, all of which were vested at a weighted average exercise price of $4.87, intrinsic value of $0.1 million, and a weighted average contractual life of 1.02 years.

Earnings Per Share

12 Months Ended

Dec. 31, 2018

Earnings Per Share [Abstract]

Earnings Per Share

The following table sets forth the components of the numerator and denominator for the computation of the basic and diluted earnings per share:



	Year Ended December 31,
	2018			2017			2016
	(amounts in thousands, except per share data)
Numerator:
Net (loss) income attributable to common shareholders - Basic	$	(16,951	)	$	37,513		$	7,967
Interest on Convertible Notes	—			694			3,383
Gain on derivative liability	—			(1,581		)	(5,805		)
Net (loss) income attributable to common shareholders - Diluted	$	(16,951	)	$	36,626		$	5,545

Denominator:
Weighted average common shares - Basic	35,657			35,018			32,132
Effective of diluted shares:
Share-based awards	—			425			593
Convertible Notes	—			723			3,521
Weighted average common shares - Diluted	35,657			36,166			36,246

Net (loss) income per share attributable to common shareholders - Basic	$	(0.48	)	$	1.07		$	0.25

Net (loss) income per share attributable to common shareholders - Diluted	$	(0.48	)	$	1.01		$	0.15

For the years 2018, 2017, and 2016, no tax benefits were assumed in the weighted average share calculation due to the Company's net operating loss position.

The following table represents the securities that could potentially dilute net income per share attributable to common shareholders in the future that were not included in the computation of diluted net income per share attributable to common shareholders because to do so would have been anti-dilutive for the periods presented.



	Year Ended December 31,
	2018	2017	2016
	(amounts in thousands)
Share-based awards	373	118	—

Related Party Transactions	12 Months Ended
Related Party Transactions	Dec. 31, 2018
Related Party Transactions [Abstract]
Related Party Transactions	Related Party Transactions The Company provides services to hospitals which are affiliated with certain members of the Company’s Board of Directors. Management believes services with related parties were conducted on terms equivalent to those prevailing in an arm's-length transaction. Revenue related to these transactions was $0.1 million, $4.9 million, and $5.0 million in 2018, 2017, and 2016, respectively. Accounts receivable due from these hospitals at December 31, 2018 and 2017 were less than $0.1 million and approximately $0.4 million, respectively. In connection with the acquisition of MSN, the Company acquired a 68% ownership interest in Cross Country Talent Acquisition Group, LLC (formerly InteliStaf of Oklahoma, LLC), a joint venture between the Company and a hospital system. The Company generated revenue providing staffing services to the hospital system of $19.4 million, $17.9 million, and $12.6 million in 2018, 2017, and 2016, respectively. At December 31, 2018 and 2017, the Company had a receivable balance of $2.8 million and $0.8 million, respectively, and a payable balance of $0.3 million at both periods. Subsequent to the Company's acquisition of Mediscan on October 30, 2015, Mediscan continued to operate at premises owned, in part, by the founding members of Mediscan. The Company paid $0.3 million in 2018, $0.4 million in 2017, and 2016 for rent for these premises. In the fourth quarter of 2018, the Company vacated the premises.

Segment Data

12 Months Ended

Dec. 31, 2018

Segment Reporting [Abstract]

Segment Data

In accordance with the Segment Reporting Topic of the FASB ASC, the Company reports three business segments – Nurse and Allied Staffing, Physician Staffing, and Other Human Capital Management Services. The Company manages and segments its business based on the services it offers to its customers as described below:

•

Nurse and Allied Staffing - Nurse and Allied Staffing provides traditional staffing, recruiting, and value-added workforce solutions including: temporary and permanent placement of travel and local branch-based nurse and allied professionals, MSP services, education healthcare services, and outsourcing services. Its clients include: public and private acute care and non-acute care hospitals, government facilities, public schools and charter schools, outpatient clinics, ambulatory care facilities, physician practice groups, retailers, and many other healthcare providers throughout the United States. Substantially all of the results of the Advantage and AP Staffing acquisitions have been aggregated with the Company's Nurse and Allied Staffing business segment. See Note 4 - Acquisitions.

•

Physician Staffing - Physician Staffing provides physicians in many specialties, as well as certified registered nurse anesthetists, nurse practitioners, and physician assistants as independent contractors on temporary assignments throughout the United States at various healthcare facilities, such as acute and non-acute care facilities, medical group practices, government facilities, and managed care organizations.


•	Other Human Capital Management Services - Other Human Capital Management Services includes retained and contingent search services for physicians, healthcare executives, and other healthcare professionals within the United States.

The Company’s management evaluates performance of each segment primarily based on revenue and contribution income. The Company defines contribution income as income or loss from operations before depreciation and amortization, acquisition and integration costs, acquisition-related contingent consideration, restructuring costs, impairment charges, applicant tracking system costs, and corporate expenses not specifically identified to a reporting segment. Contribution income is a financial measure used by management when assessing segment performance and is provided in accordance with the Segment Reporting Topic of the FASB ASC. The Company’s management does not evaluate, manage, or measure performance of segments using asset information; accordingly, total asset information by segment is not prepared or disclosed. The information in the following table is derived from the segments’ internal financial information as used for corporate management purposes. Certain corporate expenses are not allocated to and/or among the operating segments.

Information on operating segments and a reconciliation to income from operations for the periods indicated are as follows:



	Year Ended December 31,
	2018			2017			2016
	(amounts in thousands)
Revenues:
Nurse and Allied Staffing	$	720,302		$	758,267		$	721,486
Physician Staffing	82,305			93,610			98,283
Other Human Capital Management Services	13,877			13,171			13,768
	$	816,484		$	865,048		$	833,537
Contribution income:
Nurse and Allied Staffing	$	66,365		$	73,614		$	71,992
Physician Staffing	4,755			5,256			8,265
Other Human Capital Management Services	598			(357		)	(535		)
	71,718			78,513			79,722

Unallocated corporate overhead (a)	44,589			39,190			38,400
Depreciation and amortization	11,780			10,174			9,182
Acquisition and integration costs	491			1,975			78
Acquisition-related contingent consideration	2,557			44			814
Restructuring costs	2,758			1,026			753
Impairment charges (b)	22,423			14,356			24,311
(Loss) income from operations	$	(12,880	)	$	11,748		$	6,184

_______________


(a)	The Company has been centralizing administrative functions to gain efficiencies, which have been recorded in unallocated corporate overhead, which includes corporate compensation and benefits, and general and administrative expenses including rent and utilities, computer supplies and expenses, insurance, professional expenses, corporate-wide projects (initiatives), and public company expenses.


(b)	See Note 5 - Goodwill, Trade Names, and Other Intangible Assets.

Quarterly Financial Data (Unaudited)

12 Months Ended

Dec. 31, 2018

Quarterly Financial Information Disclosure [Abstract]

Quarterly Financial Data (Unaudited)

The following tables contain selected unaudited statements of operations information for each quarter of 2018 and 2017. The following information reflects all normal recurring adjustments necessary for a fair presentation of the information for the periods presented. The operating results for any quarter are not necessarily indicative of results for any future period.



	First Quarter		Second Quarter		Third Quarter			Fourth Quarter
2018	(amounts in thousands, except per share data)
Revenue from services	$	210,288	$	204,572	$	200,717		$	200,907
Gross profit (a)	53,753		53,689		51,562			50,559
Consolidated net (loss) income	1,920		1,824		(118		)	(19,343		)
Net income (loss) attributable to common shareholders	1,642		1,539		(441		)	(19,691		)
Net income (loss) per share attributable to common shareholders - Basic (b)	$	0.05	$	0.04	$	(0.01	)	$	(0.55	)
Net income (loss) per share attributable to common shareholders - Diluted (b)	$	0.05	$	0.04	$	(0.01	)	$	(0.55	)



	First Quarter			Second Quarter		Third Quarter		Fourth Quarter
2017	(amounts in thousands, except per share data)
Revenue from services	$	207,573		$	209,313	$	228,488	$	219,674
Gross profit (a)	53,275			56,528		60,480		58,303
Consolidated net (loss) income	(1,718		)	5,220		7,044		28,256
Net (loss) income attributable to common shareholders	(2,010		)	4,850		6,723		27,950
Net (loss) income per share attributable to common shareholders - Basic (b)	$	(0.06	)	$	0.14	$	0.19	$	0.78
Net (loss) income per share attributable to common shareholders - Diluted	$	(0.08	)	$	0.13	$	0.19	$	0.77

________________

(a) Excludes depreciation and amortization.

(b) The sum of the quarterly per share amounts may not equal amounts reported for year-to-date due to the effects of rounding and changes in the number of weighted average shares outstanding used in the calculation.

The following items are the most significant items that impact the comparability and presentation of our consolidated data:


•	During the fourth quarter of 2018 and 2017, the Company recorded non-cash impairment charges of $22.4 million and $14.4 million, respectively, related to the goodwill and trade names of Physician Staffing. See Note 5 - Goodwill, Trade Names, and Other Intangible Assets.


•	During the first quarter of 2017, the Company settled its Convertible Notes and recognized a loss on extinguishment of debt of $5.0 million. See Note 8 - Debt.

•

On December 1, 2018, the Company acquired AP Staffing and on July 1, 2017, the Company acquired all of the assets of Advantage. The acquisitions have been accounted for in accordance with the Business Combinations Topic of the FASB ASC, using the acquisition method. The results of the acquisitions' operations have been included in the consolidated statements of operations from their dates of acquisition. See Note 4 - Acquisitions.


•	In the fourth quarter of 2017, the Company benefited from a $43.3 million reversal of valuation allowance on its net deferred tax assets, offset by additional income tax expense of $8.0 million related to the remeasurement of its deferred tax assets as a result of the 2017 Tax Act. See Note 13 - Income Taxes.


•	The Company recorded changes in the fair value of Convertible Notes derivative liability, recording a gain in the first quarter of 2017 of $1.6 million. See Note 9 - Derivatives.

Schedule II - Valuation and Qualifying Accounts

12 Months Ended

Dec. 31, 2018

SEC Schedule, 12-09, Valuation and Qualifying Accounts [Abstract]

Schedule II - Valuation and Qualifying Accounts

Schedule II

CROSS COUNTRY HEALTHCARE, INC.

VALUATION AND QUALIFYING ACCOUNTS

FOR THE YEARS ENDED DECEMBER 31, 2018, 2017, AND 2016



	Balance at Beginning of Period		Charged to Operations			Write-Offs, net of recoveries				Other Changes			Balance at End of Period
	(amounts in thousands)
Allowances for Accounts Receivable
Year Ended December 31, 2018	$	3,688	$	5,974		$	(5,957	)	(a)	$	—		$	3,705
Year Ended December 31, 2017	$	3,245	$	4,705		$	(4,262	)	(a)	$	—		$	3,688
Year Ended December 31, 2016	$	4,045	$	4,034		$	(4,834	)	(a)	$	—		$	3,245

Valuation Allowance for Deferred Tax Assets
Year Ended December 31, 2018	$	1,076	$	113		$	—			$	—		$	1,189
Year Ended December 31, 2017	$	46,454	$	(3,007	)	$	(43,333	)	(b)	$	962	(c)	$	1,076
Year Ended December 31, 2016	$	55,336	$	(8,894	)	$	—			$	12		$	46,454

________________


(a)	Uncollectible accounts written off, net of recoveries.


(b)	Release of valuation allowances on the Company’s deferred tax assets.


(c)	Valuation allowance on deferred tax asset related to share-based compensation.

Summary of Significant Accounting Policies (Policies)	12 Months Ended
Summary of Significant Accounting Policies (Policies)	Dec. 31, 2018
Accounting Policies [Abstract]
Use of Estimates	Use of Estimates The preparation of consolidated financial statements in conformity with United States generally accepted accounting principles (U.S. GAAP), requires management to make estimates and assumptions that affect the reported amounts in the consolidated financial statements and accompanying notes. Significant estimates and assumptions are used for, but not limited to: (1) the valuation of accounts receivable; (2) goodwill, trade names, and other intangible assets; (3) other long-lived assets; (4) share-based compensation; (5) accruals for health, workers’ compensation, and professional liability claims; (6) valuation of deferred tax assets; (7) purchase price allocation; (8) fair value of interest rate swap agreement; (9) legal contingencies; (10) contingent considerations; (11) income taxes; and (12) sales and other non-income tax liabilities. Accrued insurance claims and reserves include estimated settlements from known claims and actuarial estimates for claims incurred but not reported. Actual results could differ from those estimates.
Cash and Cash Equivalents	Cash and Cash Equivalents The Company considers all investments with original maturities of three months or less to be cash and cash equivalents. The Company invests its excess cash in highly rated overnight funds and other highly rated liquid accounts. The Company is exposed to credit risk associated with these investments. The Company minimizes its credit risk relating to these positions by monitoring the financial condition of the financial institutions involved and by primarily conducting business with large, well established financial institutions, and diversifying its counterparties. The Company does not currently anticipate nonperformance by any of its significant counterparties. Interest income on cash and cash equivalents of $0.4 million for the year ended December 31, 2018, and $0.1 million for the years ended December 31, 2017 and 2016, is included in other income, net, on the Company’s consolidated statements of operations.
Accounts Receivable, Allowance for Doubtful Accounts, and Concentration of Credit Risk	Accounts Receivable, Allowance for Doubtful Accounts, and Concentration of Credit Risk Accounts receivable potentially subject the Company to concentrations of credit risk. The Company’s customers are primarily healthcare providers, and accounts receivable represent amounts due from them. The Company generally does not require collateral and mitigates its credit risk by performing credit evaluations and monitoring at-risk accounts. The allowance for doubtful accounts represents the Company’s estimate of uncollectible receivables resulting from the inability of its customers to make required payments, which results in a provision for bad debt expense. The adequacy of this allowance is determined by continually evaluating individual customer receivables, considering the customer's financial condition, credit history, and current economic conditions. The Company writes off specific accounts based on an ongoing review of collectability as well as past experience with the customer. In addition, the Company maintains a sales allowance for customer disputes which may arise in the ordinary course, which is recorded as contra-revenue. Historically, losses on uncollectible accounts and sales allowances have not exceeded our allowances. The Company’s contract terms typically require payment between 15 to 60 days from the date of invoice and are considered past due based on the particular negotiated contract terms. The majority of the Company's business activity is with hospitals located throughout the United States.
Prepaid Rent and Deposits	Prepaid Rent and Deposits The Company leases apartments for eligible field employees under short-term agreements (typically three to six months), which generally coincide with each employee’s staffing contract. Costs relating to these leases are included in direct operating expenses on the accompanying consolidated statements of operations. As a condition of these agreements, the Company may place security deposits on the leased apartments. Deposits on field employees’ apartments related to these short-term agreements are included in other current assets on the accompanying consolidated balance sheets.
Property and Equipment	Property and Equipment Property and equipment are stated at cost, less accumulated depreciation. Depreciation is determined on a straight-line basis over the estimated useful lives of the assets, which generally range from three to seven years. Leasehold improvements are depreciated over the shorter of their estimated useful life or the term of the individual lease. On an annual basis, the Company reviews its property and equipment listings and disposes of assets that are no longer in use. Certain software development costs have been capitalized in accordance with the provisions of the Intangibles-Goodwill and Other/Internal-Use Software Topic of the Financial Accounting Standards Board (FASB) Accounting Standards Codification (ASC). Such costs include charges for consulting services and costs for Company personnel associated with programming, coding, and testing such software. Amortization of capitalized software costs begins when the software is ready for use and is included in depreciation expense in the accompanying consolidated statements of operations. Software development costs are being amortized using the straight-line method over three to five years.
Business Combinations	Business Combinations The Company applies accounting in accordance with the Business Combinations Topic of the FASB ASC when it acquires control over a business. Business combinations are accounted for at fair value. The associated acquisition costs are expensed as incurred and recorded as acquisition and integration costs; noncontrolling interests, if any, are reflected at fair value at the acquisition date; restructuring costs associated with a business combination are expensed; contingent consideration is measured at fair value at the acquisition date, with changes in the fair value after the acquisition date affecting earnings; and goodwill is determined as the excess of the fair value of the consideration conveyed in the acquisition over the fair value of the net assets acquired. The accounting for business combinations requires estimates and judgments as to expectations for future cash flows of the acquired business, and the allocation of those cash flows to identifiable intangible assets, in determining the estimated fair value for assets and liabilities acquired. The fair values assigned to tangible and intangible assets acquired and liabilities assumed are based on management's estimates and assumptions, including valuations that utilize customary valuation procedures and techniques. If the actual results differ from the estimates and judgments used in these estimates, the amounts recorded in the financial statements could result in a possible impairment of the intangible assets and goodwill, or require acceleration of the amortization expense of finite-lived intangible assets. The results of the acquired businesses' operations are included in the consolidated statements of operations of the combined entity beginning on the date of acquisition. See Note 4 - Acquisitions.
Goodwill, Trade Names, and Other Intangible Assets	Goodwill, Trade Names, and Other Intangible Assets Goodwill represents the excess of purchase price and related costs over the fair value assigned to the net tangible and identifiable intangible assets of businesses acquired. Other identifiable intangible assets with definite lives are being amortized using the straight-line method over their estimated useful lives which range from 1 to 16 years. Goodwill and certain intangible assets with indefinite lives are not amortized. Instead, in accordance with the Intangibles-Goodwill and Other Topic of the FASB ASC, these assets are reviewed for impairment annually at the beginning of the fourth quarter, and whenever circumstances change that would more likely than not reduce the fair value of a reporting unit below its carrying amount. When reviewed, the Company has the option to first assess qualitative factors to determine whether it is more likely than not that the fair value of a reporting unit is less than its carrying amount, as a basis for determining whether it is necessary to perform the quantitative testing. If it is determined that a quantitative test is necessary or more efficient than a qualitative approach, the Company generally measures the fair value of its reporting units using a combination of income and market approaches. For the periods prior to the fourth quarter of 2017, the performance of the quantitative impairment test involved a two-step process. The first step required the Company to determine the fair value of each of its reporting units and compare it to the reporting unit’s carrying amount. If the reporting unit's fair value was less than its carrying amount, the Company was required to perform a second step to calculate the implied value of goodwill. The implied value was then compared to its carrying amount to calculate the impairment charge, if any. Beginning in the fourth quarter of 2017, for its annual review on October, 1, 2017, the Company early adopted the provisions of Accounting Standards Update (ASU) 2017-04, Intangibles-Goodwill and Other (Topic 350): Simplifying the Test for Goodwill Impairment. Under ASU 2017-04, the second step of the quantitative assessment is eliminated, and, if the reporting unit’s carrying value exceeds its fair value, an impairment charge is recognized for the amount by which the carrying amount exceeds the reporting unit’s fair value not to exceed the total amount of goodwill allocated to that reporting unit. Additionally, income tax effects from any tax deductible goodwill on the carrying amount of the reporting unit when measuring the goodwill impairment loss is considered, if applicable. The Company determines its reporting units by identifying its operating segments and any component businesses and aggregates the components businesses if they have similar economic characteristics. The Company had the following reporting units that it reviewed for impairment: 1) Nurse and Allied Staffing; 2) Physician Staffing; and 3) Search. Management considers historical experience and all available information at the time the fair values of its reporting units are estimated. However, fair values that could be realized in an actual transaction may have differed from those used to evaluate the potential impairment of goodwill. Long-lived assets and identifiable intangible assets with definite lives are evaluated for impairment in accordance with the Property, Plant, and Equipment Topic of the FASB ASC. In accordance with this Topic, long-lived assets and definite-lived intangible assets are reviewed for impairment whenever events or changes in circumstances indicate the carrying amount may not be recoverable. Recoverability of long-lived assets is measured by a comparison of the carrying amount of the asset group to the future undiscounted net cash flow that is expected to be generated by those assets. If such assets are considered to be impaired, the impairment charge recognized is the amount by which the carrying amount of the assets exceeds the fair value of the assets. Any related impairment losses are recognized in earnings and included in the caption impairment charges on the consolidated statements of operations. See Note 5 - Goodwill, Trade Names, and Other Intangible Assets.
Debt Discount and Debt Issuance Costs	Debt Discount and Debt Issuance Costs Stated discounts on proceeds, and other fees reimbursed to lender, as well as the initial value of any embedded derivative features of the Convertible Notes and Term Loans, as defined in Note 8 - Debt, are treated as a discount associated with the respective debt instrument and presented in the balance sheet as an offset to the carrying amount of the debt. Discounts are amortized to interest expense using the effective interest rate method, or a method that approximates the effective interest rate method, over the expected life of the debt. Deferred costs related to the issuance of the Convertible Notes and the Term Loans were capitalized and are presented in the balance sheet as a direct deduction from the carrying amount of the debt liability. Deferred costs are amortized using the effective interest method. Deferred costs related to the Convertible Notes were written off in connection with the repayment of such Convertible Notes. See Note 8 - Debt. Deferred costs related to the issuance of the Company’s Revolving Credit Facilities, as defined in Note 8 - Debt, have been capitalized and included in other assets on the consolidated balance sheets, and amortized using the straight line method over the term of the related credit agreement.
Derivative Financial Instruments	Derivative Financial Instruments The Company is exposed to interest rate risk due to its outstanding senior secured term loan entered into on August 1, 2017 with a variable interest rate. As a result, the Company has entered into an interest rate swap agreement to effectively convert a portion of its variable interest payments to a fixed rate. The principal objective of the interest rate swap is to eliminate or reduce the variability of the cash flows in those interest payments associated with the Company’s long-term debt, thus reducing the impact of interest rate changes on future interest payment cash flows. The Company has determined that the interest rate swap qualifies as a cash flow hedge in accordance with ASC 815, Derivatives and Hedging. As the critical terms of the hedging instrument and the hedged forecasted transaction are the same, the Company has concluded that changes in the cash flows attributable to the risk being hedged are expected to completely offset at inception and on an ongoing basis. Changes in the fair value of an interest rate swap agreement designated as a cash flow hedge are recorded as a component of accumulated other comprehensive income (loss), net of deferred taxes, within stockholders’ equity and are amortized to interest expense over the term of the related debt as the interest payments are made. Interest rate swap payments are included in net cash provided by operating activities on the Company’s consolidated statement of cash flows. In conjunction with entering into the interest rate swap agreement, the Company early adopted ASU 2017-12, Derivative and Hedging (Topic 815) to simplify the application of hedge accounting. See Note 9 - Derivatives. The Company evaluates embedded conversion features within its convertible debt in accordance with the Derivatives and Hedging Topic of the FASB ASC to determine whether the embedded conversion feature should be bifurcated from the host instrument and accounted for as a derivative at fair value. Changes in the fair value of these derivatives during each reporting period were reported in other expenses (income) on the consolidated statements of operations. The fair value at inception had been recorded as debt discount and was being amortized to interest expense over the term of the note using the effective interest method. On March 17, 2017, the Company paid in full its Convertible Notes and, as a result, derecognized the derivative liability. See Note 8 - Debt.
Sales and Other State Non-income Tax Liabilities	Sales and Other State Non-income Tax Liabilities The Company accrues sales and other state non-income tax liabilities based on the Company’s best estimate of its probable liability utilizing currently available information and interpretation of relevant tax regulations. Given the nature of the Company’s business, significant subjectivity exists as to both whether sales and other state non-income taxes can be assessed on its activity and how the sales tax will ultimately be measured by the relevant jurisdictions. The Company makes a determination for each reporting period whether the estimates for sales and other non-income taxes in certain states should be revised.
Insurance Claims	Insurance Claims The Company provides workers’ compensation insurance coverage, professional liability coverage, and healthcare benefits for eligible employees. The Company records its estimate of the ultimate cost of, and reserves for, workers' compensation and professional liability benefits based on actuarial models prepared or reviewed by an independent actuary using the Company’s loss history as well as industry statistics. The healthcare insurance accrual is for estimated claims that have occurred but have not been reported and is based on the Company’s historical claim submission patterns. Furthermore, in determining its reserves, the Company includes reserves for estimated claims incurred but not reported as well as unfavorable claims development. The Other Expenses/Insurance Costs Topic of the FASB ASC previously issued authoritative accounting guidance in the area of insurance contracts and related activity thereto. This topic concluded that, under circumstances such as in the Company’s insured professional liability and workers' compensation policies, since a right of legal offset does not exist due to the fact that there are three parties to an incurred claim, the insured, the insurer, and the claimant, the related liability to the claimant should be classified separately on a gross basis with a separate related receivable from the insurer recognized as being due from insurance carriers. Accordingly, the Company’s consolidated balance sheets as of December 31, 2018 and 2017 reflect the related short-term liabilities in accrued compensation and benefits and the related long-term liabilities as long-term accrued claims, and the short-term receivable portion as insurance recovery receivable and the long-term portion as non-current insurance recovery receivable. See Note 7 - Balance Sheet Details. The ultimate cost of workers’ compensation, professional liability, and health insurance claims will depend on actual amounts incurred to settle those claims and may differ from the amounts reserved by the Company for those claims. Workers’ compensation benefits are provided under a partially self-insured plan. The Company has letters of credit to guarantee payments of claims. At December 31, 2018 and 2017, the Company had outstanding approximately $18.8 million and $19.6 million, respectively, of standby letters of credit as collateral to secure the self-insured portion of this plan. The Company has occurrence-based primary professional liability policies that provide the Company and each working professional in its nurse and allied healthcare business with coverage. Effective January 1, 2016, the Company has a claims-made professional liability policy for its physicians and advanced practitioners, with a $0.5 million self-insured retention per claim. Prior to January 1, 2016, the Company had an occurrence-based professional liability policy for its independent contractor physicians and advanced practitioners which was insured by a wholly-owned subsidiary, Jamestown Indemnity, Ltd., a wholly-owned Cayman Island captive company (the Captive), until its voluntary liquidation in the third quarter of 2015. Beginning in March 2015, the Company's Physician subsidiary self-insured $0.5 million for each of its professional liability claims. Under the terms of the Captive’s reinsurance policy there was a requirement to guarantee the payment of claims to its insured party’s primary medical malpractice insurance carrier via a letter of credit. As a result of the Captive's liquidation, the letter of credit was reduced. As of December 31, 2018 and 2017, the value of the letter of credit was $1.8 million and $2.0 million, respectively. Subject to certain limitations, the Company also has umbrella liability coverage for its working nurses and allied healthcare professionals. While this umbrella coverage does not extend to professional liability claims against its independent contractor physicians and advanced practitioners, it does cover claims brought against all of the Company’s subsidiaries for non-patient general liability.
Revenue Recognition	Revenue Recognition In the first quarter of 2018, the Company adopted ASU No. 2014-09, Revenue from Contracts with Customers (Topic 606). ASU 2014-09 introduces a new five-step revenue recognition model in which an entity recognizes revenue when its customer obtains control of promised goods or services, in an amount that reflects the consideration to which the entity expects to be entitled in exchange for those goods or services. The new standard also requires additional disclosures about the nature, amount, timing, and uncertainty of revenue and cash flows arising from customer contracts. See Note 3 - Revenue Recognition for additional accounting policy and related disclosures. The Company elected to adopt the standard using a modified retrospective method, which only impacts contracts not completed as of December 31, 2017. Revenue from the Company’s services is recognized when control of the promised services are transferred to the Company’s customers, in an amount that reflects the consideration it expects to receive in exchange for the service. The Company has concluded that transfer of control of its staffing services, which represents the majority of its revenues, occurs over time as the services are provided, which is consistent with revenue recognition under the prior guidance. The following is a description of the nature, amount, timing, and uncertainty of revenue and cash flows from which the Company generates revenue. Temporary Staffing Revenue Revenue from temporary staffing is recognized as control of the services is transferred over time, and is based on hours worked by the Company’s field staff. The Company recognizes the majority of its revenue at the contractual amount the Company has the right to invoice for services completed to date. Generally, billing to customers occurs weekly, bi-weekly, or monthly and is aligned with the payment of services to the temporary staff, with payment terms of 15 to 60 days. Accounts receivable includes estimated revenue for employees’ and independent contractors’ time worked but not yet invoiced. At December 31, 2018 and December 31, 2017, the Company's estimate of amounts that had been worked but had not been billed totaled $44.1 million and $41.8 million, respectively, and are included in accounts receivable on the consolidated balance sheets. Other Service Revenue The Company offers other optional services to its customers that are transferred over time including: managed service programs (MSP) providing agency services (as further described below in Gross versus Net Policies), recruitment process outsourcing (RPO), other outsourcing services, and retained search services, which is less than 5% of its consolidated revenue for the years ended December 31, 2018, 2017, and 2016. Generally, billing and payment terms for MSP agency services is consistent with temporary staffing as the customers are similar or the same. Revenue from these services are recognized based on the contractual amount for services completed to date which best depicts the transfer of control of services. For the Company’s RPO, other outsourcing, and retained search services, revenue is generally recognized in the amount to which the entity has a right to invoice which corresponds directly with the value to the customer. The Company does not, in the ordinary course of business, offer warranties or refunds. Gross Versus Net Policies The Company records revenue on a gross basis as a principal or on a net basis as an agent depending on the contracted arrangement, as follows: Managed Service Programs The Company has certain contracts with healthcare facilities to provide comprehensive services through its MSPs. Under these contractual arrangements, the customer’s orders are filled with either one of the Company's healthcare professionals or a third party's healthcare professionals (subcontractors). When its healthcare professional is staffed, the Company determined that it acts as a principal in the arrangement, as it is considered the employer of record. Accordingly, revenue is reported on a gross basis on the consolidated statements of operations. Alternatively, the Company determined that it acts as an agent in the arrangement when a subcontracted healthcare professional is staffed, as the Company does not control the services before they are transferred to the customer. Accordingly, revenue is reported on a net basis on the consolidated statements of operations. The customer is invoiced for the hours worked by the subcontracted healthcare professional multiplied by the hourly bill rate. A subcontractor liability, which is recognized as a reduction of revenue, is established in accrued expenses for the invoiced amount, net of an administrative fee, and is generally payable after the Company has received payment from its customer. The Company’s administrative fee is calculated as a percentage of the customer’s invoice and is recognized over time as the services are rendered by the subcontracted healthcare professional. The Company does not collect or recognize an upfront placement fee. Physician Staffing The Physician Staffing business has contracts with its healthcare customers to provide temporary staffing services. The Company uses independent contractors for these services. The Company determined that it acts as a principal in these arrangements and, therefore, revenue is reported on a gross basis on the consolidated statements of operations. See Note 3 - Revenue Recognition for the Company's revenues disaggregated by revenue source. Sales and usage-based taxes are excluded from revenue. Contract Costs All contract fulfillment costs are expensed as incurred to direct operating expenses. With respect to FASB ASC 606, Revenue from Contracts with Customers, there were no contract assets or material contract liabilities as of December 31, 2018 and 2017. Practical Expedients and Exemptions For the Company’s contracts that have an original duration of one year or less, the Company uses the practical expedients and has elected to recognize any incremental costs of obtaining these contracts as expensed when incurred. Further, the Company does not disclose the value of unsatisfied performance obligations for: (i) contracts with an original expected length of one year or less, and (ii) contracts for which it recognizes revenue at the amount to which it has the right to invoice for services performed.
Share-Based Compensation	Share-Based Compensation The Company has, from time to time, granted stock options, stock appreciation rights, performance-based stock awards, and restricted stock for a fixed number of common shares to employees. In accordance with the Compensation-Stock-Compensation Topic of the FASB ASC, companies may choose from alternative valuation models. The Company used the Black-Scholes method of valuing its options and stock appreciation rights. The Company has elected to recognize compensation expense on a straight-line basis over the requisite service period of the entire award. The Company values its restricted stock awards and the fair value of its performance-based stock awards by reference to its stock price on the date of grant. The Company granted performance-based stock awards to certain key personnel pursuant to its 2014 Omnibus Incentive Plan, amended and restated on May 23, 2017 (2017 Plan) as described in Note 14 - Stockholders' Equity. Pursuant to the plan, the number of target shares that vest are determined based on the level of attainment of the targets. If a minimum level of performance is attained for the awards, restricted stock is issued based on the level of attainment. The Company recognizes performance-based restricted stock as compensation expense based on the most likely probability of attaining the prescribed performance and over the requisite service period beginning at its grant date and through the date the restricted stock vests. Compensation expense related to share-based payments is included in selling, general and administrative expenses in the consolidated statements of operations, and totaled $3.6 million, $4.1 million, and $3.4 million, during the years ended December 31, 2018, 2017, and 2016, respectively. See Note 14 - Stockholders’ Equity.
Advertising	Advertising The Company’s advertising expense consists primarily of online advertising, internet direct marketing, print media, and promotional material. Advertising costs are expensed as incurred and totaled $6.7 million, $7.6 million, and $10.2 million, for the years ended December 31, 2018, 2017, and 2016, respectively.
Restructuring Costs	Restructuring Costs The Company considers restructuring activities to be programs whereby it fundamentally changes its operations, such as closing and consolidating facilities, reducing headcount, and realigning operations in response to changing market conditions. As a result, restructuring costs on the consolidated statements of operations include on-going benefit costs for its employees, exit costs, and other costs including write-offs related to abandoned locations.
Deferred Rent	Deferred Rent Deferred rent consists of free rent, rent escalation, tenant improvement allowances, and other incentives received from landlords related to the operating leases for our facilities. Rent escalation represents the difference between actual operating lease payments due and straight-line rent expense, which we record over the term of the lease. The excess is recorded as a deferred credit in the early periods of the lease, when cash payments are generally lower than straight-line rent expense, and is reduced in the later periods of the lease when payments begin to exceed the straight-line expense. Tenant allowances from landlords for tenant improvements are generally comprised of cash received from the landlord or paid on our behalf as part of the negotiated terms of the lease. These tenant improvement allowances and other leasehold incentives are recorded when realizable as deferred rent and are amortized as a reduction of periodic rent expense, over the term of the applicable lease. See Note 12 - Commitments and Contingencies.
Income Taxes	Income Taxes The Company accounts for income taxes under the Income Taxes Topic of the FASB ASC. Deferred income tax assets and liabilities are determined based upon differences between the financial reporting and tax basis of assets and liabilities, and are measured using the enacted tax rates and laws that will be in effect when the differences are expected to reverse. The Company recognizes in its financial statements the impact of a tax position if that position is more likely than not of being sustained on audit, based on the technical merits of the position. The Company recognizes interest and penalties related to unrecognized tax benefits in the provision for income taxes. The Company maintains valuation allowances when it is more likely than not that all or a portion of a deferred tax asset will not be realized. In determining whether a valuation allowance is warranted, the Company evaluates factors such as prior earnings history, expected future earnings, carryback and carryforward periods, and tax strategies. The Company considers all positive and negative evidence to estimate if sufficient future taxable income will be generated to realize the deferred tax asset. It considers cumulative losses in recent years as well as the impact of one-time events in assessing its pre-tax earnings. Assumptions regarding future taxable income require significant judgment. The Company's assumptions are consistent with estimates and plans used to manage its business, which includes restructuring and other initiatives. In the event that actual results differ from these estimates, or the Company adjusts these estimates in future periods for current trends or changes in its estimating assumptions, it may modify the level of the valuation allowance which could materially impact its business, financial condition and results of operations. The Company will continue to assess the realizability of its deferred tax assets. See Note 13 - Income Taxes.
Comprehensive Income (Loss)	Comprehensive Income (Loss) Total comprehensive income (loss) includes net income or loss, foreign currency translation adjustments, and net change in derivative transactions, net of any related deferred taxes. Certain of the Company’s foreign subsidiaries use their respective local currency as their functional currency. In accordance with the Foreign Currency Matters Topic of the FASB ASC, assets and liabilities of these operations are translated at the exchange rates in effect on the balance sheet date. Income statement items are translated at the average exchange rates for the period. The cumulative impact of currency fluctuations related to the balance sheet translation is included in accumulated other comprehensive loss in the accompanying consolidated balance sheets and was an unrealized loss of $1.3 million at December 31, 2018 and $1.2 million at December 31, 2017. The cumulative impact of net changes in derivative instruments included in other comprehensive loss in the consolidated balance sheets was an unrealized loss of $0.2 million at December 31, 2018. See Note 9 - Derivatives. The income tax impact related to components of other comprehensive income for the period ended December 31, 2018 is reflected on the consolidated statements of comprehensive income. During the period ended December 31, 2017, $0.2 million of income tax expense was included in the consolidated statements of operations due to the impact of a change in federal tax rate on the deferred tax asset related to foreign currency cumulative translation. See Note 13 - Income Taxes. There was no income tax impact related to foreign currency translation adjustments for the period ended December 31, 2016.
Fair Value Measurements	Fair Value Measurements The Company complies with the provisions of the Fair Value Measurements and Disclosures Topic of the FASB ASC, which defines fair value, establishes a framework for measuring fair value under U.S. GAAP, and expands disclosures about fair value measurements. As of December 31, 2018 and 2017, the Company’s financial assets and liabilities required to be measured on a recurring basis were its deferred compensation liability, its interest rate swap agreements, and its contingent consideration liabilities. See Note 10 - Fair Value Measurements.
Earnings Per Share	Earnings Per Share In accordance with the requirements of the Earnings Per Share Topic of the FASB ASC, basic earnings per share is computed by dividing net income available to common shareholders (numerator) by the weighted average number of vested unrestricted common shares outstanding during the period (denominator). Diluted earnings per share gives effect to all dilutive potential common shares outstanding during the period including stock appreciation rights and options and unvested restricted stock, as calculated utilizing the treasury stock method, and Convertible Notes using the if-converted method prior to their payment in full in the first quarter of 2017.
Recent Accounting Pronouncements	Recent Accounting Pronouncements In August 2018, the FASB issued ASU No. 2018-15, Intangibles - Goodwill and Other - Internal-Use Software (Subtopic 350-40), Customer's Accounting for Implementation Costs Incurred in a Cloud Computing Arrangement That is a Service Contract. The amendments in this update align the requirements for capitalizing implementation costs incurred in a hosting arrangement that is a service contract with the requirements for capitalizing implementation costs incurred to develop or obtain internal-use software (and hosting arrangements that include an internal use software license). The amendments in this update are effective for public business entities for fiscal years beginning after December 15, 2019, and interim periods within those fiscal years, and should be applied either retrospectively or prospectively to all implementation costs incurred after the date of adoption. Early adoption is permitted for all entities, including adoption in an interim period. The Company is currently in the process of evaluating the potential impact the adoption of this standard may have and expects to adopt this standard in its first quarter of 2020. In August 2018, the FASB issued ASU No. 2018-13, Fair Value Measurement (Topic 820), Disclosure Framework - Changes to the Disclosure Requirements for Fair Value Measurement. The amendments in this update modify the disclosure requirements on fair value measurements in Topic 820, Fair Value Measurement, based on the concepts in the Concepts Statement, including the consideration of costs and benefits. The amendments in this update are effective for all entities for fiscal years, and interim periods within those fiscal years, beginning after December 15, 2019, and should be applied either prospectively or retrospectively depending on the nature of the disclosure. An entity is permitted to early adopt any removed or modified disclosures upon issuance of this update and delay adoption of the additional disclosures until their effective date. The Company is currently in the process of evaluating this standard and expects to adopt the full provisions in its first quarter of 2020. In July 2017, the FASB issued ASU No. 2017-11, Earnings Per Share (Topic 260); Distinguishing Liabilities from Equity (Topic 480); and Derivatives and Hedging (Topic 815): I. Accounting for Certain Financial Instruments with Down Round Features, and II. Replacement of the Indefinite Deferral for Mandatorily Redeemable Financial Instruments of Certain Nonpublic Entities and Certain Mandatorily Redeemable Noncontrolling Interests with a Scope Exception. The amendments in Part I of this Update change the classification analysis of certain equity-linked financial instruments (or embedded features) with down round features. When determining whether certain financial instruments should be classified as liabilities or equity instruments, a down round feature no longer precludes equity classification when assessing whether the instrument is indexed to an entity’s own stock. The amendments in Part II of this Update recharacterize the indefinite deferral of certain provisions of Topic 480 that now are presented as pending content in the Codification, to a scope exception. Those amendments do not have an accounting effect. For public business entities, the amendments in Part I of this Update are effective for fiscal years, and interim periods within those fiscal years, beginning after December 15, 2018, and should be applied retrospectively to outstanding financial instruments with a down round feature by means of either a cumulative-effect adjustment or for each prior reporting period presented. Early adoption is permitted for all entities, including adoption in an interim period. The Company expects to adopt this standard in its first quarter of 2019, and does not expect this guidance to have a material impact on its consolidated financial statements. In February 2016, the FASB issued ASU No. 2016-02, Leases (Topic 842), which will require, among other items, lessees to recognize most leases as assets and liabilities on the balance sheet. Qualitative and quantitative disclosures will be enhanced to better understand the amount, timing and uncertainty of cash flows arising from leases. The FASB has issued several other subsequent updates including the following: 1) ASU No. 2018-10, Codification Improvements to Topic 842, Leases, which includes sixteen separate narrow-scope amendments to clarify the codification and to correct unintended application of guidance; and 2) ASU No. 2018-11, Leases (Topic 842): Targeted Improvements, which provides entities with relief from the costs of implementing certain aspects of the new leasing standard by allowing them to elect not to recast the comparative periods presented when transitioning to ASC 842. The new lease standard, and the subsequent ASUs that modified Topic 842, are effective for fiscal years beginning after December 15, 2018, and interim periods within those fiscal years, with early adoption permitted. With respect to the adoption of the new standard, as of December 31, 2018, the Company had $34.6 million of undiscounted future lease payments, primarily related to real estate, that is expected to be included in its initial measurement of its lease liabilities and corresponding right of use asset, and $7.2 million of accrued rent that is expected to be reclassified from liability accounts to reduce its beginning right of use asset balance. The Company does not expect the adoption of ASU 2016-02 to have a material impact on its consolidated statements of operations and statements of cash flows.

Summary of Significant Accounting Policies (Tables)

12 Months Ended

Dec. 31, 2018

Accounting Policies [Abstract]

Schedule of restructuring costs

Reconciliations of the beginning and ending total restructuring liability balances are presented below:



	Year Ended December 31,
	2018						2017						2016
	(amounts in thousands)
	On-Going Benefit Costs			Exit Costs			On-Going Benefit Costs			Exit Costs			On-Going Benefit Costs			Exit Costs
Balance at beginning of period	$	87		$	441		$	325		$	273		$	44		$	338
Charged to restructuring costs (a)	1,600			184			522			504			563			190
Payments	(1,131		)	(235		)	(760		)	(336		)	(282		)	(255		)
Balance at end of period	$	556		$	390		$	87		$	441		$	325		$	273

________________

(a) The restructuring costs on the consolidated statements of operations include direct write-offs of $0.4 million related to abandoned locations, as well as other costs of $0.5 million.

Acquisitions (Tables)

12 Months Ended

Dec. 31, 2018

Business Combinations [Abstract]

Schedule of business acquisitions

The following is the estimated fair value of the purchase price for Advantage on July 1, 2017:



	(amounts in thousands)
Purchase price	$	88,000
Net working capital adjustments	(1,438		)
Cash consideration	86,562
Cash acquired	2,833
Total consideration	$	89,395

Schedule of assets acquired and liabilities assumed

The following table is an estimate of the fair value of the assets acquired and liabilities assumed on July 1, 2017.



	(amounts in thousands)
Cash and cash equivalents	$	2,833
Accounts receivable	14,396
Other current assets	392
Property and equipment	333
Goodwill	43,596
Other intangible assets	29,900
Total assets acquired	91,450
Accounts payable and accrued expenses	368
Accrued employee compensation and benefits	1,685
Other current liabilities	2
Total liabilities assumed	2,055
Net assets acquired	$	89,395

Pro forma information



	Year Ended December 31,
	2017		2016
	(unaudited, amounts in thousands except per share data)
Revenue from services	$	916,149	$	934,904

Net income attributable to common shareholders	$	40,255	$	11,391

Net income per common share attributable to common shareholders - basic	$	1.16	$	0.35

Net income per common share attributable to common shareholders - diluted	$	1.09	$	0.25

Revenue Recognition (Tables)

12 Months Ended

Dec. 31, 2018

Revenue from Contract with Customer [Abstract]

Disaggregation of Revenue



	For the year ended December 31, 2018
	Nurse And Allied Staffing Segment		Physician Staffing Segment		Other Human Capital Management Services Segment		Total
	(amounts in thousands)
Temporary Staffing Services	$	705,435	$	76,979	$	—	$	782,414
Other Services	14,867		5,326		13,877		34,070
Total	$	720,302	$	82,305	$	13,877	$	816,484

Goodwill, Trade Names, and Other Intangible Assets (Tables)

12 Months Ended

Dec. 31, 2018

Goodwill and Intangible Assets Disclosure [Abstract]

Acquired Intangible Assets

The Company had the following acquired intangible assets:



	December 31, 2018						December 31, 2017
	Gross Carrying Amount		Accumulated Amortization		Net Carrying Amount		Gross Carrying Amount		Accumulated Amortization		Net Carrying Amount
	(amounts in thousands)
Intangible assets subject to amortization:
Databases	$	30,530	$	9,216	$	21,314	$	42,909	$	18,702	$	24,207
Customer relationships	49,758		23,296		26,462		55,524		25,912		29,612
Non-compete agreements	320		97		223		3,919		3,600		319
Trade names	8,879		1,696		7,183		7,716		878		6,838
Other intangible assets, net	$	89,487	$	34,305	55,182		$	110,068	$	49,092	60,976
Intangible assets not subject to amortization:
Trade names					20,402						26,702
					$	75,584					$	87,678

Estimated Annual Amortization Expense

As of December 31, 2018, estimated annual amortization expense is as follows:



Years Ending December 31:	(amounts in thousands)
2019	$	7,535
2020	7,431
2021	7,131
2022	6,780
2023	6,677
Thereafter	19,628
	$	55,182

Changes in Carrying Amount of Goodwill by Segment

The changes in the carrying amount of goodwill by segment are as follows:



	Nurse and Allied Staffing Segment			Physician Staffing Segment			Other Human Capital Management Services Segment			Total
	(amounts in thousands)
Balances as of December 31, 2017
Aggregate goodwill acquired	$	347,873		$	43,405		$	19,307		$	410,585
Sale of business	—			—			(9,889		)	(9,889		)
Accumulated impairment loss	(259,732		)	(23,375		)	—			(283,107		)
Goodwill, net of impairment loss	88,141			20,030			9,418			117,589

Changes to aggregate goodwill in 2018
Goodwill acquired (a)	694			—			—			694
Impairment charge	—			(17,223		)	—			(17,223		)

Balances as of December 31, 2018
Aggregate goodwill acquired	348,567			43,405			19,307			411,279
Sale of business	—			—			(9,889		)	(9,889		)
Accumulated impairment loss	(259,732		)	(40,598		)	—			(300,330		)
Goodwill, net of impairment loss	$	88,835		$	2,807		$	9,418		$	101,060

_______________


(a)	Goodwill acquired from the acquisition of AP Staffing. See Note 4 - Acquisitions.

Property and Equipment (Tables)

12 Months Ended

Dec. 31, 2018

Property, Plant and Equipment [Abstract]

Property and Equipment

The Company's property and equipment consists of the following:



		December 31,
	Useful Lives	2018			2017
		(amounts in thousands)

Computer equipment	3-5 years	$	6,257		$	6,432
Computer software	3-5 years	26,651			24,933
Office equipment	5-7 years	1,514			1,379
Furniture and fixtures	5-7 years	4,966			4,680
Leasehold improvements	(a)	7,716			7,340
		47,104			44,764
Less accumulated depreciation and amortization		(33,476		)	(30,678		)
		$	13,628		$	14,086

_______________


(a)	See Note 2 – Summary of Significant Accounting Policies.

Balance Sheet Details (Tables)

12 Months Ended

Dec. 31, 2018

Balance Sheet Related Disclosures [Abstract]

Balance Sheet Details



	December 31,
	2018		2017
	(amounts in thousands)
Insurance recovery receivable:
Insurance recovery for workers’ compensation	$	2,295	$	1,623
Insurance recovery for professional liability	1,891		1,874
	$	4,186	$	3,497

Other non-current assets:
Insurance recovery for workers’ compensation claims	$	5,280	$	6,093
Insurance recovery for professional liability claims	9,924		10,011
Non-current security deposits	982		1,095
Non-current income tax receivable	522		1,044
Deferred compensation assets	433		—
Net debt issuance costs	935		985
	$	18,076	$	19,228

Accrued compensation and benefits:
Salaries and payroll taxes	$	15,884	$	16,342
Bonuses	1,476		2,067
Accrual for workers’ compensation claims	6,454		5,957
Accrual for professional liability claims	2,786		2,683
Accrual for healthcare benefits	5,158		5,105
Accrual for vacation	1,574		2,117
	$	33,332	$	34,271

Long-term accrued claims:
Accrual for workers’ compensation claims	$	12,997	$	13,160
Accrual for professional liability claims	16,302		15,597
	$	29,299	$	28,757

Other long-term liabilities:
Non-current deferred tax liabilities	$	95	$	105
Deferred compensation	1,725		1,467
Deferred rent	6,039		6,875
Long-term unrecognized tax benefits	590		485
Other	318		344
	$	8,767	$	9,276

Debt (Tables)

12 Months Ended

Dec. 31, 2018

Debt Disclosure [Abstract]

Long-term Debt

The Company's long-term debt consists of the following:



	December 31, 2018						December 31, 2017
	Principal			Debt Issuance Costs			Principal			Debt Issuance Costs
	(amounts in thousands)

Term Loan, interest of 4.80% and 3.61% at December 31, 2018 and 2017, respectively	$	83,876		$	(697	)	$	100,000		$	(866	)
Less current portion	(5,235		)	—			(6,875		)	—
Long-term debt	$	78,641		$	(697	)	$	93,125		$	(866	)



Level	Consolidated Net Leverage Ratio	Eurodollar Loans, LIBOR Index Rate Loans and Letter of Credit Fee	Base Rate Loans	Commitment Fee
I	Less than 1.50:1.00	1.75%	0.75%	0.25%
II	Greater than or equal to 1.50:1.00 but less than 2.00:1.00	2.00%	1.00%	0.30%
III	Greater than or equal to 2.00:1.00 but less than 2.50:1.00	2.25%	1.25%	0.30%
IV	Greater than or equal to 2.50:1.00 but less than 3.00:1.00	2.50%	1.50%	0.35%
V	Greater than or equal to 3.00:1.00	2.75%	1.75%	0.40%

Aggregate scheduled maturities of debt

As of December 31, 2018, the aggregate scheduled maturities of debt are as follows:



	Term Loan
	(amounts in thousands)
Through Years Ending December 31:
2019	$	5,235
2020	5,671
2021	6,980
2022	65,990
2023	—
Total	$	83,876

Fair Value Measurements (Tables)

12 Months Ended

Dec. 31, 2018

Fair Value Disclosures [Abstract]

Summary of Estimated Fair Values of Financial Assets and Liabilities Measured on a Recurring Basis

The table which follows summarizes the estimated fair value of the Company’s financial assets and liabilities measured on a recurring basis:

Fair Value Measurements



	December 31, 2018		December 31, 2017
Financial Liabilities:	(amounts in thousands)
(Level 1)
Deferred compensation	$	1,725	$	1,467
(Level 2)
Interest rate swaps	$	234	$	—
(Level 3)
Contingent consideration liabilities	$	7,689	$	5,368

Fair Value, Liabilities Measured on recurring Basis, Unobservable Input Reconciliation



	Contingent Consideration			Convertible Notes
	Liabilities			Derivative Liability
	(amounts in thousands)

December 31, 2016	$	5,603		$	27,532
Payments/Settlements	(280		)	(25,951		)
Accretion expense	967			—
Valuation gain for the period	(922		)	(1,581		)
December 31, 2017	5,368			—
Payments	(280		)	—
Accretion expense	903			—
Valuation loss for the period	1,698			—
December 31, 2018	$	7,689		$	—

Carrying Amounts and Estimated Fair Values of Significant Financial Instrument that were not Measured at Fair Value

The carrying amounts and estimated fair value of the Company’s significant financial instruments that were not measured at fair value are as follows:



	December 31, 2018				December 31, 2017
	Carrying Amount		Fair Value		Carrying Amount		Fair Value
	(amounts in thousands)
Financial Liabilities:
(Level 2)
Term Loan, net	$	83,179	$	81,800	$	99,134	$	100,500

Commitments and Contingencies (Tables)

12 Months Ended

Dec. 31, 2018

Commitments and Contingencies Disclosure [Abstract]

Future Minimum Lease Payments

Future minimum lease payments, as of December 31, 2018, associated with these agreements with terms of one year or more are as follows:



Years Ending December 31:	(amounts in thousands)
2019	$	7,451
2020	6,287
2021	5,407
2022	4,857
2023	4,700
Thereafter	5,893
	$	34,595

Income Taxes (Tables)

12 Months Ended

Dec. 31, 2018

Income Tax Disclosure [Abstract]

Components of Income (Loss) Before Income Taxes

The components of the Company's (loss) income before income taxes are as follows:



	Year Ended December 31,
	2018			2017		2016
	(amounts in thousands)
United States	$	(18,619	)	$	3,826	$	3,309
Foreign	424			475		1,236
(Loss) income before income taxes	$	(18,195	)	$	4,301	$	4,545

Components of Income Tax Expense (Benefit)

The components of the Company’s income tax benefit are as follows:



	Year Ended December 31,
	2018			2017			2016
	(amounts in thousands)
Current:
Federal	$	43		$	(555	)	$	227
State	620			(273		)	587
Foreign	269			139			322
Total	932			(689		)	1,136
Deferred:
Federal	(2,137		)	(23,245		)	(4,114		)
State	(1,277		)	(10,684		)	(866		)
Foreign	4			117			(342		)
Total	(3,410		)	(33,812		)	(5,322		)
Income tax benefit	$	(2,478	)	$	(34,501	)	$	(4,186	)

Significant Components of Deferred Tax Assets and Liabilities

Significant components of the Company’s deferred tax assets and liabilities are as follows:



	December 31,
	2018			2017
	(amounts in thousands)
Deferred Tax Assets:
Accrued other and prepaid expenses	$	2,734		$	2,955
Allowance for doubtful accounts	607			624
Intangible Assets	11,300			7,776
Net operating loss carryforwards	15,717			14,718
Accrued professional liability claims	1,952			1,709
Accrued workers’ compensation claims	2,729			2,512
Share-based compensation	646			734
Credit carryforwards	188			189
Other	542			444
Gross deferred tax assets	36,415			31,661
Valuation allowance	(1,189		)	(1,076		)
	35,226			30,585
Deferred Tax Liabilities:
Depreciation	(52		)	(41		)
Indefinite intangibles	(11,136		)	(9,964		)
Tax on unrepatriated earnings	(383		)	(466		)
	(11,571		)	(10,471		)
Net deferred taxes	$	23,655		$	20,114

Reconciliation of Income Tax Computed At U. S. Federal Statutory Rate to Income Tax (Benefit) Expense

The reconciliation of income tax computed at the U.S. federal statutory rate to income tax benefit is as follows:



	Year Ended December 31,
	2018			2017			2016
	(amounts in thousands)
Tax at U.S. statutory rate	$	(3,821	)	$	1,506		$	1,591
State taxes, net of federal benefit	(543		)	(1,374		)	344
Noncontrolling interest	(252		)	(455		)	(260		)
Non-deductible items (a)	625			2,676			1,546
Foreign tax expense	180			175			(5		)
Valuation allowances	—			(45,354		)	(8,379		)
Uncertain tax positions	1,629			1,145			1,090
Return to provision	(458		)	—			—
Federal rate change	—			8,011			—
Other	162			(831		)	(113		)
Income tax benefit	$	(2,478	)	$	(34,501	)	$	(4,186	)

________________

(a) Includes non-deductible meals and incidentals, miscellaneous non-deductible items, and beginning in 2018, non-deductible stock-based compensation.

Reconciliation of Beginning and Ending Amounts of Unrecognized Tax Benefits

A reconciliation of the beginning and ending amounts of unrecognized tax benefits is as follows:



	2018		2017			2016
	(amounts in thousands)
Balance at January 1	$	3,807	$	5,180		$	4,071
Additions based on tax positions related to the current year	1,401		1,145			1,054
Additions based on tax positions related to prior years	204		—			55
Reductions based on settlements of tax positions related to prior years	—		(439		)	—
2017 Tax Act federal tax rate change	—		(1,859		)	—
Other	—		(220		)	—
Balance at December 31	$	5,412	$	3,807		$	5,180

Stockholders' Equity (Tables)

12 Months Ended

Dec. 31, 2018

Equity [Abstract]

Summary of Restricted Stock Award Activity

The following table summarizes restricted stock awards and performance stock awards activity issued under the 2017 Plan for the year ended December 31, 2018:



	Restricted Stock Awards				Performance Stock Awards
	Number of Shares		Weighted Average Grant Date Fair Value		Number of Target Shares		Weighted Average Grant Date Fair Value
Unvested restricted stock awards, January 1, 2018	515,601		$	13.03	257,575		$	13.49
Granted	391,108		$	10.96	238,328		$	11.11
Vested	(219,881	)	$	12.64	(66,692	)	$	11.63
Forfeited	(97,708	)	$	13.18	(64,062	)	$	13.03
Unvested restricted stock awards, December 31, 2018	589,120		$	12.00	365,149		$	12.35

Stock Options and Stock Appreciation Rights Granted and Exercised

The following table represents information about stock options and stock appreciation rights exercised in each year.



	Year Ended December 31,
	2018		2017		2016
	(amounts in thousands)
Total intrinsic value of options exercised	$	234	$	516	$	1,323

Summary of Share Option Plans Activities

The following table summarizes the Company’s activities with respect to all of its share option plans (issued under the 2014 Plan and the 1999 Plan) for the year ended December 31, 2018:



	Number of Shares		Option Price	Weighted Average Exercise Price	Weighted- Average Remaining Contractual Life (in years)	Aggregate Intrinsic Value (amounts in thousands)
Share options outstanding, January 1, 2018	94,500		$4.16-$7.44	$5.19
Granted	—		—	—
Exercised	(40,500	)	$4.16-$7.44	$5.46
Forfeited/expired	(2,500	)	$7.44	$7.44
Share options outstanding and exercisable, December 31, 2018	51,500		$4.35-$5.21	$4.87	1.02	$	127

Earnings Per Share (Tables)

12 Months Ended

Dec. 31, 2018

Earnings Per Share [Abstract]

Components of Numerator and Denominator for Computation of Basic and Diluted Earnings per Share

The following table sets forth the components of the numerator and denominator for the computation of the basic and diluted earnings per share:



	Year Ended December 31,
	2018			2017			2016
	(amounts in thousands, except per share data)
Numerator:
Net (loss) income attributable to common shareholders - Basic	$	(16,951	)	$	37,513		$	7,967
Interest on Convertible Notes	—			694			3,383
Gain on derivative liability	—			(1,581		)	(5,805		)
Net (loss) income attributable to common shareholders - Diluted	$	(16,951	)	$	36,626		$	5,545

Denominator:
Weighted average common shares - Basic	35,657			35,018			32,132
Effective of diluted shares:
Share-based awards	—			425			593
Convertible Notes	—			723			3,521
Weighted average common shares - Diluted	35,657			36,166			36,246

Net (loss) income per share attributable to common shareholders - Basic	$	(0.48	)	$	1.07		$	0.25

Net (loss) income per share attributable to common shareholders - Diluted	$	(0.48	)	$	1.01		$	0.15

Schedule of Antidilutive Securities Excluded from Computation of Earnings Per Share



	Year Ended December 31,
	2018	2017	2016
	(amounts in thousands)
Share-based awards	373	118	—

Segment Data (Tables)

12 Months Ended

Dec. 31, 2018

Segment Reporting [Abstract]

Information on Operating Segments and Reconciliation to Income From Operations

Information on operating segments and a reconciliation to income from operations for the periods indicated are as follows:



	Year Ended December 31,
	2018			2017			2016
	(amounts in thousands)
Revenues:
Nurse and Allied Staffing	$	720,302		$	758,267		$	721,486
Physician Staffing	82,305			93,610			98,283
Other Human Capital Management Services	13,877			13,171			13,768
	$	816,484		$	865,048		$	833,537
Contribution income:
Nurse and Allied Staffing	$	66,365		$	73,614		$	71,992
Physician Staffing	4,755			5,256			8,265
Other Human Capital Management Services	598			(357		)	(535		)
	71,718			78,513			79,722

Unallocated corporate overhead (a)	44,589			39,190			38,400
Depreciation and amortization	11,780			10,174			9,182
Acquisition and integration costs	491			1,975			78
Acquisition-related contingent consideration	2,557			44			814
Restructuring costs	2,758			1,026			753
Impairment charges (b)	22,423			14,356			24,311
(Loss) income from operations	$	(12,880	)	$	11,748		$	6,184

_______________


(a)	The Company has been centralizing administrative functions to gain efficiencies, which have been recorded in unallocated corporate overhead, which includes corporate compensation and benefits, and general and administrative expenses including rent and utilities, computer supplies and expenses, insurance, professional expenses, corporate-wide projects (initiatives), and public company expenses.


(b)	See Note 5 - Goodwill, Trade Names, and Other Intangible Assets.

Quarterly Financial Data (Unaudited) (Tables)

12 Months Ended

Dec. 31, 2018

Quarterly Financial Information Disclosure [Abstract]

Quarterly Financial Data



	First Quarter		Second Quarter		Third Quarter			Fourth Quarter
2018	(amounts in thousands, except per share data)
Revenue from services	$	210,288	$	204,572	$	200,717		$	200,907
Gross profit (a)	53,753		53,689		51,562			50,559
Consolidated net (loss) income	1,920		1,824		(118		)	(19,343		)
Net income (loss) attributable to common shareholders	1,642		1,539		(441		)	(19,691		)
Net income (loss) per share attributable to common shareholders - Basic (b)	$	0.05	$	0.04	$	(0.01	)	$	(0.55	)
Net income (loss) per share attributable to common shareholders - Diluted (b)	$	0.05	$	0.04	$	(0.01	)	$	(0.55	)



	First Quarter			Second Quarter		Third Quarter		Fourth Quarter
2017	(amounts in thousands, except per share data)
Revenue from services	$	207,573		$	209,313	$	228,488	$	219,674
Gross profit (a)	53,275			56,528		60,480		58,303
Consolidated net (loss) income	(1,718		)	5,220		7,044		28,256
Net (loss) income attributable to common shareholders	(2,010		)	4,850		6,723		27,950
Net (loss) income per share attributable to common shareholders - Basic (b)	$	(0.06	)	$	0.14	$	0.19	$	0.78
Net (loss) income per share attributable to common shareholders - Diluted	$	(0.08	)	$	0.13	$	0.19	$	0.77

________________

(a) Excludes depreciation and amortization.

The following items are the most significant items that impact the comparability and presentation of our consolidated data:


•	During the fourth quarter of 2018 and 2017, the Company recorded non-cash impairment charges of $22.4 million and $14.4 million, respectively, related to the goodwill and trade names of Physician Staffing. See Note 5 - Goodwill, Trade Names, and Other Intangible Assets.


•	During the first quarter of 2017, the Company settled its Convertible Notes and recognized a loss on extinguishment of debt of $5.0 million. See Note 8 - Debt.

•


•	In the fourth quarter of 2017, the Company benefited from a $43.3 million reversal of valuation allowance on its net deferred tax assets, offset by additional income tax expense of $8.0 million related to the remeasurement of its deferred tax assets as a result of the 2017 Tax Act. See Note 13 - Income Taxes.


•	The Company recorded changes in the fair value of Convertible Notes derivative liability, recording a gain in the first quarter of 2017 of $1.6 million. See Note 9 - Derivatives.

Summary of Significant Accounting Policies - Narrative (Details) - USD ($)	12 Months Ended			46 Months Ended
	Dec. 31, 2018	Dec. 31, 2017	Dec. 31, 2016	Dec. 31, 2018
Significant Accounting Policies [Line Items]
Interest income	$ 400,000	$ 100,000	$ 100,000
Outstanding standby letters of credit as collateral	18,800,000	19,600,000		$ 18,800,000
Equity compensation	3,600,000	4,100,000	3,400,000
Advertising costs	6,700,000	7,600,000	10,200,000
Cumulative impact of currency fluctuations	1,300,000	1,200,000		1,300,000
Net change in derivative instruments	200,000			200,000
Income tax expense related to deferred tax asset	100,000	200,000
Income tax expense (benefit) related to items of other comprehensive (loss) income			$ 0
Occurrence-Based Professional Liability Insurance \| MDA Holdings Inc
Significant Accounting Policies [Line Items]
Coverage for professional liability claims				500,000.0
Claims-Based Liability Insurance
Significant Accounting Policies [Line Items]
Self insured retention per claim	500,000			500,000
Claims-Based Liability Insurance \| MDA Holdings Inc
Significant Accounting Policies [Line Items]
Letter of credit for malpractice claims	$ 1,800,000	$ 2,000,000		$ 1,800,000
Minimum
Significant Accounting Policies [Line Items]
Contract terms	15 days
Short term leases period	3 months
Estimated useful life of assets	3 years
Intangible assets- useful life	1 year
Minimum \| Computer software
Significant Accounting Policies [Line Items]
Estimated useful life of assets	3 years
Maximum
Significant Accounting Policies [Line Items]
Contract terms	60 days
Short term leases period	6 months
Estimated useful life of assets	7 years
Intangible assets- useful life	16 years
Maximum \| Computer software
Significant Accounting Policies [Line Items]
Estimated useful life of assets	5 years

Summary of Significant Accounting Policies - Revenue Recognition (Details) - USD ($) $ in Millions	9 Months Ended	12 Months Ended
	Sep. 30, 2018	Dec. 31, 2018	Dec. 31, 2017	Dec. 31, 2016
Concentration Risk [Line Items]
Unbilled contracts receivable		$ 44.1	$ 41.8
Services \| Revenue
Concentration Risk [Line Items]
Concentration risk percentage		5.00%	5.00%	5.00%
Minimum
Concentration Risk [Line Items]
Contract terms		15 days
Minimum \| Temporary Staffing Services
Concentration Risk [Line Items]
Contract terms	15 days
Maximum
Concentration Risk [Line Items]
Contract terms		60 days
Maximum \| Temporary Staffing Services
Concentration Risk [Line Items]
Contract terms	60 days

Summary of Significant Accounting Policies - Reconciliation of Restructuring Liabilities (Details) - USD ($) $ in Thousands	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017	Dec. 31, 2016
Restructuring Reserve [Roll Forward]
Charged to restructuring costs (a)	$ 2,758	$ 1,026	$ 753
Cost Optimization Project
Restructuring Reserve [Roll Forward]
Direct write offs related to abandoned locations	400
Cost Optimization Project \| On-Going Benefit Costs
Restructuring Reserve [Roll Forward]
Balance at beginning of period	87	325	44
Charged to restructuring costs (a)	1,600	522	563
Payments	(1,131)	(760)	(282)
Balance at end of period	556	87	325
Cost Optimization Project \| Exit Costs
Restructuring Reserve [Roll Forward]
Balance at beginning of period	441	273	338
Charged to restructuring costs (a)	184	504	190
Payments	(235)	(336)	(255)
Balance at end of period	390	$ 441	$ 273
Cost Optimization Project \| Other costs
Restructuring Reserve [Roll Forward]
Charged to restructuring costs (a)	$ 500

Summary of Significant Accounting Policies - ASU Adoption (Details) $ in Thousands	Dec. 31, 2018 USD ($)
New Accounting Pronouncements or Change in Accounting Principle [Line Items]
Undiscounted future lease payments	$ 34,595
ASU 2016-02
New Accounting Pronouncements or Change in Accounting Principle [Line Items]
Accrued rent	$ (7,200)

Acquisitions - American Personnel, Inc. (Details) - USD ($) $ in Thousands		12 Months Ended
	Dec. 01, 2018	Dec. 31, 2018	Dec. 31, 2017	Dec. 31, 2016
Business Acquisition [Line Items]
Goodwill		$ 101,060	$ 117,589
Acquisition related costs		491	$ 1,975	$ 78
American Personnel, Inc.
Business Acquisition [Line Items]
Purchase price	$ 2,000
Assets acquired	$ 400
Weighted average useful life of assets acquired	10 years
Goodwill	$ 700
Acquisition related costs		$ 200

Revenue Recognition - Disaggregation of Revenue (Details) $ in Thousands	12 Months Ended
	Dec. 31, 2018 USD ($)
Disaggregation of Revenue [Line Items]
Revenue	$ 816,484
Temporary Staffing Services
Disaggregation of Revenue [Line Items]
Revenue	782,414
Other Services
Disaggregation of Revenue [Line Items]
Revenue	34,070
Nurse and Allied Staffing Segment
Disaggregation of Revenue [Line Items]
Revenue	720,302
Nurse and Allied Staffing Segment \| Temporary Staffing Services
Disaggregation of Revenue [Line Items]
Revenue	705,435
Nurse and Allied Staffing Segment \| Other Services
Disaggregation of Revenue [Line Items]
Revenue	14,867
Physician Staffing Segment
Disaggregation of Revenue [Line Items]
Revenue	82,305
Physician Staffing Segment \| Temporary Staffing Services
Disaggregation of Revenue [Line Items]
Revenue	76,979
Physician Staffing Segment \| Other Services
Disaggregation of Revenue [Line Items]
Revenue	5,326
Other Human Capital Management Services Segment
Disaggregation of Revenue [Line Items]
Revenue	13,877
Other Human Capital Management Services Segment \| Temporary Staffing Services
Disaggregation of Revenue [Line Items]
Revenue	0
Other Human Capital Management Services Segment \| Other Services
Disaggregation of Revenue [Line Items]
Revenue	$ 13,877

Acquisitions - Advantage RN (Details) - USD ($) $ in Thousands			3 Months Ended		6 Months Ended	12 Months Ended
	Jul. 28, 2017	Jul. 01, 2017	Mar. 31, 2019	Sep. 30, 2017	Dec. 31, 2017	Dec. 31, 2018	Dec. 31, 2017	Dec. 31, 2016
Business Acquisition [Line Items]
Cash consideration						$ 1,930	$ 85,977	$ 1,900
Proceeds from issuance of debt						0	$ 62,000	$ 40,000
Advantage RN, LLC
Business Acquisition [Line Items]
Cash consideration		$ 86,562
Net working capital adjustment		600
Reimbursement from working capital adjustment settled				$ 800
Contingent liability						$ 100
Release of remaining contingent liability					$ 500
Escrow payment related to tax liabilities		14,500
Escrow payment related to post-close liabilities		7,500
Release of escrow to seller	$ 7,300
Escrow deposit related to tax liabilities	$ 7,200
Consideration transferred, available cash		19,900
Revenue since acquisition					47,000
Net income since acquisition					$ 3,800
Deferred Consideration Transferred \| Advantage RN, LLC
Business Acquisition [Line Items]
Contingent liability		$ 600
Period of deferred consideration		20 months
Credit Agreement
Business Acquisition [Line Items]
Proceeds from issuance of debt		$ 66,900
Term Loan, net \| Incremental Term Loan
Business Acquisition [Line Items]
Proceeds from issuance of debt		40,000
Purchase Price \| Advantage RN, LLC
Business Acquisition [Line Items]
Purchase price		$ 88,000
Forecast \| Advantage RN, LLC
Business Acquisition [Line Items]
Release of escrow to seller			$ 7,000
Escrow deposit related to post close liabilities			$ 500

Acquisitions - Fair Value of Purchase Price (Details) - USD ($) $ in Thousands		12 Months Ended
	Jul. 01, 2017	Dec. 31, 2018	Dec. 31, 2017	Dec. 31, 2016
Business Acquisition [Line Items]
Cash consideration		$ 1,930	$ 85,977	$ 1,900
Advantage RN, LLC
Business Acquisition [Line Items]
Cash consideration	$ 86,562
Cash acquired	2,833
Total consideration	89,395
Purchase Price \| Advantage RN, LLC
Business Acquisition [Line Items]
Purchase price	88,000
Net Working Capital Adjustments \| Advantage RN, LLC
Business Acquisition [Line Items]
Purchase price	$ (1,438)

Acquisitions - Assets Acquired and Liabilities Assumed (Details) - USD ($) $ in Thousands	Dec. 31, 2018	Dec. 31, 2017	Jul. 01, 2017
Business Acquisition [Line Items]
Goodwill	$ 101,060	$ 117,589
Advantage RN, LLC
Business Acquisition [Line Items]
Cash and cash equivalents			$ 2,833
Accounts receivable			14,396
Other current assets			392
Property and equipment			333
Goodwill			43,596
Other intangible assets			29,900
Total assets acquired			91,450
Accounts payable and accrued expenses			368
Accrued employee compensation and benefits			1,685
Other current liabilities			2
Total liabilities assumed			2,055
Net assets acquired			$ 89,395

Acquisitions - Additional Information (Details) - USD ($) $ in Thousands		12 Months Ended
	Jul. 01, 2017	Dec. 31, 2018	Dec. 31, 2017	Dec. 31, 2016
Business Acquisition [Line Items]
Acquisition related costs		$ 491	$ 1,975	$ 78
Advantage RN, LLC
Business Acquisition [Line Items]
Assets acquired	$ 29,900
Weighted average useful life of assets acquired	10 years
Goodwill expected to be deductible	$ 43,600
Acquisition related costs			$ 2,000
Trade names \| Advantage RN, LLC
Business Acquisition [Line Items]
Assets acquired	$ 4,500
Weighted average useful life of assets acquired	10 years
Customer relationships \| Advantage RN, LLC
Business Acquisition [Line Items]
Assets acquired	$ 13,800
Weighted average useful life of assets acquired	10 years
Databases \| Advantage RN, LLC
Business Acquisition [Line Items]
Assets acquired	$ 11,300
Weighted average useful life of assets acquired	10 years
Non-compete agreements \| Advantage RN, LLC
Business Acquisition [Line Items]
Assets acquired	$ 300
Weighted average useful life of assets acquired	5 years

Acquisitions - Pro Forma (Details) - USD ($) $ / shares in Units, $ in Thousands	3 Months Ended								12 Months Ended
	Dec. 31, 2018	Sep. 30, 2018	Jun. 30, 2018	Mar. 31, 2018	Dec. 31, 2017	Sep. 30, 2017	Jun. 30, 2017	Mar. 31, 2017	Dec. 31, 2018	Dec. 31, 2017	Dec. 31, 2016
Business Acquisition, Pro Forma Information, Nonrecurring Adjustment [Line Items]
Consolidated net (loss) income	$ (19,343)	$ (118)	$ 1,824	$ 1,920	$ 28,256	$ 7,044	$ 5,220	$ (1,718)	$ (15,717)	$ 38,802	$ 8,731
Revenue from services										916,149	934,904
Net income attributable to common shareholders										$ 40,255	$ 11,391
Net income per share attributable to common shareholders - Basic (in dollars per share)										$ 1.16	$ 0.35
Net income per share attributable to common shareholders - Diluted (in dollars per share)										$ 1.09	$ 0.25
Acquisition-related costs
Business Acquisition, Pro Forma Information, Nonrecurring Adjustment [Line Items]
Consolidated net (loss) income										$ 2,000

- Definition

The consolidated profit or loss for the period, net of income taxes, including the portion attributable to the noncontrolling interest.

+ References

Reference 1: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 220
-SubTopic 10
-Section 45
-Paragraph 1A
-Subparagraph (a)
-URI http://asc.fasb.org/extlink&oid=114867106&loc=SL7669619-108580

Reference 2: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 810
-SubTopic 10
-Section 50
-Paragraph 1A
-Subparagraph (a)(1)
-URI http://asc.fasb.org/extlink&oid=109239629&loc=SL4573702-111684

Reference 3: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 220
-SubTopic 10
-Section 45
-Paragraph 1B
-Subparagraph (a)
-URI http://asc.fasb.org/extlink&oid=114867106&loc=SL7669625-108580

Reference 4: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 810
-SubTopic 10
-Section 50
-Paragraph 1A
-Subparagraph (c)(1)
-URI http://asc.fasb.org/extlink&oid=109239629&loc=SL4573702-111684

Reference 5: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 280
-SubTopic 10
-Section 50
-Paragraph 22
-URI http://asc.fasb.org/extlink&oid=115929826&loc=d3e8736-108599

Reference 6: http://www.xbrl.org/2003/role/exampleRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 810
-SubTopic 10
-Section 55
-Paragraph 4J
-URI http://asc.fasb.org/extlink&oid=84234705&loc=SL4591551-111686

Reference 7: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 230
-SubTopic 10
-Section 45
-Paragraph 2
-URI http://asc.fasb.org/extlink&oid=109223946&loc=d3e3000-108585

Reference 8: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 810
-SubTopic 10
-Section 45
-Paragraph 19
-URI http://asc.fasb.org/extlink&oid=108774443&loc=SL4569616-111683

Reference 9: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 280
-SubTopic 10
-Section 50
-Paragraph 32
-Subparagraph (c)
-URI http://asc.fasb.org/extlink&oid=115929826&loc=d3e8933-108599

Reference 10: http://www.xbrl.org/2003/role/exampleRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 810
-SubTopic 10
-Section 55
-Paragraph 4K
-URI http://asc.fasb.org/extlink&oid=84234705&loc=SL4591552-111686

+ Details

Acquisitions - Narrative (Details) - USD ($) $ in Millions				3 Months Ended		21 Months Ended
Acquisitions - Narrative (Details) - USD ($) $ in Millions	May 03, 2017	Oct. 30, 2015	Jun. 30, 2014	Dec. 31, 2017	Mar. 31, 2016	Mar. 31, 2016	Dec. 31, 2018	Dec. 31, 2016	Dec. 01, 2016	Apr. 01, 2016
US Resources Healthcare, LLC
Business Acquisition [Line Items]
Contingent consideration, range of outcomes, high									$ 4.5
Mediscan
Business Acquisition [Line Items]
Contingent consideration, range of outcomes, high		$ 7.0
Cash purchase price paid at closing		29.9
Cash consideration plus working capital estimate		28.0
Fair value of shares		$ 4.7
Fair value of shares (in shares)		349,871
Net working capital adjustment					$ 0.0
Release of escrow to seller	$ 5.0
Medical Staffing Network
Business Acquisition [Line Items]
Release of remaining contingent liability						$ 0.4
Contingent consideration liabilities										$ 2.1
Potential Earnout, Attainment of Specific Performance Criteria in 2017 \| US Resources Healthcare, LLC
Business Acquisition [Line Items]
Contingent consideration, range of outcomes, high									1.0
Potential Earnout, Attainment of Specific Performance Criteria in 2017 \| Mediscan
Business Acquisition [Line Items]
Contingent consideration, range of outcomes, high		$ 3.5
Potential Earnout, Attainment of Specific Performance Criteria in 2018 \| US Resources Healthcare, LLC
Business Acquisition [Line Items]
Contingent consideration, range of outcomes, high									2.0
Potential Earnout, Attainment of Specific Performance Criteria in 2019 \| US Resources Healthcare, LLC
Business Acquisition [Line Items]
Contingent consideration, range of outcomes, high									$ 1.5
Acquisition-Related Contingent Consideration \| US Resources Healthcare, LLC
Business Acquisition [Line Items]
Release of remaining contingent liability				$ 1.3
Assumed Additional Contingent Purchase Price Liabilities \| Mediscan
Business Acquisition [Line Items]
Contingent consideration, range of outcomes, high				$ 0.3			$ 0.3	$ 0.3
Contingent consideration liabilities							$ 7.7
Potential Earnout, Attainment of Specific Performance Criteria in 2016 \| Mediscan
Business Acquisition [Line Items]
Contingent consideration, range of outcomes, high		$ 3.5
Deferred Consideration Transferred \| Medical Staffing Network
Business Acquisition [Line Items]
Contingent consideration liabilities			$ 2.5
Period of deferred consideration			21 months

Goodwill, Trade Names, and Other Intangible Assets - Acquired Intangible Assets (Details) - USD ($) $ in Thousands	Dec. 31, 2018	Oct. 01, 2018	Dec. 31, 2017
Finite-Lived and Indefinite-Lived Intangible Assets [Line Items]
Gross Carrying Amount	$ 89,487		$ 110,068
Accumulated Amortization	34,305		49,092
Net Carrying Amount	55,182		60,976
Trade names	20,402		26,702
Intangible assets not subject to amortization, net	75,584		87,678
Databases
Finite-Lived and Indefinite-Lived Intangible Assets [Line Items]
Gross Carrying Amount	30,530		42,909
Accumulated Amortization	9,216		18,702
Net Carrying Amount	21,314		24,207
Customer relationships
Finite-Lived and Indefinite-Lived Intangible Assets [Line Items]
Gross Carrying Amount	49,758		55,524
Accumulated Amortization	23,296		25,912
Net Carrying Amount	26,462		29,612
Non-compete agreements
Finite-Lived and Indefinite-Lived Intangible Assets [Line Items]
Gross Carrying Amount	320		3,919
Accumulated Amortization	97		3,600
Net Carrying Amount	223		319
Trade names
Finite-Lived and Indefinite-Lived Intangible Assets [Line Items]
Gross Carrying Amount	8,879		7,716
Accumulated Amortization	1,696		878
Net Carrying Amount	$ 7,183	$ 1,100	$ 6,838

Goodwill, Trade Names, and Other Intangible Assets - Estimated Annual Amortization Expense (Details) - USD ($) $ in Thousands	Dec. 31, 2018	Dec. 31, 2017
Goodwill and Intangible Assets Disclosure [Abstract]
2019	$ 7,535
2020	7,431
2021	7,131
2022	6,780
2023	6,677
Thereafter	19,628
Net Carrying Amount	$ 55,182	$ 60,976

Goodwill, Trade Names, and Other Intangible Assets - Changes in Carrying Amount of Goodwill by Segment (Details) - USD ($) $ in Thousands		3 Months Ended		12 Months Ended
	Jun. 30, 2016	Dec. 31, 2018	Dec. 31, 2017	Dec. 31, 2018
Goodwill balances
Goodwill, net of impairment loss, beginning of period				$ 117,589
Goodwill, Translation and Purchase Accounting Adjustments [Abstract]
Goodwill, net of impairment loss, end of period		$ 101,060	$ 117,589	101,060
Physician Staffing Segment
Goodwill, Translation and Purchase Accounting Adjustments [Abstract]
Impairment charge	$ (17,700)	(17,200)	(5,700)
Operating Segments
Goodwill balances
Goodwill, net of impairment loss, beginning of period				117,589
Sale of business, beginning of period				(9,889)
Accumulated impairment loss, beginning of period				(283,107)
Aggregate goodwill acquired, beginning of period				410,585
Goodwill, Translation and Purchase Accounting Adjustments [Abstract]
Goodwill acquired				694
Impairment charge				(17,223)
Aggregate goodwill acquired, end of period		411,279	410,585	411,279
Sale of business, end of period		(9,889)	(9,889)	(9,889)
Accumulated impairment loss, end of period		300,330	283,107	300,330
Goodwill, net of impairment loss, end of period		101,060	117,589	101,060
Operating Segments \| Nurse and Allied Staffing Segment
Goodwill balances
Goodwill, net of impairment loss, beginning of period				88,141
Sale of business, beginning of period				0
Accumulated impairment loss, beginning of period				(259,732)
Aggregate goodwill acquired, beginning of period				347,873
Goodwill, Translation and Purchase Accounting Adjustments [Abstract]
Goodwill acquired				694
Impairment charge				0
Aggregate goodwill acquired, end of period		348,567	347,873	348,567
Sale of business, end of period		0	0	0
Accumulated impairment loss, end of period		259,732	259,732	259,732
Goodwill, net of impairment loss, end of period		88,835	88,141	88,835
Operating Segments \| Physician Staffing Segment
Goodwill balances
Goodwill, net of impairment loss, beginning of period				20,030
Sale of business, beginning of period				0
Accumulated impairment loss, beginning of period				(23,375)
Aggregate goodwill acquired, beginning of period				43,405
Goodwill, Translation and Purchase Accounting Adjustments [Abstract]
Goodwill acquired				0
Impairment charge				(17,223)
Aggregate goodwill acquired, end of period		43,405	43,405	43,405
Sale of business, end of period		0	0	0
Accumulated impairment loss, end of period		40,598	23,375	40,598
Goodwill, net of impairment loss, end of period		2,807	20,030	2,807
Operating Segments \| Other Human Capital Management Services Segment
Goodwill balances
Goodwill, net of impairment loss, beginning of period				9,418
Sale of business, beginning of period				(9,889)
Accumulated impairment loss, beginning of period				0
Aggregate goodwill acquired, beginning of period				19,307
Goodwill, Translation and Purchase Accounting Adjustments [Abstract]
Goodwill acquired				0
Impairment charge				0
Aggregate goodwill acquired, end of period		19,307	19,307	19,307
Sale of business, end of period		(9,889)	(9,889)	(9,889)
Accumulated impairment loss, end of period		0	0	0
Goodwill, net of impairment loss, end of period		$ 9,418	$ 9,418	$ 9,418

Goodwill, Trade Names, and Other Intangible Assets - Narrative (Details) $ in Thousands			3 Months Ended		12 Months Ended
	Oct. 01, 2018 USD ($)	Jun. 30, 2016 USD ($)	Dec. 31, 2018 USD ($)	Dec. 31, 2017 USD ($)	Dec. 31, 2018 USD ($)	Dec. 31, 2017 USD ($)	Dec. 31, 2016 USD ($)
Goodwill and Intangible Assets Disclosure [Line Items]
Carrying amount			$ 55,182	$ 60,976	$ 55,182	$ 60,976
Impairment charges			22,400	14,400	22,423	14,356	$ 24,311
Physician Staffing Segment
Goodwill and Intangible Assets Disclosure [Line Items]
Goodwill impairment charge		$ 17,700	17,200	5,700
Impairment charges		24,300
Trade names
Goodwill and Intangible Assets Disclosure [Line Items]
Carrying amount	$ 1,100		7,183	6,838	7,183	6,838
Intangible assets- useful life	3 years
Amortization of assets			100
Customer relationships
Goodwill and Intangible Assets Disclosure [Line Items]
Carrying amount			26,462	29,612	$ 26,462	$ 29,612
Customer relationships \| Physician Staffing Segment
Goodwill and Intangible Assets Disclosure [Line Items]
Impairment of intangibles finite lived		6,000
Income Approach Valuation Technique \| Physician Staffing Segment
Goodwill and Intangible Assets Disclosure [Line Items]
Weighted applied percentage					75.00%
Income Approach Valuation Technique \| Search Reporting Unit [Member]
Goodwill and Intangible Assets Disclosure [Line Items]
Weighted applied percentage					75.00%
Income Approach Valuation Technique \| Nurse and Allied Staffing Segment
Goodwill and Intangible Assets Disclosure [Line Items]
Weighted applied percentage					50.00%
Income and Market Approach Valuation Technique
Goodwill and Intangible Assets Disclosure [Line Items]
Forecast period					10 years
Market Approach Valuation Technique \| Physician Staffing Segment
Goodwill and Intangible Assets Disclosure [Line Items]
Weighted applied percentage					25.00%
Market Approach Valuation Technique \| Search Reporting Unit [Member]
Goodwill and Intangible Assets Disclosure [Line Items]
Weighted applied percentage					25.00%
Market Approach Valuation Technique \| Nurse and Allied Staffing Segment
Goodwill and Intangible Assets Disclosure [Line Items]
Weighted applied percentage					50.00%
Minimum
Goodwill and Intangible Assets Disclosure [Line Items]
Intangible assets- useful life					1 year
Minimum \| Income Approach Valuation Technique
Goodwill and Intangible Assets Disclosure [Line Items]
Terminal value growth rate percentage					1.00%
Minimum \| Market Approach Valuation Technique
Goodwill and Intangible Assets Disclosure [Line Items]
Ratio of total enterprise value by EBITDA					3.0
Maximum
Goodwill and Intangible Assets Disclosure [Line Items]
Intangible assets- useful life					16 years
Maximum \| Income Approach Valuation Technique
Goodwill and Intangible Assets Disclosure [Line Items]
Terminal value growth rate percentage					3.00%
Maximum \| Market Approach Valuation Technique
Goodwill and Intangible Assets Disclosure [Line Items]
Ratio of total enterprise value by EBITDA					10.5
Trade names \| Physician Staffing Segment
Goodwill and Intangible Assets Disclosure [Line Items]
Impairment of intangibles indefinite lived		$ 600	$ 5,200	$ 8,700
Discount Rate \| Income Approach Valuation Technique \| Customer relationships \| Physician Staffing Segment
Goodwill and Intangible Assets Disclosure [Line Items]
Discount rate percentage		0.135
Discount Rate \| Minimum \| Income Approach Valuation Technique
Goodwill and Intangible Assets Disclosure [Line Items]
Discount rate percentage			0.12		0.12
Discount Rate \| Maximum \| Income Approach Valuation Technique
Goodwill and Intangible Assets Disclosure [Line Items]
Discount rate percentage			0.150		0.150

Property and Equipment (Details) - USD ($) $ in Thousands	12 Months Ended
Property and Equipment (Details) - USD ($) $ in Thousands	Dec. 31, 2018	Dec. 31, 2017
Property, Plant and Equipment [Line Items]
Property and equipment	$ 47,104	$ 44,764
Less accumulated depreciation and amortization	(33,476)	(30,678)
Property and equipment, net of accumulated depreciation and amortization	13,628	14,086
Computer equipment
Property, Plant and Equipment [Line Items]
Property and equipment	6,257	6,432
Computer software
Property, Plant and Equipment [Line Items]
Property and equipment	26,651	24,933
Office equipment
Property, Plant and Equipment [Line Items]
Property and equipment	1,514	1,379
Furniture and fixtures
Property, Plant and Equipment [Line Items]
Property and equipment	4,966	4,680
Leasehold improvements
Property, Plant and Equipment [Line Items]
Property and equipment	$ 7,716	$ 7,340
Minimum
Property, Plant and Equipment [Line Items]
Estimated useful life	3 years
Minimum \| Computer equipment
Property, Plant and Equipment [Line Items]
Estimated useful life	3 years
Minimum \| Computer software
Property, Plant and Equipment [Line Items]
Estimated useful life	3 years
Minimum \| Office equipment
Property, Plant and Equipment [Line Items]
Estimated useful life	5 years
Minimum \| Furniture and fixtures
Property, Plant and Equipment [Line Items]
Estimated useful life	5 years
Maximum
Property, Plant and Equipment [Line Items]
Estimated useful life	7 years
Maximum \| Computer equipment
Property, Plant and Equipment [Line Items]
Estimated useful life	5 years
Maximum \| Computer software
Property, Plant and Equipment [Line Items]
Estimated useful life	5 years
Maximum \| Office equipment
Property, Plant and Equipment [Line Items]
Estimated useful life	7 years
Maximum \| Furniture and fixtures
Property, Plant and Equipment [Line Items]
Estimated useful life	7 years

Balance Sheet Details (Details) - USD ($) $ in Thousands	Dec. 31, 2018	Dec. 31, 2017
Balance Sheet Related Disclosures [Abstract]
Insurance recovery for workers’ compensation	$ 2,295	$ 1,623
Insurance recovery for professional liability	1,891	1,874
Insurance recovery receivable	4,186	3,497
Insurance recovery for workers’ compensation claims	5,280	6,093
Insurance recovery for professional liability claims	9,924	10,011
Non-current security deposits	982	1,095
Non-current income tax receivable	522	1,044
Deferred compensation assets	433	0
Net debt issuance costs	935	985
Other non-current assets	18,076	19,228
Salaries and payroll taxes	15,884	16,342
Bonuses	1,476	2,067
Accrual for workers’ compensation claims	6,454	5,957
Accrual for professional liability claims	2,786	2,683
Accrual for healthcare benefits	5,158	5,105
Accrual for vacation	1,574	2,117
Accrued compensation and benefits	33,332	34,271
Accrual for workers’ compensation claims	12,997	13,160
Accrual for professional liability claims	16,302	15,597
Long-term accrued claims	29,299	28,757
Non-current deferred tax liabilities	95	105
Deferred compensation	1,725	1,467
Deferred rent	6,039	6,875
Long-term unrecognized tax benefits	590	485
Other	318	344
Other long-term liabilities	$ 8,767	$ 9,276

Debt - Long- Term Debt (Details) - USD ($) $ in Thousands	Dec. 31, 2018	Dec. 31, 2017
Debt Instrument [Line Items]
Less current portion	$ (5,235)	$ (6,875)
Long-term debt	78,641	93,125
Debt Issuance Costs	(697)	(866)
Senior Debt
Debt Instrument [Line Items]
Long-term debt	83,876
Senior Debt \| Term Loan, net
Debt Instrument [Line Items]
Term Loan, interest of 4.80% and 3.61% at December 31, 2018 and 2017, respectively	83,876	100,000
Debt Issuance Costs	$ (697)	$ (866)
Interest Rate	4.80%	3.61%

Debt - Amendment And Restatement Of Senior Credit Facility (Details)			3 Months Ended		12 Months Ended
	Oct. 30, 2018 USD ($)	Aug. 01, 2017 USD ($)	Dec. 31, 2018 USD ($)	Sep. 30, 2018 USD ($)	Dec. 31, 2018 USD ($) financial_covenant	Dec. 31, 2017 USD ($)	Dec. 31, 2016 USD ($)	Oct. 29, 2018
Debt Instrument [Line Items]
Proceeds from issuance of debt					$ 0	$ 62,000,000	$ 40,000,000
Debt issuance costs					$ 308,000	$ 901,000	$ 1,182,000
Amended And Restated Credit Agreement
Debt Instrument [Line Items]
Face amount		$ 215,000,000.0
Sub facility for swingline loans		15,000,000.0
Line of credit, subfacility for standby letters of credit		35,000,000.0
Proceeds from issuance of debt		106,500,000
Interest rate increase (decrease) (percent)					2.00%
Quarterly commitment fee on the average daily unused portion (percent)					0.35%
Number of financial covenants \| financial_covenant					2
Amended And Restated Credit Agreement \| Minimum
Debt Instrument [Line Items]
Consolidated fixed charge coverage ratio			1.50		1.50
Amended And Restated Credit Agreement \| Fiscal Quarters Ending September 30, 2018 through June 30, 2019 \| Maximum
Debt Instrument [Line Items]
Consolidated total leverage ratio								3.25
Amended And Restated Credit Agreement \| Fiscal Quarter Ending September 30, 2019 \| Maximum
Debt Instrument [Line Items]
Consolidated total leverage ratio								3.00
Amended And Restated Credit Agreement \| Fiscal Quarter Ending December 31, 2019 \| Maximum
Debt Instrument [Line Items]
Consolidated total leverage ratio								3.00
Amended And Restated Credit Agreement \| Each Fiscal Quarter Ending Thereafter \| Maximum
Debt Instrument [Line Items]
Consolidated total leverage ratio								3.00
First Amendment, Amended And Restated Credit Agreement
Debt Instrument [Line Items]
Debt issuance costs	$ 300,000
First Amendment, Amended And Restated Credit Agreement \| Fiscal Quarters Ending September 30, 2018 through June 30, 2019 \| Maximum
Debt Instrument [Line Items]
Consolidated total leverage ratio	3.75
First Amendment, Amended And Restated Credit Agreement \| Fiscal Quarter Ending September 30, 2019 \| Maximum
Debt Instrument [Line Items]
Consolidated total leverage ratio	3.50
First Amendment, Amended And Restated Credit Agreement \| Fiscal Quarter Ending December 31, 2019 \| Maximum
Debt Instrument [Line Items]
Consolidated total leverage ratio	3.25
First Amendment, Amended And Restated Credit Agreement \| Each Fiscal Quarter Ending Thereafter \| Maximum
Debt Instrument [Line Items]
Consolidated total leverage ratio	3.00
Term Loan, net \| Amended And Restated Credit Agreement
Debt Instrument [Line Items]
Face amount		100,000,000.0
Additional capacity		50,000,000.0
Payment for debt prepayment			$ 5,000,000	$ 5,000,000
Revolving Credit Facility \| Amended And Restated Credit Agreement
Debt Instrument [Line Items]
Letters of credit outstanding			$ 20,600,000		$ 20,600,000
Revolving Credit Facility \| Amended And Restated Credit Agreement \| LIBOR
Debt Instrument [Line Items]
Interest margin					2.50%
Revolving Credit Facility \| Line of Credit \| Amended And Restated Credit Agreement
Debt Instrument [Line Items]
Maximum borrowing capacity		115,000,000.0
Proceeds from issuance of debt		$ 6,500,000

Debt - Debt Maturities (Details) - USD ($) $ in Thousands	Dec. 31, 2018	Dec. 31, 2017
Long-term Debt, Fiscal Year Maturity [Abstract]
Total	$ 78,641	$ 93,125
Term Loan
Long-term Debt, Fiscal Year Maturity [Abstract]
2019	5,235
2020	5,671
2021	6,980
2022	65,990
2023	0
Total	$ 83,876

Debt - Consolidated Net Leverage Ratio (Details) - Credit Agreement		12 Months Ended
	Jul. 05, 2017	Dec. 31, 2018
Covenant Term 1
Line of Credit Facility [Line Items]
Commitment fee percentage		0.25%
Covenant Term 1 \| Eurodollar Loans
Line of Credit Facility [Line Items]
Interest margin		1.75%
Covenant Term 1 \| LIBOR Index Rate Loans
Line of Credit Facility [Line Items]
Interest margin		1.75%
Covenant Term 1 \| Letter of Credit Fee
Line of Credit Facility [Line Items]
Interest margin		1.75%
Covenant Term 1 \| Base Rate Loans
Line of Credit Facility [Line Items]
Interest margin		0.75%
Covenant Term 1 \| Maximum
Line of Credit Facility [Line Items]
Consolidated Net Leverage Ratio		1.50
Covenant Term 2
Line of Credit Facility [Line Items]
Commitment fee percentage		0.30%
Covenant Term 2 \| Eurodollar Loans
Line of Credit Facility [Line Items]
Interest margin		2.00%
Covenant Term 2 \| LIBOR Index Rate Loans
Line of Credit Facility [Line Items]
Interest margin		2.00%
Covenant Term 2 \| Letter of Credit Fee
Line of Credit Facility [Line Items]
Interest margin		2.00%
Covenant Term 2 \| Base Rate Loans
Line of Credit Facility [Line Items]
Interest margin		1.00%
Covenant Term 2 \| Minimum
Line of Credit Facility [Line Items]
Consolidated Net Leverage Ratio		1.50
Covenant Term 2 \| Maximum
Line of Credit Facility [Line Items]
Consolidated Net Leverage Ratio		2.00
Covenant Term 3
Line of Credit Facility [Line Items]
Commitment fee percentage	0.30%	0.30%
Covenant Term 3 \| Eurodollar Loans
Line of Credit Facility [Line Items]
Interest margin	2.25%	2.25%
Covenant Term 3 \| LIBOR Index Rate Loans
Line of Credit Facility [Line Items]
Interest margin	2.25%	2.25%
Covenant Term 3 \| Letter of Credit Fee
Line of Credit Facility [Line Items]
Interest margin		2.25%
Covenant Term 3 \| Base Rate Loans
Line of Credit Facility [Line Items]
Interest margin	1.25%	1.25%
Covenant Term 3 \| Minimum
Line of Credit Facility [Line Items]
Consolidated Net Leverage Ratio		2.00
Covenant Term 3 \| Maximum
Line of Credit Facility [Line Items]
Consolidated Net Leverage Ratio		2.50
Covenant Term 4
Line of Credit Facility [Line Items]
Commitment fee percentage		0.35%
Covenant Term 4 \| Eurodollar Loans
Line of Credit Facility [Line Items]
Interest margin		2.50%
Covenant Term 4 \| LIBOR Index Rate Loans
Line of Credit Facility [Line Items]
Interest margin		2.50%
Covenant Term 4 \| Letter of Credit Fee
Line of Credit Facility [Line Items]
Interest margin		2.50%
Covenant Term 4 \| Base Rate Loans
Line of Credit Facility [Line Items]
Interest margin		1.50%
Covenant Term 4 \| Minimum
Line of Credit Facility [Line Items]
Consolidated Net Leverage Ratio		2.50
Covenant Term 4 \| Maximum
Line of Credit Facility [Line Items]
Consolidated Net Leverage Ratio		3.00
Covenant Term 5
Line of Credit Facility [Line Items]
Commitment fee percentage		0.40%
Covenant Term 5 \| Eurodollar Loans
Line of Credit Facility [Line Items]
Interest margin		2.75%
Covenant Term 5 \| LIBOR Index Rate Loans
Line of Credit Facility [Line Items]
Interest margin		2.75%
Covenant Term 5 \| Letter of Credit Fee
Line of Credit Facility [Line Items]
Interest margin		2.75%
Covenant Term 5 \| Base Rate Loans
Line of Credit Facility [Line Items]
Interest margin		1.75%
Covenant Term 5 \| Minimum
Line of Credit Facility [Line Items]
Consolidated Net Leverage Ratio		3.00

Debt - 2016 Senior Credit Facilities (Details) - USD ($)			3 Months Ended	12 Months Ended
	Jul. 05, 2017	Jun. 22, 2016	Jun. 30, 2016	Dec. 31, 2018	Dec. 31, 2017	Dec. 31, 2016
Debt Instrument [Line Items]
Prepayment penalty		$ 600,000
Loss on early extinguishment of debt				$ 79,000	$ 4,969,000	$ 1,568,000
Second Lien Term Loan, net
Debt Instrument [Line Items]
Loss on early extinguishment of debt			$ 1,600,000
Senior Debt \| Credit Agreement
Debt Instrument [Line Items]
Maximum borrowing capacity		40,000,000.0
Subordinated Debt \| Second Lien Term Loan, net
Debt Instrument [Line Items]
Maximum borrowing capacity		30,000,000.0
Term Loan, net \| Incremental Term Loan
Debt Instrument [Line Items]
Face amount	$ 40,000,000.0
Term Loan, net \| Incremental Term Loan \| First Eight Installments
Debt Instrument [Line Items]
Periodic payment, percentage of principal	1.875%
Term Loan, net \| Incremental Term Loan \| Remaining Installments
Debt Instrument [Line Items]
Periodic payment, percentage of principal	2.50%
Term Loan, net \| Incremental Term Loan \| Eurodollar
Debt Instrument [Line Items]
Interest margin	2.25%
Term Loan, net \| Incremental Term Loan \| LIBOR
Debt Instrument [Line Items]
Interest margin	2.25%
Term Loan, net \| Incremental Term Loan \| Base Rate Loans
Debt Instrument [Line Items]
Interest margin	1.25%
Revolving Credit Facility \| Credit Agreement
Debt Instrument [Line Items]
Maximum borrowing capacity		100,000,000.0
Sub facility for swingline loans		15,000,000.0
Line of credit, subfacility for standby letters of credit		$ 35,000,000.0
Covenant Term 3 \| Credit Agreement
Debt Instrument [Line Items]
Commitment fee percentage	0.30%			0.30%
Covenant Term 3 \| Credit Agreement \| Eurodollar
Debt Instrument [Line Items]
Interest margin	2.25%			2.25%
Covenant Term 3 \| Credit Agreement \| LIBOR
Debt Instrument [Line Items]
Interest margin	2.25%			2.25%
Covenant Term 3 \| Credit Agreement \| Base Rate Loans
Debt Instrument [Line Items]
Interest margin	1.25%			1.25%

Debt - Private Placement of Convertible Notes Narrative (Details)		3 Months Ended	12 Months Ended
	Mar. 17, 2017 USD ($) day instrument d $ / shares shares	Mar. 31, 2017 USD ($)	Dec. 31, 2018 USD ($) $ / shares	Dec. 31, 2017 USD ($) $ / shares	Dec. 31, 2016 USD ($)	Jun. 30, 2014 USD ($)
Debt Instrument [Line Items]
Common stock, par value (usd per share) \| $ / shares			$ 0.0001	$ 0.0001
Repayments of debt			$ 16,124,000	$ 1,500,000	$ 30,500,000
Extinguishment fees			0	578,000	641,000
Loss on early extinguishment of debt			$ 79,000	$ 4,969,000	$ 1,568,000
Convertible Notes
Debt Instrument [Line Items]
Face amount						$ 25,000,000.0
Common stock, par value (usd per share) \| $ / shares	$ 0.0001
Payment of debt and extinguishment fees	$ 5,600,000
Repayments of debt	5,000,000
Extinguishment fees	600,000
Loss on early extinguishment of debt	5,000,000	$ (5,000,000)
Non-cash write off related to settlement of convertible notes	$ 46,000,000
Debt conversion price (in usd per share) \| $ / shares	$ 7.10
Debt instrument, convertible, number of equity instruments \| instrument	3,521,126
Debt Instrument, convertible, threshold period following issuance date (in years)	3 years
Debt instrument, convertible, threshold percentage of stock price trigger	125.00%
Debt instrument, convertible, threshold trading days \| day	20
Debt instrument, convertible, threshold consecutive trading days \| d	30
Interest rate (percent)	8.00%
Common Stock
Debt Instrument [Line Items]
Shares issued (in shares) \| shares	3,175,584
8% Convertible Notes \| Convertible Notes
Debt Instrument [Line Items]
Original debt amount in debt conversion	$ 20,000,000
Convertible Note Derivative Liability \| Convertible Notes
Debt Instrument [Line Items]
Original debt amount in debt conversion	$ 26,000,000

Derivatives - Additional Information (Details) - USD ($) $ in Millions	Dec. 31, 2018	Mar. 31, 2018
Interest rate swaps
Derivative [Line Items]
Derivative fixed interest rate		2.627%
Notional amount		$ 48.8
Interest rate swaps	$ 0.2
Senior Debt \| Term Loan, net
Derivative [Line Items]
Debt fixed interest rate		50.00%

Fair Value Measurements - Estimated Fair values Assets and Liabilities Measured on Recurring Basis (Details) - USD ($) $ in Thousands	Dec. 31, 2018	Dec. 31, 2017
Level 3
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Contingent consideration liabilities	$ 7,689	$ 5,368
Deferred compensation \| Level 1
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Deferred compensation	1,725	1,467
Interest rate swaps
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Interest rate swaps	200
Interest rate swaps \| Level 2
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Interest rate swaps	$ 234	$ 0

Fair Value Measurements - Schedule of reconciliation of opening and closing balances for fair value measurements categorized within Level 3 (Details) - USD ($) $ in Thousands	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017
Contingent Purchase Liabilities
Fair Value, Liabilities Measured on Recurring Basis, Unobservable Input Reconciliation, Calculation [Roll Forward]
Beginning balance	$ 5,368	$ 5,603
Payments/Settlements	(280)	(280)
Accretion expense	903	967
Valuation gain (loss) for the period	1,698	(922)
Ending balance	7,689	5,368
Convertible Notes Derivative Liability
Fair Value, Liabilities Measured on Recurring Basis, Unobservable Input Reconciliation, Calculation [Roll Forward]
Beginning balance	0	27,532
Payments/Settlements	0	(25,951)
Accretion expense	0	0
Valuation gain (loss) for the period	0	(1,581)
Ending balance	$ 0	$ 0

Fair Value Measurements - Financial Instruments that were not Measured at Fair Value (Details) - USD ($) $ in Thousands	Dec. 31, 2018	Dec. 31, 2017
Fair Value, Option, Quantitative Disclosures [Line Items]
Carrying Amount	$ 78,641	$ 93,125
Term Loan, net \| Level 2 \| Carrying Amount
Fair Value, Option, Quantitative Disclosures [Line Items]
Carrying Amount	83,179	99,134
Term Loan, net \| Level 2 \| Fair Value
Fair Value, Option, Quantitative Disclosures [Line Items]
Fair Value	$ 81,800	$ 100,500

Fair Value Measurements - Narrative (Details)	12 Months Ended
Fair Value Measurements - Narrative (Details)	Dec. 31, 2018
Minimum
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Threshold period, past due for payment of services provided	15 days
Maximum
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Threshold period, past due for payment of services provided	60 days

Employee Benefit Plans - Narrative (Details) - USD ($) $ in Thousands	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017	Dec. 31, 2016
Retirement Benefits [Abstract]
Company contribution net of forfeitures	$ 800	$ 700	$ 800
Deferred compensation liabilities	$ 1,725	$ 1,467

Commitments and Contingencies - Future Minimum Lease Payments (Details) $ in Thousands	Dec. 31, 2018 USD ($)
Commitments and Contingencies Disclosure [Abstract]
2019	$ 7,451
2020	6,287
2021	5,407
2022	4,857
2023	4,700
Thereafter	5,893
Total	$ 34,595

Commitments and Contingencies - Narrative (Details) - USD ($) $ in Millions	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017	Dec. 31, 2016
Commitments and Contingencies Disclosure [Abstract]
Operating lease expense	$ 9.3	$ 9.4	$ 8.4

Income Taxes - Components of Income (Loss) Before Income Taxes (Details) - USD ($) $ in Thousands	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017	Dec. 31, 2016
Income Tax Disclosure [Abstract]
United States	$ (18,619)	$ 3,826	$ 3,309
Foreign	424	475	1,236
(Loss) income before income taxes	$ (18,195)	$ 4,301	$ 4,545

Income Taxes - Components of Income Tax Expense (Benefit) (Details) - USD ($) $ in Thousands	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017	Dec. 31, 2016
Current:
Federal	$ 43	$ (555)	$ 227
State	620	(273)	587
Foreign	269	139	322
Total	932	(689)	1,136
Deferred:
Federal	(2,137)	(23,245)	(4,114)
State	(1,277)	(10,684)	(866)
Foreign	4	117	(342)
Total	(3,410)	(33,812)	(5,322)
Income tax benefit	$ (2,478)	$ (34,501)	$ (4,186)

Income Taxes - Significant Components of Deferred Tax Assets and Liabilities (Details) - USD ($) $ in Thousands	Dec. 31, 2018	Dec. 31, 2017
Deferred Tax Assets:
Accrued other and prepaid expenses	$ 2,734	$ 2,955
Allowance for doubtful accounts	607	624
Intangible Assets	11,300	7,776
Net operating loss carryforwards	15,717	14,718
Accrued professional liability claims	1,952	1,709
Accrued workers’ compensation claims	2,729	2,512
Share-based compensation	646	734
Credit carryforwards	188	189
Other	542	444
Gross deferred tax assets	36,415	31,661
Valuation allowance	(1,189)	(1,076)
Deferred tax assets	35,226	30,585
Deferred Tax Liabilities:
Depreciation	(52)	(41)
Indefinite intangibles	(11,136)	(9,964)
Tax on unrepatriated earnings	(383)	(466)
Deferred tax liabilities	(11,571)	(10,471)
Net deferred taxes	$ 23,655	$ 20,114

Income Taxes - Narrative (Details) - USD ($) $ in Thousands	3 Months Ended	12 Months Ended
Income Taxes - Narrative (Details) - USD ($) $ in Thousands	Dec. 31, 2017	Dec. 31, 2018	Dec. 31, 2017	Dec. 31, 2016	Dec. 31, 2015
Income Tax Contingency [Line Items]
Provision income tax expense related to deferred tax asset	$ 8,000	$ 0	$ 8,011	$ 0
Income tax expense related to deferred tax asset		100	200
Reduction in valuation allowance	43,300		45,400
Valuation allowance	1,076	1,189	1,076
Federal, state and foreign net operating loss carryforwards	166,100	185,100	166,100
Deferred liabilities on undistributed foreign earnings	466	383	466
Unrecognized tax benefits	3,807	5,412	3,807	5,180	$ 4,071
Unrecognized tax benefits, which would affect the effective tax rate	4,000	5,600	4,000	4,900
Gross increases in current year unrecognized tax		1,600
Increase (decrease) in recognized interest and penalties			200
Unrecognized tax benefit accrued interest and penalties	200	300	200	500
State
Income Tax Contingency [Line Items]
Valuation allowance		1,200
India
Income Tax Contingency [Line Items]
Deferred liabilities on undistributed foreign earnings		100
Repatriated amount of foreign earnings		500
Other Current Liabilities
Income Tax Contingency [Line Items]
Unrecognized tax benefits	100	100	100	100
Other Noncurrent Liabilities
Income Tax Contingency [Line Items]
Unrecognized tax benefits	$ 500	$ 600	500	$ 900
Net Operating Losses \| U.S.
Income Tax Contingency [Line Items]
Reduction in valuation allowance			15,700
Net Operating Losses \| State
Income Tax Contingency [Line Items]
Reduction in valuation allowance			4,400
Other Net Deferred Tax Assets
Income Tax Contingency [Line Items]
Reduction in valuation allowance			$ 25,300

Income Taxes - Reconciliation of Income Tax Computed At U. S. Federal Statutory Rate to Income Tax (Benefit) Expense (Details) - USD ($) $ in Thousands	3 Months Ended	12 Months Ended
	Dec. 31, 2017	Dec. 31, 2018	Dec. 31, 2017	Dec. 31, 2016
Income Tax Disclosure [Abstract]
Tax at U.S. statutory rate		$ (3,821)	$ 1,506	$ 1,591
State taxes, net of federal benefit		(543)	(1,374)	344
Noncontrolling interest		(252)	(455)	(260)
Non-deductible items		625	2,676	1,546
Foreign tax expense		180	175	(5)
Valuation allowances		0	(45,354)	(8,379)
Uncertain tax positions		1,629	1,145	1,090
Return to provision		(458)	0	0
Federal rate change	$ 8,000	0	8,011	0
Other		162	(831)	(113)
Income tax benefit		$ (2,478)	$ (34,501)	$ (4,186)

Income Taxes - Reconciliation of Beginning and Ending Balance of Unrecognized Tax Benefits (Details) - USD ($) $ in Thousands	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017	Dec. 31, 2016
Reconciliation of Unrecognized Tax Benefits, Excluding Amounts Pertaining to Examined Tax Returns [Roll Forward]
Balance at January 1	$ 3,807	$ 5,180	$ 4,071
Additions based on tax positions related to the current year	1,401	1,145	1,054
Additions based on tax positions related to prior years	204	0	55
Reductions based on settlements of tax positions related to prior years	0	(439)	0
2017 Tax Act federal tax rate change	0	(1,859)	0
Other	0	(220)	0
Balance at December 31	$ 5,412	$ 3,807	$ 5,180

Stockholders' Equity - Narrative (Details) - USD ($) $ / shares in Units, $ in Thousands		12 Months Ended
	Mar. 17, 2017	Dec. 31, 2018	Dec. 31, 2017	Dec. 31, 2016
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Stock repurchase and retirement (in shares)			0	0
Stock repurchase and retirement		$ 5,000
Common stock left remaining to repurchase under the plan (in shares)		510,004
Common Stock
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Stock repurchase and retirement (in shares)		432,439
Stock repurchase and retirement		$ 5,000
Stock repurchase and retirement (in dollars per share)		$ 11.54
Shares converted (in shares)	3,175,584

Stockholders' Equity - 2014 Omnibus Incentive Plan (Details) - USD ($) $ in Millions				3 Months Ended	12 Months Ended
	Mar. 31, 2018	May 23, 2017	Mar. 31, 2017	Mar. 31, 2017	Dec. 31, 2018	Dec. 31, 2017	Dec. 31, 2016
Omnibus Plan
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Additional shares authorized (in shares)		2,000,000
Shares reserved for future issuance (in shares)		6,100,000
Minimum \| Omnibus Plan
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Exercise price percentage of the fair market value of common stock					100.00%
Maximum \| Omnibus Plan
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Stock expiration period					10 years
Ten Percent Or More Stockholders \| Minimum \| Omnibus Plan
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Exercise price percentage of the fair market value of common stock					110.00%
Ten Percent Or More Stockholders \| Maximum \| Omnibus Plan
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Stock expiration period					5 years
Restricted Stock Awards
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Pretax of total unrecognized compensation cost related to non-vested restricted stock awards					$ 3.8
Pretax total unrecognized compensation cost related to share options- period					1 year 5 months 13 days
Fair value of shares vested					$ 2.5	$ 0.0	$ 4.3
Restricted Stock Awards \| Omnibus Plan
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Stock vesting period					3 years
Performance Stock Awards
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Pretax of total unrecognized compensation cost related to non-vested restricted stock awards					$ 0.3
Pretax total unrecognized compensation cost related to share options- period					1 year 10 months 14 days
Fair value of shares vested					$ 0.5	$ 1.6	$ 1.2
Performance Stock Awards \| Omnibus Plan
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Shares issued (in shares)	238,328		181,067	66,692
Percentage of performance attained				48.00%
Stock Appreciation Rights \| 2007 Stock Incentive Plan
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Stock expiration period					7 years
Stock vesting period					4 years
Stock vesting percentage per year					25.00%

Stockholders' Equity - Summary of Restricted Stock Award Activity and Performance Stock Awards (Details)	12 Months Ended
	Dec. 31, 2018 $ / shares shares
Restricted Stock Awards
Number of Shares
Unvested restricted stock awards, beginning balance (in shares) \| shares	515,601
Granted (in shares) \| shares	391,108
Vested (in shares) \| shares	(219,881)
Forfeited (in shares) \| shares	(97,708)
Unvested restricted stock awards, ending balance (in shares) \| shares	589,120
Weighted average grant date fair value
Unvested restricted stock awards, beginning balance (usd per share) \| $ / shares	$ 13.03
Granted (usd per share) \| $ / shares	10.96
Vested (usd per share) \| $ / shares	12.64
Forfeited (usd per share) \| $ / shares	13.18
Unvested restricted stock awards, ending balance (usd per share) \| $ / shares	$ 12.00
Performance Stock Awards
Number of Shares
Unvested restricted stock awards, beginning balance (in shares) \| shares	257,575
Granted (in shares) \| shares	238,328
Vested (in shares) \| shares	(66,692)
Forfeited (in shares) \| shares	(64,062)
Unvested restricted stock awards, ending balance (in shares) \| shares	365,149
Weighted average grant date fair value
Unvested restricted stock awards, beginning balance (usd per share) \| $ / shares	$ 13.49
Granted (usd per share) \| $ / shares	11.11
Vested (usd per share) \| $ / shares	11.63
Forfeited (usd per share) \| $ / shares	13.03
Unvested restricted stock awards, ending balance (usd per share) \| $ / shares	$ 12.35

Stockholders' Equity - Stock Options and Stock Appreciation Rights Granted and Exercised (Details) - USD ($) $ in Thousands	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017	Dec. 31, 2016
Equity [Abstract]
Total intrinsic value of options exercised	$ 234	$ 516	$ 1,323

Stockholders' Equity - 1999 Stock Option Plan and Equity Participation Plan (Details) - USD ($) $ / shares in Units, $ in Millions	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017	Oct. 25, 2001
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Share options outstanding (in shares)	51,500	94,500
Shares options outstanding vested or expected to vest -weighted average exercise price (usd per share)	$ 4.87
Shares options outstanding vested or expected to vest ,intrinsic value	$ 0.1
Shares options outstanding vested or expected to vest -weighted average contractual life	1 year 7 days
The 1999 Plan
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Aggregate number of common stock shares authorized for issuance (in shares)			4,398,001

Stockholders' Equity - Summary of Company's Share Option Plans Activities (Details) $ / shares in Units, $ in Thousands	12 Months Ended
	Dec. 31, 2018 USD ($) $ / shares shares
Number of Shares
Share options outstanding at beginning of year (in shares) \| shares	94,500
Granted (in shares) \| shares	0
Exercised (in shares) \| shares	(40,500)
Forfeited/expired (in shares) \| shares	(2,500)
Share options outstanding at end of year (in shares) \| shares	51,500
Weighted Average Exercise Price
Share options outstanding at beginning of year, weighted average exercise price (usd per share)	$ 5.19
Granted, weighted average exercise price (usd per share)	0.00
Exercised, weighted average exercise price (usd per share)	5.46
Forfeited/expired, weighted average exercise price (usd per share)	7.44
Share options outstanding at end of year, weighted average exercise price (usd per share)	$ 4.87
Share options outstanding at end of year, weighted-average remaining contractual life	1 year 6 days
Share options outstanding at end of year \| $	$ 127
Exercise Price Range One
Number of Shares
Exercise Price, Lower Limit (usd per share)	$ 4.16
Exercise Price, Upper Limit (usd pre share)	7.44
Exercise Price Range Two
Number of Shares
Exercise Price, Upper Limit (usd pre share)	0.00
Exercise Price Range Three
Number of Shares
Exercise Price, Lower Limit (usd per share)	4.16
Exercise Price, Upper Limit (usd pre share)	7.44
Exercise Price Range Four
Number of Shares
Exercise Price, Upper Limit (usd pre share)	7.44
Exercise Price Range Five
Number of Shares
Exercise Price, Lower Limit (usd per share)	4.35
Exercise Price, Upper Limit (usd pre share)	$ 5.21

Earnings Per Share - Components of Numerator and Denominator for Computation of Basic and Diluted Earnings per Share (Details) - USD ($) $ / shares in Units, shares in Thousands, $ in Thousands	3 Months Ended								12 Months Ended
	Dec. 31, 2018	Sep. 30, 2018	Jun. 30, 2018	Mar. 31, 2018	Dec. 31, 2017	Sep. 30, 2017	Jun. 30, 2017	Mar. 31, 2017	Dec. 31, 2018	Dec. 31, 2017	Dec. 31, 2016
Numerator:
Net (loss) income attributable to common shareholders - Basic									$ (16,951)	$ 37,513	$ 7,967
Interest on Convertible Notes									0	694	3,383
Gain on derivative liability								$ (1,600)	0	(1,581)	(5,805)
Net (loss) income attributable to common shareholders - Diluted									$ (16,951)	$ 36,626	$ 5,545
Denominator:
Weighted average common shares - Basic (shares)									35,657	35,018	32,132
Effective of diluted shares:
Share-based awards (shares)									0	425	593
Convertible Notes (shares)									0	723	3,521
Weighted average common shares - Diluted (shares)									35,657	36,166	36,246
Net (loss) income per share attributable to common shareholders - Basic (usd per share)	$ (0.55)	$ (0.01)	$ 0.04	$ 0.05	$ 0.78	$ 0.19	$ 0.14	$ (0.06)	$ (0.48)	$ 1.07	$ 0.25
Net (loss) income per share attributable to common shareholders - Diluted (usd per share)	$ (0.55)	$ (0.01)	$ 0.04	$ 0.05	$ 0.77	$ 0.19	$ 0.13	$ (0.08)	$ (0.48)	$ 1.01	$ 0.15

Earnings Per Share - Antidilutive Securities (Details) - shares shares in Thousands	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017	Dec. 31, 2016
Share-based awards
Antidilutive Securities Excluded from Computation of Earnings Per Share [Line Items]
Antidilutive securities	373	118	0

Related Party Transactions (Details) - USD ($) $ in Millions	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017	Dec. 31, 2016
Related Party Transaction [Line Items]
Revenue from related parties	$ 0.1	$ 4.9	$ 5.0
Account receivable due from related parties	0.1	0.4
Corporate Joint Venture
Related Party Transaction [Line Items]
Revenue from related parties	$ 19.4	17.9	12.6
Percent ownership in joint venture unit	68.00%
Receivable balance with joint venture	$ 2.8	0.8
Due to joint venture	0.3	0.3
Affiliated Entity
Related Party Transaction [Line Items]
Rent expense	$ 0.3	$ 0.4	$ 0.4

Segment Data - Additional Information (Details)	12 Months Ended
Segment Data - Additional Information (Details)	Dec. 31, 2018 segment
Segment Reporting [Abstract]
Number of operating segments	3

Segment Data - Operating Segments (Details) - USD ($) $ in Thousands		3 Months Ended								12 Months Ended
	Jun. 30, 2016	Dec. 31, 2018	Sep. 30, 2018	Jun. 30, 2018	Mar. 31, 2018	Dec. 31, 2017	Sep. 30, 2017	Jun. 30, 2017	Mar. 31, 2017	Dec. 31, 2018	Dec. 31, 2017	Dec. 31, 2016
Segment Reporting, Reconciling Item for Operating Profit (Loss) from Segment to Consolidated [Line Items]
Revenues		$ 200,907	$ 200,717	$ 204,572	$ 210,288	$ 219,674	$ 228,488	$ 209,313	$ 207,573	$ 816,484	$ 865,048	$ 833,537
Contribution income										71,718	78,513	79,722
Unallocated corporate overhead										44,589	39,190	38,400
Depreciation and amortization										11,780	10,174	9,182
Acquisition and integration costs										491	1,975	78
Acquisition-related contingent consideration										2,557	44	814
Restructuring costs										2,758	1,026	753
Impairment charges		$ 22,400				$ 14,400				22,423	14,356	24,311
(Loss) income from operations										(12,880)	11,748	6,184
Physician Staffing Segment
Segment Reporting, Reconciling Item for Operating Profit (Loss) from Segment to Consolidated [Line Items]
Impairment charges	$ 24,300
Operating Segments \| Nurse and Allied Staffing Segment
Segment Reporting, Reconciling Item for Operating Profit (Loss) from Segment to Consolidated [Line Items]
Revenues										720,302	758,267	721,486
Contribution income										66,365	73,614	71,992
Operating Segments \| Physician Staffing Segment
Segment Reporting, Reconciling Item for Operating Profit (Loss) from Segment to Consolidated [Line Items]
Revenues										82,305	93,610	98,283
Contribution income										4,755	5,256	8,265
Operating Segments \| Other Human Capital Management Services Segment
Segment Reporting, Reconciling Item for Operating Profit (Loss) from Segment to Consolidated [Line Items]
Revenues										13,877	13,171	13,768
Contribution income										$ 598	$ (357)	$ (535)

Quarterly Financial Data (Unaudited) (Details) - USD ($) $ / shares in Units, $ in Thousands		3 Months Ended								12 Months Ended
	Mar. 17, 2017	Dec. 31, 2018	Sep. 30, 2018	Jun. 30, 2018	Mar. 31, 2018	Dec. 31, 2017	Sep. 30, 2017	Jun. 30, 2017	Mar. 31, 2017	Dec. 31, 2018	Dec. 31, 2017	Dec. 31, 2016
Quarterly Financial Information Disclosure [Abstract]
Revenue from services		$ 200,907	$ 200,717	$ 204,572	$ 210,288	$ 219,674	$ 228,488	$ 209,313	$ 207,573	$ 816,484	$ 865,048	$ 833,537
Gross profit		50,559	51,562	53,689	53,753	58,303	60,480	56,528	53,275
Consolidated net (loss) income		(19,343)	(118)	1,824	1,920	28,256	7,044	5,220	(1,718)	(15,717)	38,802	8,731
Net income (loss) attributable to common shareholders		$ (19,691)	$ (441)	$ 1,539	$ 1,642	$ 27,950	$ 6,723	$ 4,850	$ (2,010)	$ (16,951)	$ 37,513	$ 7,967
Net income (loss) per share attributable to common shareholders - Basic (usd per share)		$ (0.55)	$ (0.01)	$ 0.04	$ 0.05	$ 0.78	$ 0.19	$ 0.14	$ (0.06)	$ (0.48)	$ 1.07	$ 0.25
Net income (loss) per share attributable to common shareholders - Diluted (usd per share)		$ (0.55)	$ (0.01)	$ 0.04	$ 0.05	$ 0.77	$ 0.19	$ 0.13	$ (0.08)	$ (0.48)	$ 1.01	$ 0.15
Income Statement, Balance Sheet and Additional Disclosures by Disposal Groups, Including Discontinued Operations [Line Items]
Impairment charges		$ 22,400				$ 14,400				$ 22,423	$ 14,356	$ 24,311
Loss on extinguishment of debt										79	4,969	1,568
Reduction in valuation allowance						43,300					45,400
Income tax expense related to deferred tax asset						$ 8,000				0	8,011	0
Gain on derivative liability									$ (1,600)	$ 0	$ (1,581)	$ (5,805)
Convertible Notes
Income Statement, Balance Sheet and Additional Disclosures by Disposal Groups, Including Discontinued Operations [Line Items]
Loss on extinguishment of debt	$ 5,000								$ (5,000)

Schedule II - Valuation and Qualifying Accounts (Details) - USD ($) $ in Thousands	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017	Dec. 31, 2016
Allowances for Accounts Receivable
SEC Schedule, 12-09, Movement in Valuation Allowances and Reserves [Roll Forward]
Balance at Beginning of Period	$ 3,688	$ 3,245	$ 4,045
Charged to Operations	5,974	4,705	4,034
Write-Offs, net of recoveries	(5,957)	(4,262)	(4,834)
Other Changes	0	0	0
Balance at End of Period	3,705	3,688	3,245
Valuation Allowance for Deferred Tax Assets
SEC Schedule, 12-09, Movement in Valuation Allowances and Reserves [Roll Forward]
Balance at Beginning of Period	1,076	46,454	55,336
Charged to Operations	113	(3,007)	(8,894)
Write-Offs, net of recoveries	0	(43,333)	0
Other Changes	0	962	12
Balance at End of Period	$ 1,189	$ 1,076	$ 46,454