Post-Pandemic Nursing Home Capacity Declines Tied to Longer Hospital Stays, Increased Patient Travel

Skilled nursing facilities (SNFs), also known as nursing homes, experienced a decline in operating capacity following the COVID-19 pandemic, which was associated with patients experiencing longer hospital stays and increased travel distances, according to a study published today in JAMA Internal Medicine.¹

Post-Pandemic SNF Strains Lead to Hospital Discharge Challenges

The COVID-19 pandemic severely disrupted the US SNF industry, as it experienced a historic workforce decline and a strain in facility operations. The researchers noted that these staffing and resulting financial challenges may be forcing SNFs to close or scale back their operations. An industry report indicated that by 2024, 46% had limited new admissions, while 20% had closed entire units due to staffing shortages.²

SNFs are a critical source of post-acute care for hospitalized older adults, with nearly 1 in 5 hospitalized patients with Medicare discharged to one.³ Consequently, the investigators explained that losing available SNF beds may impede hospitals’ ability to discharge clinically stable patients in need of rehabilitation, resulting in hospital bottlenecks.¹

Despite these risks, there is limited empirical evidence on recent SNF capacity trends. To fill this gap, the researchers conducted a cross-sectional study to describe changes in SNF capacity post-2020 and assess whether changes were associated with staffing shortages and hospital discharge outcomes. Secondary outcomes also included mean hospital length of stay, percentage of hospital admissions lasting 28 days or more, and the median distance traveled to admitting SNFs.

The primary data source was the 2018-2024 CMS Payroll-Based Journal (PBJ), which contains daily information on staffing hours and patient censuses for all Medicare- and Medicaid-certified SNFs. The researchers merged these data with information on licensed SNF bed counts and other facility characteristics, which they obtained from the CMS Provider Information file.

They used county-level regression analyses to examine the association between SNF capacity changes and staffing shortage frequency. Additionally, hospital-level regression analyses evaluated the association between changes in nearby capacity and discharge outcomes.

SNF Bed Losses, Staffing Shortages Increase Hospital Stays, Patient Travel

The study included 15,915 SNFs, with the number of beds at each declining over the study period. There was a mean (SD) of 1.60 (0.001) million SNF beds, with the number decreasing to 1.56 (0.00020) by quarter 4 of 2024, resulting in a 2.5% relative decline.

However, the estimated operating capacity experienced much larger changes. It declined from the 2019 mean (SD) of 1.36 (0.004) million to a low of 1.16 (0.009) million in the first quarter of 2021. This was followed by an increase to 1.29 (0.0009) million by quarter 4 of 2024. These reductions represented operating capacity declines of 14.7% in quarter 1 of 2021 and 5.1% by quarter 4 of 2024.

The estimated number of available beds for new admissions also declined throughout the study period. Following a short increase in 2021, the number of open beds declined between 2022 and 2024. Specifically, there was a mean (SD) of 3850 (313.3) fewer SNF beds available for new admissions each day in 2024, which was 5.6% below the 2019 mean (SD) of 68,707 (4042) open beds.

When comparing US counties, the researchers found substantial geographic variation in SNF operating capacity changes. Most counties experienced some degree of operating capacity decline in 2024 compared with 2019, with 25% experiencing relative declines of at least 15.1%.

Compared with counties that did not lose SNF capacity, those experiencing the largest declines were more likely to be rural (66.8% vs 49.5%), have lower population densities (mean [SD], 80.4 [315] vs 185 [452] population per square mile), and have higher proportions of residents aged 75 and older (mean [SD], 7.87% [2.35%] vs 6.96% [2.19%]) and of non-Hispanic White race (mean [SD], 88.0% [14.1%] vs 82.7% [16.8%]).

The researchers added that SNF capacity declines were larger in counties with more frequent reports of SNF staffing shortages, as a 1-percentage point decline in county SNF capacity was associated with a 0.20-percentage point (95% CI, 0.11-0.29) increase in the frequency of reported shortages.

Lastly, hospitals that experienced larger declines in nearby SNF capacity experienced greater increases in mean length of stay, percentage of stays lasting 28 days or more, and median distance traveled to admitting SNFs.

Improving SNF Capacity to Support an Aging Population

The researchers acknowledged their limitations, one being that they relied on a self-reported measure of staffing shortages, subjecting their findings to potential bias and measurement error. Also, the estimated associations between operating capacity, reported staffing shortages, and hospital discharge outcomes are not causal, meaning they should be interpreted with caution. Nonetheless, they concluded by expressing confidence in their findings.

“These results suggest the value of readily available, but more sophisticated, measures of SNF operating capacity to understand the changing market for post-acute care,” the authors wrote. “The findings also raise concerns that current and future SNF capacity may not meet the needs of an aging US population, particularly in rural areas.”

References

1. McGarry BE, Wilcock AD, Gandhi AD, Grabowski DC, Geng F, Barnett ML. Changes in US skilled nursing facility capacity following the COVID-19 pandemic. JAMA Intern Med. Published online January 12, 2026. doi:10.1001/jamainternmed.2025.7197
2. ACHA/NCAL. Access to career report. 2024. Accessed January 12, 2025. https://www.ahcancal.org/News-and-Communications/Fact-Sheets/FactSheets/AHCA%20Access%20to%20Care%20Report%202024%20FINAL.pdf
3. Burke RE, Roy I, Hutchins F, et al. Trends in post-acute care use in Medicare Advantage versus traditional Medicare: a retrospective cohort analysis. J Am Med Dir Assoc. 2024;25(10):105202. doi:10.1016/j.jamda.2024.105202