Decline in U.S. Nursing Home Capacity Since COVID-19: Rural Areas Hit Hardest
Though the U.S. population is aging, nursing home capacity has declined nationwide since the COVID-19 pandemic began. According to a study published in JAMA Internal Medicine this week, one quarter of U.S. counties experienced declines of 15 percent or more, with the greatest declines reported in rural areas.
Analyzing licensed beds, staffing, and patient census data from nearly 16,000 skilled nursing facilities, researchers found that national nursing home operating capacity fell by five percent between 2019 and 2024. That translates to nearly 4,000 fewer beds available for new patients each day.
But this decline was not felt by all communities equally. It varied widely across geographic regions, with rural counties more likely to face declines of 25 percent or more. That tracks with broader trends in the rural health care system, where physicians are in short supply and hospitals are closing or curtailing vital services, making it ever more difficult for rural residents to access health care.
Consequences for Patients and Families
In addition to providing long-term care for older adults, nursing homes provide crucial skilled nursing care for patients after hospitalization. According to the study, the reduction in nursing home capacity was linked to longer hospital stays, especially extended stays of 28 days or more.
“In rare cases, patients can get stuck in the hospital for several months or indefinitely,” said study author Brian McGarry, PhD, assistant professor of Geriatrics & Aging at the University of Rochester Medical Center. “If you’ve ever spent time in a hospital, you know they’re not designed for long-term care. It’s not a comfortable place to live."
The study also suggests that, once discharged, patients had to settle for skilled nursing facilities farther from home. Patients tend to choose nursing homes that are close to home, making it easier for family to visit and provide vital support, but declining nursing home capacity was linked to increasing distance between a patient’s home and the nursing home they were able to get into.
“We also worry about the patients in need of long-term care being admitted from the community,” McGarry said. “There are often wait lists for these patients, and with reduced capacity, they spend a longer time at home without the care they need, increasing the risk of falls or other life-threatening events.”
Drivers of the Decline
Capacity issues in nursing homes have been studied for years, but most research focused solely on the number of licensed beds at facilities. This study estimated nursing homes’ operating capacity by taking other resource constraints into account.
“Licensed beds are hard to get and free to keep,” said McGarry. “The beds may physically exist, but the facility may not have the staff or other resources to fill every bed.”
While more research is needed to understand what caused the decline, the study found an association between declining nursing home operating capacity and staff shortages. According to McGarry, operating capacity hit a low in 2021 and has been slowly recovering since then, likely due to rebounding labor markets as the chaos of the pandemic subsided.
“Medicaid is the largest payer for nursing-home care nationally, which means cuts to the Medicaid budget could have trickledown effects to stunt or reverse that recovery,” McGarry said. “Our study points to the need for strategies that increase investment in nursing homes and staff.”
Broader Impacts
Nursing homes are a vital part of the total health care system. When they experience shortages, they may create bottlenecks.
Patients who are ready to be discharged from the hospital to a nursing home, but unable to find a placement, are called alternate level of care (ALC) patients. In communities where inpatient bed capacity is limited, having ALC patients live for months in the hospital can cause admitted patients to wait many hours or days for a room. This can lead to longer ED wait times for non-critical patients and create operational challenges for hospital care teams.
Overcrowding within his own regional health system helped motivate McGarry to conduct this study. Strong Memorial Hospital, the flagship hospital of the UR Medicine health system, offers an example. It serves the Finger Lakes region of New York, which faces a severe shortage of staffed nursing home beds and has fewer hospital beds per capita of any region in the state, more than 25 percent lower than national averages.
As a result, ALC patients frequently occupy 10 percent or more of Strong Memorial’s 897 licensed inpatient beds, and 50 to 75 admitted patients routinely receive care in overflow clinical spaces as they await an inpatient room.
“The motivation for this study was to start pulling threads to understand the causes of ongoing capacity issues in my own community and many others across the country,” McGarry said. “The findings of the paper help underscore the interconnected nature of the health care system. Staffing difficulties in the nursing home sector can have ripple effects that determine how difficult it is to get care at an ED or in the hospital. Ensuring we have adequate health system capacity requires looking at the big picture to capture these relationships.”
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