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 healthcare.
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 and 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.
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.
“But the upcoming cuts to the Medicaid budget could have trickledown effects to stunt or reverse that recovery,” McGarry said. “We need to invest more in nursing homes and staff. It's hard to do that when the primary payer for nursing home services—Medicaid—is having its budget slashed.”