Changes in US Skilled Nursing Facility Capacity Following the COVID-19 Pandemic.

Importance: Skilled nursing facilities (SNFs) are the primary provider of institutional postacute care. Following the COVID-19 pandemic, there have been reports of SNFs reducing their capacity, affecting access to care and disrupting hospital discharges, yet little empirical evidence exists. Objective: To describe changes in SNF capacity after 2020 and assess whether changes were associated with staffing shortages and hospital discharge outcomes. Design, Setting, and Participants: In this cross-sectional study, data from the 2018-2024 Centers for Medicare & Medicaid Services Payroll-Based Journal on patient censuses in US skilled nursing facilities were assessed. Descriptive analyses characterized trends in SNF capacity from 2018 to 2024. Main Outcomes and Measures: Main outcomes were SNF licensed bed count and estimated operating capacity. Secondary outcomes included SNF staffing shortages, mean hospital length of stay, percentage of hospital admissions lasting 28 days or more, and the median distance traveled to admitting SNFs. County-level regression analyses examined the association between changes in SNF capacity and the frequency of SNF staffing shortages. Hospital-level regressions examined the association between changes in nearby SNF capacity and discharge outcomes. Results: Among US skilled nursing facilities, the number of licensed SNF beds declined by 2.5% between 2019 and 2024, while operating capacity declined by 5.0% over the same time period. There was substantial geographic variation-1 in 4 counties experienced operating capacity declines of 15.1% or more, with the largest declines being more common among rural counties. SNF capacity declines were larger in counties with more frequent reports of SNF staffing shortages-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. Additionally, hospitals that experienced larger declines in nearby SNF capacity experienced greater increases in mean length of stay, percentage of stays lasting 28 or more days, and median distance traveled to admitting SNFs. Conclusions and Relevance: Results of this study suggest that SNF operating capacity declined following the pandemic and these declines were larger than the observed declines in licensed SNF bed counts, potentially because of staffing shortages. Greater loss of SNF capacity was associated with longer hospital stays and increased travel distances to SNFs, suggesting that declines in operating capacity may be impairing access to care.