Despite the steady ageing of the U.S. population, the nation’s nursing home system has been contracting since the start of the COVID-19 pandemic. New research published this week shows that this decline has been both widespread and uneven, and around one quarter of U.S. counties experienced reductions in nursing home capacity of at least 15 per cent, with the most severe losses occurring in rural areas. These findings highlight a growing mismatch between rising demand for elder care and the system’s diminishing ability to provide it.
The study examined data from nearly 16,000 skilled nursing facilities across the country, analysing licensed beds alongside staffing levels and patient census figures to estimate actual operating capacity. Researchers found that between 2019 and 2024, national nursing home operating capacity fell by roughly five per cent. While that figure may appear modest at first glance, it translates to nearly 4,000 fewer beds being available for new patients on any given day, significantly constraining access to care.
Significantly, the decline did not affect all communities equally. Capacity changes varied substantially by geography, with rural counties far more likely to experience steep losses of 25 per cent or more. This pattern reflects broader trends in rural health care, where persistent workforce shortages and the closure or downsizing of hospitals have already limited access to services. For rural residents, the reduction in nursing home capacity has compounded existing barriers, making it increasingly difficult to obtain timely and appropriate care close to home.
The consequences of shrinking nursing home capacity extend well beyond long-term residential care. Nursing homes are a critical part of the post-hospital care pathway, providing skilled nursing and rehabilitation for patients who are no longer acutely ill but are not yet able to return home safely. The study found that reduced nursing home capacity was associated with longer hospital stays, particularly extended stays lasting 28 days or more. In some cases, patients remained in hospital beds for months simply because no suitable nursing home placement was available.
Such prolonged hospital stays can be profoundly disruptive for patients and families alike. Hospitals are designed for short-term treatment, not long-term living, and extended stays can be uncomfortable, isolating, and detrimental to recovery. Even when discharge is possible, patients increasingly find themselves placed in facilities farther from home. As nursing home options shrink, especially in rural areas, families may have to travel long distances to visit loved ones, reducing the social support that is often crucial to patient well-being.
A key contribution of this research is its focus on operating capacity rather than licensed beds alone. While beds may exist on paper, they cannot be used without adequate staffing and resources. The study found a strong association between declining capacity and staff shortages, with operating capacity reaching its lowest point in 2021 before beginning a slow recovery. That recovery, however, remains fragile. Potential reductions in Medicaid funding, the primary payer for nursing home services, could undermine progress by limiting facilities’ ability to invest in staff and infrastructure. Without sustained investment, the gap between the needs of an ageing population and available nursing home care is likely to widen further.
More information: Brian McGarry et al, Changes in US Skilled Nursing Facility Capacity Following the COVID-19 Pandemic, JAMA Internal Medicine. DOI: 10.1001/jamainternmed.2025.7197
Journal information: JAMA Internal Medicine Provided by University of Rochester Medical Center
