The past few years have exposed a fragile link in the healthcare spectrum affecting both acute and post-acute care. A recent JAMA Internal Medicine study found that operating capacity in U.S. skilled nursing facilities declined 5% between 2019 and 2024, even though the total number of licensed beds fell just 2.5%. More concerning is that one in four counties experienced operating-capacity losses of 15% or more.
Rural counties were more likely to experience the steepest drops, due to long-standing access challenges in post-acute care. Researchers tied these capacity losses directly to workforce constraints. Where there was decline in county-level skilled nursing facility capacity, there was a corresponding increase in reported workforce shortages.
The resulting impact on hospitals is significant. In markets where skilled nursing capacity fell the most, hospitals saw longer inpatient stays, a higher share of stays exceeding 28 days and greater distances traveled for post-acute placement. In practical terms, patients who were medically ready for discharge often had nowhere to go.
Research from the University of Rochester underscores the scale of the issue. Nationally, the 5% decline in operating capacity translated into nearly 4,000 fewer skilled nursing beds available each day. Those waiting for placement, such as alternate-level-of-care patients, can occupy 10% or more of hospital beds in some systems, creating bottlenecks across emergency departments and inpatient units.
This is not just a post-acute challenge. The American Hospital Association reports that delays in discharge to post-acute settings have become a major driver of longer hospital stays. Between 2019 and 2024, the average length of stay for Medicare Advantage patients prior to discharge to post-acute care doubled compared with traditional Medicare. These delays increase hospital crowding, raise costs and limit access for new admissions.
The key takeaway: When skilled nursing facilities cannot operate at full capacity, hospitals feel it immediately. Capacity constraints on one side of the care equation ripple across the entire system.
The workforce pressures behind shrinking capacity
Several structural factors contribute to limit skilled nursing and hospital capacity at the same time. As ShiftKey’s "2026 Healthcare Facilities Trends Outlook" highlights, a retirement wave is looming with up to 40% of facilities' leaders expected to retire by 2026 in some regions. At the same time, new skill sets are required as facilities adopt digital tools, automation and more complex compliance processes.
The outlook also points to a cooling but still tight workforce environment. Senior housing occupancy continues to climb, but overall job growth slows. The result is increased competition among facilities for qualified professionals, especially in rural and underserved markets. Cross-training, local talent pipelines, and partnerships with trusted workforce marketplaces are becoming more important in maintaining coverage and continuity of care.
Policy and regulatory dynamics add another layer of complexity. CMS is tightening enforcement around Payroll-Based Journal reporting, and the Department of Labor is expected to issue additional guidance affecting workforce technology marketplaces. These shifts make flexibility and transparency more important than ever.
These trends mean many facilities have licensed beds they cannot operate consistently. Census swings, call-outs and seasonal surges quickly overwhelm traditional workforce models that rely on fixed schedules and long-term hiring cycles.
Flexible workforce models as a stabilizing force
As workforce shortages persist across care settings, flexibility has become a core strategy for stabilizing capacity and maintaining access to care. The AHA "2026 Health Care Workforce Scan" underscores this shift, noting that health systems are moving away from reactive coverage models and toward proactive redesign of how work is structured and deployed.
The report highlights how workforce challenges are most acute in rural and underserved communities, where limited access strain care delivery. As patient needs grow more complex and demand continues to rise, fixed schedules and static coverage models cannot respond well to disruption. Flexible workforce approaches are more necessary to keep beds operational and care moving.
Expanded internal float pools, cross-training initiatives and digital scheduling tools better align workforce availability with real-time demand. Earlier visibility into coverage gaps helps reduce last-minute disruptions that can force capacity offline or delay care transitions.
By improving responsiveness and reducing friction in coverage planning, organizations can absorb census fluctuations, maintain service lines and support patient throughput without relying on overcapacity. This is particularly important as hospitals and post-acute providers work together to reduce discharge delays and extended inpatient stays.
Flexible workforce models also support long-term sustainability. The AHA emphasizes that greater autonomy over when and where professionals work is among the most effective ways to support engagement and retention across a multigenerational workforce. When flexibility is embedded into operations, organizations are better positioned to sustain coverage over time.
Leaders can build stronger operations for their organizations by starting with a few basic actions:
- Invest in scheduling and credentialing technology that supports flexible workforce deployment while maintaining compliance and visibility.
- Align policies and contracts with evolving regulations, including CMS reporting requirements and federal workforce guidance.
- Build local pipelines through partnerships with colleges and training programs, while using flexible models to extend reach.
- Focus on retention by supporting well-being, autonomy and clear growth pathways.
Taken together, the AHA’s findings reinforce a clear conclusion: Flexibility is now foundational to workforce resilience and capacity stability across both hospital and post-acute settings.
Looking ahead
The evidence is clear that declining skilled nursing facility capacity, driven by workforce constraints, is lengthening hospital stays and limiting access to care. Because hospitals and post-acute providers are interconnected, stabilizing the system requires flexibility on both.
Flexible workforce models, supported by technology and digital marketplaces, offer a practical way forward. Facilities gain more options, improve resilience and help keep care moving when demand shifts.
For a deeper look at the trends reshaping facility operations, from workforce dynamics to policy, technology and resilience, explore ShiftKey’s "2026 Healthcare Facilities Trends Outlook." The First Look highlights the signals already shaping 2026 and outlines how flexible workforce strategies can turn uncertainty into stability.
Sources
Health Care Workforce: A System Under Pressure, Poised for Reinvention, (AHA).
The Cost of Caring: Challenges Facing America’s Hospitals in 2025, (AHA).
Changes in US Skilled Nursing Facility Capacity Following the COVID-19 Pandemic, (JAMA).
Decline in U.S. Nursing Home Capacity Since COVID-19: Rural Areas Hit Hardest, (University of Rochester Medical Center).
