{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,4]],"date-time":"2026-05-04T04:49:15Z","timestamp":1777870155711,"version":"3.51.4"},"reference-count":36,"publisher":"American Medical Association (AMA)","issue":"4","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JAMA Netw Open"],"abstract":"\n Importance<\/jats:title>\n Delays in hospital discharge to skilled nursing facilities (SNFs) are widely viewed by hospital administrators and policymakers as a significant contributor to hospital crowding and adverse patient outcomes. However, the extent to which regional SNF capacity is associated with hospital length of stay (LOS) is not well understood.<\/jats:p>\n <\/jats:sec>\n \n Objectives<\/jats:title>\n To construct empirically derived hospital-SNF markets using a network science approach and to examine whether variation in SNF capacity within these markets is associated with hospital LOS.<\/jats:p>\n <\/jats:sec>\n \n Design, Setting, and Participants<\/jats:title>\n This cross-sectional study used 2018 and 2019 Medicare fee-for-service claims linked with publicly available SNF data and included 3.34 million inpatient admissions discharged to SNFs from short-term hospitals in the US. Data were analyzed from October 1, 2024, to February 28, 2026.<\/jats:p>\n <\/jats:sec>\n \n Exposures<\/jats:title>\n Monthly mean SNF occupancy rates and nurse and therapy staffing levels within an empirically defined regional hospital-SNF market from a patient-sharing network analysis.<\/jats:p>\n <\/jats:sec>\n \n Main Outcomes and Measures<\/jats:title>\n The main outcome was hospital LOS. Linear regression models estimated associations between market-level SNF capacity measures and LOS, adjusting for patient characteristics, hospital-level postacute care demand, SNF organizational features, and time and hospital-SNF market fixed effects. Analyses were stratified by dual Medicare-Medicaid eligibility.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n The study sample included 3.34 million Medicare inpatient admissions (mean [SD] age, 78.6 [11.3] years; 60.2% women) discharged to SNFs across 62\u202f303 hospital-SNF dyads, and 421 empirically derived hospital-SNF markets. The mean (SD) hospital LOS was 6.9 (6.8) days (7.4 [7.8] days for dual-eligible patients and 6.7 [6.2] days for non\u2013dual-eligible patients). Within markets, each additional nurse staffing hour per patient-day was associated with a 3.5% shorter LOS (95% CI, \u22125.5% to \u22121.4%); associations were also found among dual-eligible patients (\u20133.9% [95% CI, \u20136.7% to \u20130.9%) and non\u2013dual-eligible patients (\u20133.2% [95% CI, \u20135.4% to \u20130.9%]). Differences in occupancy rates and therapy staffing within networks were not associated with differences in LOS after adjusting for patient, hospital, and network factors.<\/jats:p>\n <\/jats:sec>\n \n Conclusions and Relevance<\/jats:title>\n Hospital-SNF markets defined by the strength of patient-sharing relationships provide a reproducible framework for examining postacute care capacity across payer populations. Within these markets, for the Medicare fee-for-service population, higher nurse staffing levels were associated with shorter hospital LOS. Strategies to reduce discharge delays and hospital crowding may require closer alignment between hospitals and highly connected SNFs to maintain adequate postacute care capacity.<\/jats:p>\n <\/jats:sec>","DOI":"10.1001\/jamanetworkopen.2026.9930","type":"journal-article","created":{"date-parts":[[2026,4,30]],"date-time":"2026-04-30T15:31:01Z","timestamp":1777563061000},"page":"e269930","source":"Crossref","is-referenced-by-count":0,"title":["Skilled Nursing Facility Network Capacity and Hospital Length of Stay"],"prefix":"10.1001","volume":"9","author":[{"given":"Rachel A.","family":"Prusynski","sequence":"first","affiliation":[{"name":"Department of Rehabilitation Medicine, School of Medicine, University of Washington, Seattle"},{"name":"Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Zhiyu","family":"Yan","sequence":"additional","affiliation":[{"name":"Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Kori S.","family":"Zachrison","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts"},{"name":"Department of Emergency Medicine, Massachusetts General Hospital, Boston"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Tracy M.","family":"Mroz","sequence":"additional","affiliation":[{"name":"Department of Rehabilitation Medicine, School of Medicine, University of Washington, Seattle"},{"name":"Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Renee Y.","family":"Hsia","sequence":"additional","affiliation":[{"name":"Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco"},{"name":"Department of Emergency Medicine, University of California, San Francisco"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Amber K.","family":"Sabbatini","sequence":"additional","affiliation":[{"name":"Department of Rehabilitation Medicine, School of Medicine, University of Washington, Seattle"},{"name":"Department of Emergency Medicine, School of Medicine, University of Washington, Seattle"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"10","published-online":{"date-parts":[[2026,4,30]]},"reference":[{"key":"zoi260307r2","doi-asserted-by":"publisher","DOI":"10.1016\/j.apmr.2024.08.017","author":"Prusynski","year":"2025","journal-title":"Arch Phys Med Rehabil"},{"issue":"11","key":"zoi260307r3","doi-asserted-by":"publisher","first-page":"1362","DOI":"10.1001\/jamainternmed.2025.4411","article-title":"Extended hospital stays in Medicare Advantage and traditional Medicare.","volume":"185","author":"McGarry","year":"2025","journal-title":"JAMA Intern Med"},{"issue":"3","key":"zoi260307r5","doi-asserted-by":"publisher","first-page":"285","DOI":"10.1001\/jamainternmed.2025.7197","article-title":"Changes in US skilled nursing facility capacity following the COVID-19 pandemic.","volume":"186","author":"McGarry","year":"2026","journal-title":"JAMA Intern Med"},{"issue":"2","key":"zoi260307r7","doi-asserted-by":"publisher","first-page":"609","DOI":"10.1111\/jgs.18208","article-title":"Dual impacts of Medicare payment reform and the COVID-19 pandemic on therapy staffing in skilled nursing facilities.","volume":"71","author":"Prusynski","year":"2023","journal-title":"J Am Geriatr Soc"},{"issue":"9","key":"zoi260307r9","doi-asserted-by":"publisher","first-page":"2124","DOI":"10.1007\/s11606-024-09288-3","article-title":"New minimum staffing standards for nursing homes: an overdue directive.","volume":"40","author":"Adashi","year":"2025","journal-title":"J Gen Intern Med"},{"issue":"2","key":"zoi260307r10","doi-asserted-by":"publisher","DOI":"10.1093\/haschl\/qxad025","article-title":"Rates of nursing home closures were relatively stable over the past decade, but warrant continuous monitoring.","volume":"1","author":"Hughes","year":"2023","journal-title":"Health Aff Sch"},{"issue":"3","key":"zoi260307r12","doi-asserted-by":"publisher","first-page":"175","DOI":"10.1016\/j.hjdsi.2018.05.001","article-title":"Trends in hospital-SNF relationships in the care of Medicare beneficiaries.","volume":"6","author":"Liao","year":"2018","journal-title":"Healthc (Amst)"},{"issue":"2","key":"zoi260307r13","doi-asserted-by":"publisher","first-page":"138","DOI":"10.5034\/inquiryjrnl_48.02.03","article-title":"Geographic market definition: the case of Medicare-reimbursed skilled nursing facility care.","volume":"48","author":"Bowblis","year":"2011","journal-title":"Inquiry"},{"issue":"1","key":"zoi260307r14","doi-asserted-by":"publisher","first-page":"204","DOI":"10.1186\/s12913-023-09184-2","article-title":"Development and evaluation of rehabilitation service areas for the United States.","volume":"23","author":"Reistetter","year":"2023","journal-title":"BMC Health Serv Res"},{"issue":"6","key":"zoi260307r15","doi-asserted-by":"publisher","first-page":"510","DOI":"10.1097\/MLR.0000000000000356","article-title":"Do hospital service areas and hospital referral regions define discrete health care populations?","volume":"53","author":"Kilaru","year":"2015","journal-title":"Med Care"},{"issue":"8","key":"zoi260307r16","doi-asserted-by":"publisher","DOI":"10.1161\/CIRCOUTCOMES.119.005526","article-title":"A network approach to stroke systems of care.","volume":"12","author":"Zachrison","year":"2019","journal-title":"Circ Cardiovasc Qual Outcomes"},{"issue":"7","key":"zoi260307r17","doi-asserted-by":"publisher","first-page":"787","DOI":"10.1097\/MLR.0b013e318197b1f5","article-title":"The structure of critical care transfer networks.","volume":"47","author":"Iwashyna","year":"2009","journal-title":"Med Care"},{"issue":"1","key":"zoi260307r18","doi-asserted-by":"publisher","DOI":"10.1088\/1742-6596\/2129\/1\/012028","article-title":"Comparison between Louvain and Leiden algorithm for network structure: a review.","volume":"2129","author":"Hairol Anuar","year":"2021","journal-title":"J Phys Conf Ser"},{"issue":"1","key":"zoi260307r19","doi-asserted-by":"publisher","first-page":"5233","DOI":"10.1038\/s41598-019-41695-z","article-title":"From Louvain to Leiden: guaranteeing well-connected communities.","volume":"9","author":"Traag","year":"2019","journal-title":"Sci Rep"},{"issue":"6, pt 2","key":"zoi260307r20","doi-asserted-by":"publisher","DOI":"10.1103\/PhysRevE.76.066102","article-title":"Modularity and community detection in bipartite networks.","volume":"76","author":"Barber","year":"2007","journal-title":"Phys Rev E Stat Nonlin Soft Matter Phys"},{"key":"zoi260307r23","doi-asserted-by":"publisher","first-page":"13","DOI":"10.1093\/biomet\/73.1.13","article-title":"Longitudinal data analysis using generalized linear models.","volume":"73","author":"Liang","year":"1986","journal-title":"Biometrika"},{"issue":"4","key":"zoi260307r24","doi-asserted-by":"publisher","first-page":"384","DOI":"10.1177\/1077558714533824","article-title":"Dual eligibility, selection of skilled nursing facility, and length of Medicare paid postacute stay.","volume":"71","author":"Rahman","year":"2014","journal-title":"Med Care Res Rev"},{"issue":"1","key":"zoi260307r25","doi-asserted-by":"publisher","first-page":"78","DOI":"10.1377\/hlthaff.2017.0714","article-title":"Medicare Advantage enrollees more likely to enter lower-quality nursing homes compared to fee-for-service enrollees.","volume":"37","author":"Meyers","year":"2018","journal-title":"Health Aff (Millwood)"},{"issue":"5","key":"zoi260307r26","doi-asserted-by":"publisher","first-page":"819","DOI":"10.1377\/hlthaff.2014.1084","article-title":"Nursing home 5-star rating system exacerbates disparities in quality, by payer source.","volume":"34","author":"Konetzka","year":"2015","journal-title":"Health Aff (Millwood)"},{"issue":"6","key":"zoi260307r27","doi-asserted-by":"publisher","first-page":"383","DOI":"10.1016\/j.jamda.2013.12.080","article-title":"Nurse staffing impact on quality of care in nursing homes: a systematic review of longitudinal studies.","volume":"15","author":"Backhaus","year":"2014","journal-title":"J Am Med Dir Assoc"},{"issue":"6","key":"zoi260307r29","doi-asserted-by":"publisher","DOI":"10.1111\/1475-6773.14355","article-title":"Skilled nursing facility staffing shortages: sources, strategies, and impacts on staff who stayed.","volume":"59","author":"Leland","year":"2024","journal-title":"Health Serv Res"},{"issue":"7","key":"zoi260307r30","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2023.25993","article-title":"Examination of staffing shortages at US nursing homes during the COVID-19 pandemic.","volume":"6","author":"Brazier","year":"2023","journal-title":"JAMA Netw Open"},{"issue":"5","key":"zoi260307r31","doi-asserted-by":"publisher","DOI":"10.1016\/j.jamda.2025.105530","article-title":"Impacts of skilled nursing facility change of ownership on staffing: a staggered difference-in-difference analysis.","volume":"26","author":"Prusynski","year":"2025","journal-title":"J Am Med Dir Assoc"},{"issue":"4","key":"zoi260307r32","doi-asserted-by":"publisher","first-page":"1198","DOI":"10.1111\/jgs.17678","article-title":"Facility characteristics and costs associated with meeting proposed minimum staffing levels in skilled nursing facilities.","volume":"70","author":"Hawk","year":"2022","journal-title":"J Am Geriatr Soc"},{"issue":"3","key":"zoi260307r33","doi-asserted-by":"publisher","first-page":"303","DOI":"10.1177\/0733464815570670","article-title":"Ownership status and length of stay in skilled nursing facilities: does endogeneity matter?","volume":"35","author":"Bowblis","year":"2016","journal-title":"J Appl Gerontol"},{"issue":"6","key":"zoi260307r34","doi-asserted-by":"publisher","first-page":"758","DOI":"10.1177\/1077558720960326","article-title":"Inside the black box of improving on nursing home quality measures.","volume":"78","author":"Davila","year":"2021","journal-title":"Med Care Res Rev"},{"issue":"2","key":"zoi260307r35","doi-asserted-by":"publisher","first-page":"227","DOI":"10.1111\/j.0887-378X.2004.00309.x","article-title":"Driven to tiers: socioeconomic and racial disparities in the quality of nursing home care.","volume":"82","author":"Mor","year":"2004","journal-title":"Milbank Q"},{"issue":"1","key":"zoi260307r36","doi-asserted-by":"publisher","first-page":"161","DOI":"10.1111\/1475-6773.12204","article-title":"Higher Medicare SNF care utilization by dual-eligible beneficiaries: can Medicaid long-term care policies be the answer?","volume":"50","author":"Rahman","year":"2015","journal-title":"Health Serv Res"},{"key":"zoi260307r8","year":"2024"},{"key":"zoi260307r1","unstructured":"Growing discharge delays leading to hospital overcrowding, other problems. California Hospital Association. October 16, 2023. Accessed June 10, 2024. https:\/\/calhospital.org\/growing-discharge-delays-leading-to-hospital-overcrowding-other-problems\/"},{"key":"zoi260307r4","unstructured":"Issue brief: patients and providers faced with increasing delays in timely discharges. American Hospital Association. December 2022. Accessed January 24, 2022. https:\/\/www.aha.org\/system\/files\/media\/file\/2022\/12\/Issue-Brief-Patients-and-Providers-Faced-with-Increasing-Delays-in-Timely-Discharges.pdf"},{"key":"zoi260307r6","unstructured":"Report to the Congress: Medicare payment policy. Medicare Payment Advisory Commission (MedPAC). March 2025. Accessed April 2, 2025. https:\/\/www.medpac.gov\/wp-content\/uploads\/2025\/03\/Mar25_MedPAC_Report_To_Congress_SEC.pdf"},{"key":"zoi260307r11","unstructured":"Nursing home closures did not increase in 2020 and 2021, despite financial challenges caused by the COVID-19 pandemic. Assistant Secretary for Planning and Evaluation; Office of Behavioral Health, Disability, and Aging Policy. May 31, 2024. Accessed June 10, 2025. https:\/\/aspe.hhs.gov\/sites\/default\/files\/documents\/769776e3d2e8e1693929430ea3ce3add\/nh-closure-financial-challenges-covid.pdf"},{"key":"zoi260307r21","unstructured":"Five-star quality rating system. Centers for Medicare & Medicaid Services. 2023. Accessed November 13, 2023. https:\/\/www.cms.gov\/medicare\/health-safety-standards\/certification-compliance\/five-star-quality-rating-system"},{"key":"zoi260307r22","unstructured":"LTCFocus. Published online 2018. Accessed October 31, 2024. http:\/\/www.ltcfocus.org"},{"key":"zoi260307r28","unstructured":"Prusynski? RA, Frogner? BK, Mroz? TM. Staffing trends for non-nursing occupations in skilled nursing facilities in the United States between 2018-2022. Center for Health Workforce Studies, University of Washington. November 2023. Accessed November 15, 2023. https:\/\/familymedicine.uw.edu\/chws\/publications\/staffing-trends-for-non-nursing-occupations-in-skilled-nursing-facilities-in-the-united-states-between-2018-2022\/"}],"container-title":["JAMA Network Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/jamanetwork.com\/journals\/jamanetworkopen\/articlepdf\/2848405\/prusynski_2026_oi_260307_1776978922.58207.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,4,30]],"date-time":"2026-04-30T15:31:08Z","timestamp":1777563068000},"score":1,"resource":{"primary":{"URL":"https:\/\/jamanetwork.com\/journals\/jamanetworkopen\/fullarticle\/2848405"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,4,30]]},"references-count":36,"journal-issue":{"issue":"4","published-print":{"date-parts":[[2026,4,1]]}},"URL":"https:\/\/doi.org\/10.1001\/jamanetworkopen.2026.9930","relation":{},"ISSN":["2574-3805"],"issn-type":[{"value":"2574-3805","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,4,30]]}}}