AHA Statement on Supporting Access to Long-Term Services and Supports

of the
American Hospital Association
for the
Committee on Energy and Commerce
Subcommittee on Health
of the
U.S. House of Representatives
“Supporting Access to Long-Term Services and Supports: An Examination of the
Impacts of Proposed Regulations on Workforce and Access to Care”

October 25, 2023

On behalf of our nearly 5,000 member hospitals, health systems who work with long-term care (LTC) facilities to serve hundreds of thousands of patients each year, our professional membership groups and affiliates including the American Organization for Nursing Leadership (AONL), and our 2,425 post-acute care members, the American Hospital Association (AHA) writes to share the hospital field’s comments on proposed regulations for minimum staffing standards for LTC facilities and their potential impact on access to care.

The AHA and its members are committed to safe staffing to ensure high quality, equitable and patient-centered care in all health care settings, including LTC facilities. However, CMS’ proposal to implement mandatory nurse staffing levels would have serious, negative, unintended consequences not only for nursing home patients and facilities, but the entire health care continuum. Safe staffing is complex and dynamic. It must account for the acuity of patients’ needs, the experience and clinical expertise of the nurses and health care professionals on the care team, and the technical capabilities of the facility. Organizational leaders, nurse managers and direct care nurses who know the needs of the patients they serve best must be empowered to collaboratively make staffing decisions, rather than having “one-size-fits-all” thresholds.

The AHA opposes implementation of minimum thresholds for registered nurse (RN) and nurse aide (NA) care. This type of standard is a static and ineffective tool that CMS’s own commissioned analysis shows does not guarantee safe health care environments or quality levels that result in optimum patient outcomes. The number of patients for whom nurses and other health care providers can provide safe, competent and quality care is dependent upon multiple factors that are not captured in a raw number of hours, including the type and degree of illness; functional status and level of independence of residents; the makeup of the overall care team including caregivers who may not be nurses; the physical layout of the facility; and the experience and tenure of the professionals in question.

If implemented, the rule could severely limit access to nursing home care, particularly in rural and other underserved communities. Such access issues can lead to longer waits for emergency and inpatient hospital care, worsen staffing shortages across the care continuum and hinder innovative, new approaches to delivering quality care. The AHA recommends that, instead of implementing these universal standards as proposed, CMS develop an approach that builds upon the knowledge and experiences of nurses and other caregivers themselves and supports the continual process of safe staffing.


Mandated nurse staffing standards remove real-time, clinical judgment and flexibility from the practice of nursing. Numerical staffing thresholds do not consider advanced capabilities in technology or the interprofessional team care model that supports data-driven decision-making and collaborative practice. Emerging care models incorporate nurses at various levels of licensure, respiratory therapists, occupational therapists, speech-language pathologists, physical therapists and case managers. A simple mandate of a base number of RN and NA hours per resident day emphasizes staff roles of yesterday, rather than what current and emerging practices may show is most effective and safe for the patient and best aligned with the capabilities of the care team.

AHA is concerned that these rigid standards would stymie innovation in care delivery. Our members have begun to deploy technology-enabled solutions such as virtual nursing models to help with remote patient monitoring in order to help provide an extra support to bedside nurses. As they look at their non-physician and non-nursing caregivers, some organizations are using these professionals to take on tasks that may not require a physician or nursing license to perform. Enabling practice at the top of one’s education and license can lead to greater staff satisfaction while maximizing the use of limited clinical staff resources. Nursing homes need the flexibility to test, evaluate and — when the evidence supports it — implement these new models.


Mandating staffing levels would exacerbate severe long-term shortages of nursing staff across the care continuum. In 2017, the majority of the nursing workforce was close to retirement, with more than half aged 50 and older, and almost 30% aged 60 and older. A comprehensive analysis from a survey conducted by the National Council of State Boards of Nursing and National Forum of State Nursing Workforce Centers showed that nearly 900,000 — or one-fifth of the 4.5 million total registered nurses — expressed an intention to leave the workforce due to stress, burnout and retirement. The study also 3 noted that over 33,800 licensed practical nurses (LPNs) and vocational nurses left the field since 2020, disproportionately impacting nursing homes and LTCs.1

In the CMS proposed rule, the agency estimates that 75% of LTC facilities would have to increase staffing to meet the proposed standards, including the new standard requiring 24/7 RN staffing. Considering the massive structural shortages described by recent studies, it is unclear where this supply of nurses will come. Given the shortages we described above, it is inconceivable that LTC facilities will be able to meet these standards without detrimental effects to workforce availability throughout the care continuum.


Faced with required staffing levels, skilled nursing facilities and other LTC facilities may be forced to reduce capacity or even close their doors when they are unable to meet these mandates. Organizations considering opening new LTC facilities would likely be discouraged from doing so. This would have a ripple effect across the entire continuum of care, especially because general acute care hospitals, inpatient rehabilitation facilities and other health care facilities already struggle to find appropriate placement for their patients.

Hospitals and health systems already are experiencing significant challenges in moving patients through the health care continuum generally, and into skilled nursing facility care specifically. Longer stays in hospitals result in delays in patients receiving the next level of medically necessary care. They also lead to longer wait times in hospital emergency departments because hospitals are unable to move current patients out of inpatient beds. Constrained access to LTC facilities is a quality-of-care issue affecting all types of patients across the care continuum.


Thank you for your consideration of the AHA’s comments on proposed regulations for minimum staffing standards for LTC facilities and their potential impact on access to care. We look forward to continuing to work with you to address these important topics on behalf of our patients and communities.