Factors Predicting Swing Bed Versus Skilled Nursing Facility Use

Lead researcher:
Project funded:
September 2021
Project completed:
October 2022

Some policymakers have argued that Medicare could achieve considerable savings by reimbursing swing beds using skilled nursing facility (SNF) prospective payment system (PPS) rates instead of critical access hospital (CAH) cost-based payments. Because the reimbursement formula treats swing bed and acute days equally, there is concern that CAH skilled swing days are "over-reimbursed" as compared with skilled days provided in other settings.

Authorized by Congress in the early 1980s, the swing bed program was designed to respond to declining inpatient volume and long-term care in rural communities. Swing beds allow small rural and critical access hospitals to use their beds for either inpatient care or skilled nursing services as needed. Many CAHs have come to rely on swing beds to manage patients and staffing and to help ensure financial stability of their organizations.

This project considered patient characteristics and experience, and the extent to which there are differences between those in swing beds and those in SNFs.

  • Hypothesis 1: Patients discharged to facility-based, post-acute care from CAHs will be to SNFs and swing beds at comparable rates.
  • Hypothesis 2: Patient characteristics will be comparable regardless of hospital type or post-acute care discharge destination.
  • Hypothesis 3: Patients discharged to swing beds will have shorter acute stays than those discharged to SNFs regardless of hospital type.
  • Hypothesis 4: Primary health conditions will be similar for patients discharged to swing beds and to SNFs whether from a CAH or from a rural PPS hospital.

Although those concerned with swing bed use tend to focus on the financial aspects, it is important to understand the role that swing beds play in ensuring access to the full continuum of care in rural areas, and the underlying reasons for decisions administrators make regarding their use. A deeper understanding of the clinical factors associated with post-acute setting allows contrast with the financial incentives to operate swing beds. That is, swing beds may offer clinical advantages over SNF settings (e.g., easier ability to provide infusion services) that are often lost in the focus on the financial aspects. The purpose of this project was to update earlier research identifying clinical factors associated with the specific post-acute setting and to determine whether those associations vary by non-clinical characteristics.


  • Factors Predicting Swing Bed Versus Skilled Nursing Facility Use
    Policy Brief
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 10/2022
    This study examines differences between patients discharged to swing beds versus skilled nursing facilities, stratifying by admitting hospital type (i.e., rural Critical Access Hospital versus rural Prospective Payment System hospital).