Defense Date


Document Type


Degree Name

Doctor of Philosophy


Health Administration

First Advisor

Jan Clement, Ph.D.

Second Advisor

Gloria Bazzoli, Ph.D.

Third Advisor

David Harless, Ph.D.

Fourth Advisor

Shoou-Yih Lee, Ph.D.

Fifth Advisor

Patrick Shay, Ph.D.


Since the early 2000s, skilled nursing facilities (SNFs) have operated in an environment made uncertain by changes in health care policy, growth in substitutes for nursing care, and increasing demand for services. To better understand how SNFs are strategically positioning themselves to survive and thrive, this study develops a taxonomy of strategic groups of SNFs.

A conceptual framework is based in Strategic Management Theory and classification of SNFs is based on scope of business decisions including length of stay, complexity of patients, and referral networks with hospitals. Two-step, hierarchical cluster analysis finds six strategy groups of SNFs: Post-Acute Care Focus – Wide Network, Private Pay Focus – Narrow Network, High Acuity Care Focus – Wide Network, Intermediate Care Focus – Wide Network, Long-Stay Care Focus – Narrow Network, and Long-Stay Complex Care Focus – Narrow Network.

Support is found for a structure-performance link between membership in a particular strategy group and financial and quality performance. A longitudinal analysis finds stability in the structure of the groups, but fluidity of movement from one strategy group to another. A comparison of strategy groups with those in prior studies suggests changes in reimbursement policies and industry trends align with shifts in strategy.

This study contributes to the understanding of how SNFs adjust strategically to environmental uncertainty and provides a unique assessment of the relational dynamics of referrals to SNFs from hospitals. A better understanding of the industry structure can benefit managers as they make strategic decisions and help policymakers better target funding and policy changes to improve patient outcomes.


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