Geriatrician Bill Thomas, who dubs himself a Nursing Home Abolitionist, is no stranger to attempting to rebuild nursing homes from the inside out. As founder of The Eden Alternative,  he has helped nudge the hidebound institutional nursing home culture to a model incorporating plants, animals, and children into the daily lives of residents — along with “person-directed” care, taking their individual needs and preferences into account.

While working with existing facilities interested in the Eden Alternative about 10 or 15 years ago, he says another disrupting thunderbolt struck: “I suddenly thought, ‘What if I could design housing for older people from the ground up?’” This planted the seed for The Green House Project, another innovative way to “reinvent” skilled nursing facilities by providing person-centered care.

What Makes a Nursing Home a Green House

Green House residences are distinguished by the following features:

• A series of 10 to 12 self-contained residences, affording each of the residents private bedrooms and bathrooms;
• An intimate common space, referred to as the “hearth,” that includes a common living area, an open kitchen, and a single dining table large enough to accommodate residents and staff for meals, recreation, and meetings;
• Specially trained and certified nursing assistants, called Shahbazim, to provide direct care who work in self-managed teams; and
• A team of licensed nurses, therapists, social workers, a medical director, and dietary and activities specialists to support the direct caregivers.

“A lot of us will spend time living with people we’re not related to,” Thomas says. “It’s easier in a smaller, homelike setting. And in a Green House, you’re never around strangers.” He also underscores another benefit of the Green House model: “It’s just healthier for people to have their own rooms,” he says.

And because the homes are built new, there is special attention to other beneficial aspects of the building including good sight lines, plentiful natural light, and easily accessible exterior spaces. Green Homes are also intentionally built to blend in with the surrounding community as opposed to sticking out as austere institutions, as most nursing facilities do currently.

The kitchens, based in the central “hearth” areas of the Green Homes, are pivotal places—just as kitchens are so often natural gathering spots in many other residences. But these are constructed with seniors in mind, with built-in safety features that allow open kitchens to be a part of the residents’ lives.

All meals are prepared in the kitchen, with residents urged to help with preparations. Meals are served family-style, with sufficient chairs for all residents and staff around a single table; the chairs signify that “everyone has a set at the table”—literally and figuratively. Residents’ food preferences are accommodated as often as possible, and their suggestions about new foods to prepare and serve are welcomed. While residents are free to eat in their own rooms or anywhere else they choose, most naturally gravitate toward the communal dining, according to Scott Brown, Director of the Green House Project. “That’s true even for the newcomers, who tend to hang back on their own at first,” he says. “But they soon get curious about what’s going on in the kitchen, since it’s such a hub of activity.” That curiosity soon helps build a sense of community.

As added measures of privacy and protection, medications are kept in each resident’s room — locked with a key kept by one of the nurses — and are prepared and administered in private. And all private rooms are also equipped with overhead lifts, as opposed to the manual lift equipment, which creates a safer work environment while encouraging elders to age in place.

Finally, and perhaps most profoundly, the staff at Green Houses is structured, trained, and organized completely differently than in traditional nursing homes — with their roles and responsibilities redefined. Most nursing homes follow a top-down structure, headed by an administrator who oversees the director of nursing and supervisors of other departments — with the certified nurse assistants (CNAs) and others providing direct care at the very bottom of the chart. This emphasizes one of the prime problems in nursing home operations: that the caregivers are made to feel disempowered and expendable. In contrast, Green Houses are staffed by Shahbazim, whose responsibilities broadly include direct care, light housekeeping, laundry, cooking, and arranging for activities in the home. They are entrusted to manage the home, and work collaboratively with members of the clinical support team. They receive 176 more hours of training than traditional CNAs — becoming versed in diverse topics including management skills, safe food handling and dementia care. They are also paid between 15 percent and 30 percent more than traditional CNAs.

Following the Money — and the Satisfaction

The Green House Project prides itself on being the only culture change model backed by ongoing research to evaluate quality of care delivered and quality of life of the residents in them, as well as the financial viability of building and running them.

Recent findings comparing traditional nursing homes and Green House homes revealed some persuasive statistics.

From a financial and return on investment perspective, Green House homes had:

• 7{d0e74b8a3596e4326b45924d39792f257a1f9983beed4201831d386befd3d18e} higher occupancy rates
• 24{d0e74b8a3596e4326b45924d39792f257a1f9983beed4201831d386befd3d18e} higher occupancy by private payers
• 0{d0e74b8a3596e4326b45924d39792f257a1f9983beed4201831d386befd3d18e} average change in staffing costs, and
• $1,300 to $2,300 less in annual Medicare and Medicaid/Medi-Cal costs per resident.

As far as direct care given and received, Green House staff:

• Had 4 times more engagement with the elder residents, and
• Spent an average of 23 to 31 minutes more delivering care to each resident daily.

Of the consumers educated about the Green House concept:

• 97{d0e74b8a3596e4326b45924d39792f257a1f9983beed4201831d386befd3d18e} favored it over the traditional nursing home model
• 60{d0e74b8a3596e4326b45924d39792f257a1f9983beed4201831d386befd3d18e} said they were willing to pay more for care there, and
• 73{d0e74b8a3596e4326b45924d39792f257a1f9983beed4201831d386befd3d18e} were willing to drive farther to visit a resident there compared to a traditional nursing home.

Roadblocks to Building

The first Green House was built in Tupelo, Mississippi, in 2003; more than 260 are now operating in 30 states; and the number nationwide will approach 300 by the year 2018.

While that growth is significant, and the research backing the project is compelling, there are many reasons the model has not taken a more substantial hold.

The first and hardest reason is that when Medicaid established a licensing system for nursing facilities back in 1964, the emphasis was on delivering care efficiently. Hospital-like structures built then — with centralized nursing stations, double-loaded corridors shared rooms branching out on either side, pre-plated food served on trays, medication carts and overhead paging — became and remains the norm. While nursing homes throughout the country are typically 30 to 40 years old, there are limited funds to refurbish them, not to mention build new structures.

In most places, local, state, and federal laws and regulations that dictate nursing facilities’ physical environments often hamper creating more homelike settings. Green House kitchens, for example have proven particularly nettlesome — as many licensing agencies view them as potential health and safety hazards despite the development of specific safety features. In some states, the Green House structure replacing institutional corridors in favor of rooms opening onto the hearth area have been held to run afoul of regulations mandating bedrooms with access to the corridor. And in some locations, laws regulating spaces for staff bathrooms, offices, and file storage get in the way of the more homelike construction the Green House Project envisions.