A New Model for Nursing Home Care
'Green Houses' offer homier atmospheres and more individual attention from caregivers.
It's a common refrain that adult children hear from their parents: "No matter what, promise that you'll never put me in a nursing home." These seniors obviously have not visited a Green House, a unique alternative to the traditional nursing facility.
Lois Gallo, 79, lives with nine other residents -- known as "elders" -- in one of the 10 condominium-style homes at the Leonard Florence Center for Living, in Chelsea, Mass., an inner suburb of Boston. Gallo suffers from a degenerative nerve and muscle condition and gets around by motorized wheelchair. "This place is a godsend," says Gallo, a widow and former psychotherapist.
There are two 7,000-square-foot Green Houses on each of five floors. Each Green House has its own entrance and 10 residents. Four Green Houses provide skilled-nursing care for elders while three provide short-term rehabilitation, two accommodate residents with ALS, and one serves people with multiple sclerosis.
I met with Gallo in late January in the nursing home's café, near the well-appointed lobby. (The café offers residents and visitors free coffee and home-baked pastries.) She smiled brightly as she described her life there. Like elders in all Green Houses, Gallo has her own bedroom and bathroom. "Privacy is really respected," she says. "If I want to watch something on my TV, I will just shut the door." In a typical nursing home, two residents share a room.
The 10 bedrooms in her home surround a state-of-the-art kitchen and a large dining table, where the residents usually sit together for meals. But you can "eat when you want," Gallo says. If she gets up early, a caregiver will whip up something she likes, often cereal and toast. Just off the kitchen area is a cozy living room with a fireplace -- a group of visiting friends gather there on Wednesday nights. Gallo enjoys trips to musicals, movies and the ballet. The facility, which is run by the Chelsea Jewish Foundation, uses a half-dozen wheelchair vans to take residents to these events.
I also spent a day at another Green House complex -- Eddy Village Green at Cohoes, outside Albany, N.Y., which is run by St. Peter's Health Partners. Eddy, which opened in 2008, is a development of 16 spiffy ranch-style homes, each accommodating 12 elders.
When I walked into one of the Green Houses at Eddy Village Green, several elders were watching TV in the light- and plant-filled living room. A few feet away, at the large open kitchen, two caregivers were preparing lunch while another was setting the large wooden table. There were no nurses' stations or carts clattering down long hallways -- as I'd seen at hospital-like nursing facilities. The atmosphere was the same at Leonard Florence. "When you walk into a Green House, it's a home," says Betsy Mullen, chief operating officer of the Chelsea Jewish Foundation. "You feel a calmness, a peacefulness."
But it's more than the physical ambiance that distinguishes a Green House from a traditional facility, says Scott Brown, director of outreach for The Green House Project, which provides guidance to nonprofits and businesses that seek to build Green Houses. Elders at Green Houses tend to get more individualized attention than residents at traditional facilities. And elders, perhaps with the exception of those with severe dementia, make many decisions themselves, such as waking up and going to bed when they want, and choosing activities they like, such as planting flowers by the patio. "When you diminish someone's decision-making ability, you take away who they really are," Brown says.
The Green House is the brainchild of Dr. Bill Thomas, a geriatrician who came up with the concept to alleviate the "three plagues" of nursing-home life -- loneliness, boredom and helplessness. The Green House "goes to the idea that regardless of age people still have a chance to have a meaningful life where they can experience joy and create value," Brown says.
There are 187 Green Houses operating in 28 states, with 150 more under development. Most complexes range in size from two to six Green Houses. (To look for a Green House in your community, go to www.thegreenhouseproject.org.)
Research shows that Green House elders are happier and healthier than residents in traditional nursing homes -- even though they have similar conditions, such as dementia, post-stroke ailments, Parkinson's disease and heart disease. They're less likely to become hospitalized or to experience declines in their ability to eat, dress or go to the bathroom on their own.
Building Connections: Elders, Aides and Relatives
In a traditional nursing home, it's all about efficiency -- perhaps six or seven aides dressing, feeding and moving 40 residents on a schedule. To pick up the pace, an aide may start feeding a slow eater or use the wheelchair for a person who walks too slowly to the dining room. Because this system promotes "forced dependency," skills may deteriorate, says Diana Lloyd, director of nursing at Eddy Village Green.
At a Green House, the number of staff providing direct care is higher -- about three certified nursing assistants are permanently assigned to each house of 12. This aide is known as a Shahbaz (the plural is Shahbazim), which is Persian for royal falcon. Working as a team, the Shahbazim order and prepare food, do light housekeeping, and plan schedules and activities.
Even when a Shahbaz is preparing a meal, she may be chatting with an elder or watching over an activity. "In the traditional nursing home, you don't have time to develop the relationships that you have in these homes," says James Farnan, administrator of Eddy Village Green. "When you have the same group of people taking care of the same group of elders, you get to know what they like and don't like."
These aides undergo 128 hours of training in addition to their nursing training. They learn the Green House "core principles" of building team skills and developing loving, respectful relations with elders. The aides also learn how to cook healthy meals.
I met with Maria Fana, a Leonard Florence Shahbaz, after a tasty salmon lunch. She's been there since it opened in 2010, after 17 years at another Chelsea Jewish Foundation nursing home. While she says the other facility was well run, "Wow, what a difference. The residents there had to run for their life -- wake up, take a shower, everyone eat breakfast," she says. "Here, you take time to give good care. It's calm."
Shahbazim learn about all facets of an elder's life -- their childhood, careers, children, and likes and dislikes. "If we know who the elders were before they came here and who they are now, it's easier to make them feel more comfortable," says Lakiya Hall, who has worked at Eddy Village Green for five years.
Hall says the elders and aides become so close that when one Shahbaz received his degree as a registered nurse, the elders were taken by a wheelchair-accessible van to his graduation. "They were so excited and happy, and he was ecstatic," she says.
At Eddy Village Green, Shahbazim choose an "Elder of the Month" for each house. With help from the elder and family members, the caregivers create a poster board with childhood photos, family pictures and information on the elder's life milestones and hobbies. The house and the families celebrate with a party.
When I visited, Kay Neilson, 85, was the honoree in her house, and her poster was on the wall outside her room. "It's an honor to be recognized," says Neilson, a retired high school secretary. She's in a wheelchair because she cannot use her legs.
Neilson says she represents her house on a residential council, which meets monthly and sometimes suggests menu items. She enjoys the music and other activities at the community center and sitting outside in the courtyard. "I'm happy here," she says.
Studies show that Green House caregivers suffer less stress than those at traditional facilities. Eddy Village Green's Farnan says turnover among certified nursing assistants was 19% in 2014, compared with 50% at the nursing home he ran on the property before it was demolished and the Green Houses opened.
Similarly, says Leonard Florence's Mullen, "it's always our mission to take care of our staff if they are taking care of our residents." The facility operates a "company store" where staff can get enough fresh produce and other food to feed their own families for several days a week -- at no charge.
Like their loved ones, family members are close to the staff. Relatives can visit at any time and often share meals at the dining table. Families have even used Eddy's community house for wedding receptions and grandkids' graduation parties -- so Mom or Dad doesn't have to travel far to celebrate.
My discussion with a group of five daughters of elders at Eddy seemed to confirm academic studies that Green House families are happier with the care their loved ones receive than are relatives of residents at traditional nursing homes. Their parents all lived in House 16. Besides regular visits, there are parties for residents and families -- Christmas parties where the grandkids decorate the house tree and barbeques on the patio. On Halloween, neighborhood kids travel from one Green House to another collecting candy.
I was struck by their enthusiasm and laughter as they shared stories -- an excitement you wouldn't expect from loving daughters whose parents were in a nursing home. But their relief was palpable.
Karen Diener's dad had made the progression from independent living to assisted living. When it was time for a nursing home, she says, his only request was that she find a place with a private room. Luckily, she says, there were openings at Eddy. Diener says, "When we pulled up, they had the whole welcome wagon sort of thing. It met all of his criteria more than he imagined it could." A plus: He plays the organ, and there happened to be one on campus that was moved into his house.
The women say the elders watch out for each other -- much like family members would. Carol Connolly, whose mother is deaf, says that when she visits, another resident, who lives across the hall, "will tell me things about my mother" to keep Connolly up to date.
The family members get to know the other elders well. Diener says that one of the elders who has dementia "adopted me as her best friend." After she visits her dad, she stops by to see the other elder for a bit. (Editor's note: Diener's father died about six weeks after the interview.)
Although there are downtimes, the women seemed astonished by how happy their parents seem to be. "My mother says she loves it here, and she is very picky," Connolly says. "She's said, 'Everyone takes good care of me, so don't worry about me.' "
The Future of the Green House
More than 10 years ago, it was time to tear down or renovate aging buildings in Cohoes that included 177 skilled-nursing beds and other senior health services, says Farnan. Rather than "spend millions of dollars to create a place no one wants to be," he says he decided to go with the Green House model.
Farnan says that per-bed operating costs did not rise when Eddy Village Green opened. And while the number of full-time employees is the same, he says, "the proportion has shifted heavily to direct care." That's in part because Green Houses can eliminate the labor-intensive central kitchen and laundry -- services the Shahbazim now provide.
While the Green House may be the ideal, the model is just a tiny portion of all nursing-home beds. When all the Green Houses under development are completed, there will be a total of 3,500 beds in the U.S. -- compared with 1.5 million beds in traditional homes.
It's unlikely there will be a wholesale transformation of existing facilities into Green Houses. While operating costs are similar, capital costs can be enormous. "It's more expensive to build 10 bedrooms and 10 bathrooms for 10 people than it is to build shared bedrooms and bathrooms," Brown says.
The daily private-pay rates -- $433 for Eddy Village Green and $495 for Leonard Florence -- are on the high end for private-room beds in their metropolitan areas, but not the highest. Forty-two percent of Green Houses' residents are on Medicaid -- somewhat less than in traditional homes, Brown says. The states' Medicaid reimbursement rates do not take into account the cost of the extra square feet for individual bedrooms. Thus, private-pay patients and other funding sources subsidize those lower-income residents.
As nursing-home operators renovate or tear down aging buildings, a number will go to full Green Houses, but it's more likely that they will incorporate some elements of the model. Exhilarated by the success of Leonard Florence, Barry Berman, chief executive officer of the Chelsea Jewish Foundation, is now turning his attention to a $14 million renovation of his 120-bed traditional Chelsea Jewish Nursing Home. The foundation does not have the funds to turn the facility into full-fledged Green Houses. But, Berman's son Adam, who is president, says the project "is still a radical transformation."
Rather than 40 residents to a floor, there will be 20 residents in six units, each with its own kitchen, family dining tables, living room and fireplace. Cooks will prepare home-cooked meals on site. There will be three or four Shahbazim for each house -- not as many per resident as at a Green House but better than the current staffing ratio. The renovation calls for shorter hallways, more glass and natural light, and new furniture. Two residents will still share a room.
Barry Berman says while the renovation is not as extensive as a Green House, "we designed what we would want for ourselves and our families." And he says combining Green House values with architectural changes in this way can be a model for others in the nursing industry.