Green House® Cooperative Homes for Seniors
Green House Homes for Skilled Nursing CareGreen House® homes are residences for 6 to 10 elders who require skilled nursing care and want to live a rich life. They are a radical departure from traditional skilled nursing homes and assisted living facilities, altering size, design, and organization to create a warm community. Their innovative architecture and services offer privacy, autonomy, support, enjoyment and a place to call home. Green House® homes are developed and operated by long-term care organizations in partnership with The Green House Project and NCB Capital Impact.
While adhering to all codes required by regulations, Green House homes look and feel like a home, and contain few medical signposts.
NCB Capital for Green House HomesOrganizations interested in becoming a registered Green House Project must apply following the steps outlined on NCB's Information & Workshops webpage.
With grant funding from The Robert Wood Johnson Foundation (RWJF), NCB Capital Impact is pursuing replication of The Green House model on a national level, offering technical assistance and pre-development loans (PDLs) to organizations that want to establish a partnership with The Green House Project. Over the next five years, under the leadership of Robert Jenkens, NCB Capital Impact plans to develop Green House homes with 50 or more organizations throughout the country.
Project goals include:
The US Senate Finance Committee named the Green House® Project as a program that should be piloted. Read white paper: Call to Action - Health Reform 2009, (11/12/08 PDF).
Written by U.S. Senator Max Baucus, Chairman of the Senate Finance Committee, this white paper details his vision for health care reform.
Institutional or residential care is appropriate in some cases; however, it should be a choice for individuals and families. This plan would pilot new models of institutional care, such as the Green House model, that has shown promise for both improving the quality of life and care in these settings. In addition, this plan incorporates several options to reform the delivery system to provide better care coordination and chronic disease management. Others may include investment in aging and disability resource centers (ADRCs) and programs that limit secondary disabilities by promoting nutrition, exercise and fall prevention.
The Green House Model creates a small community for a group of elders and staff. They differ from traditional skilled nursing homes and assisted living facilities, by altering size, interior design, staffing patterns, and methods of delivering skilled professional services. Its primary purpose is to serve as a place where elders can receive assistance and support with activities of daily living and clinical care, without the assistance and care becoming the focus of their existence.
Developed by Dr. William Thomas and rooted in the tradition of the Eden Alternative, it is a model for cultural change within nursing facilities, www.nbccapitalimpact.org.
The Green House Project - Testimony to the SenatePicture elders waking up when they choose, to a breakfast of their choice, made fresh and hot just for them. They spend their day according to their choices and preferences, with staff who know them very well. Their family and friends are welcome and feel comfortable visiting a place that is truly mom’s, dad’s, or grandma’s home. Person-directed care is about creating a place where people live life on their own terms, with dignity and control. The Green House® Model is a powerful example of person-centered care in action, of creating private places for private lives.
Green House Model OverviewThe Green House® model de-institutionalizes nursing homes and reinvents them with the goal of restoring elders to a place they consider home. It combines small houses with the full range of personal care and clinical services needed by elders typically served in skilled nursing facilities. Green House® homes are licensed as nursing homes, but totally transform the elder care experience in a home that is small, warm and private. The program creates an intentional community to support the most positive elderhood and work life possible. To achieve these goals, the model changes the architecture, organizational structure, and the philosophy of care.
The Green House® model was created by Dr. William Thomas, from who you just heard. The replication of The Green House model is being spearheaded by a team at NCB Capital Impact with generous financial and technical assistance from The Robert Wood Johnson Foundation. NCB Capital Impact is a not-for-profit, mission- driven organization providing innovative assistance and services to low and middle income communities, in the areas of healthcare, affordable housing, and education. The Robert Wood Johnson Foundation is the nation’s largest philanthropy dedicated to improving health and helping Americans get the care they need. This team works hand-in-hand with long-term care providers and other community-based organizations to bring Green House® homes to communities across the country.
The Robert Wood Johnson Foundation has provided support for this replication effort, with the goal of developing Green House® homes in at least 50 communities.
The Green House model is a fully integrated approach to transforming the way long-term care is provided. It calls upon an organization to transform 3 areas simultaneously:
The Green House approach is about much more than building small, residential-style homes. The elements of philosophy and structure are at least as important as architecture, if not more so, in creating an environment that truly supports person-directed care and an empowered workforce.
Tracking Successes of Person-centered Care in The Green House® ModelCurrently there are 41 Green House® homes on 15 campuses in 10 states, with another 12 homes due to open by then end of this year. There are 120 additional houses in planning on 19 campuses, expanding Green House homes to 22 states. In time, the model in expected to spread to all 50 states. One indicator of success is the future plans of many of the current sites to build additional Green House® homes.
Rosalie Kane, Ph.D. of the University of Minnesota conducted an independent evaluation of the first Green House® homes, developed by Mississippi Methodist Senior Services in Tupelo, MS.
A 2-year longitudinal study compared elders living in the first 4 Green House® homes with elders in traditional nursing home care and found significant improvements for the elders in Green House® homes in the areas of privacy, dignity, autonomy, enjoyment of food, relationships, emotional well-being, feeling safer and meaningful engagement.
Just as important, areas of clinical care improved as well. This was an added benefit and one we believe is attributable to the smaller environment where staff know and understand the elders much better. Areas of improvement included greater independence in functional areas defined as “late-loss activities of daily living” (ie., bed mobility, transfer, eating and toileting), less depression, and fewer elders who were bedfast or had little or no daily activity. These successes illustrate improvement in major domains of quality of life and quality of care that translate into better lives and care.
Successes Related to The Green House Workforce
1. Significant decreases in staff turnover are consistently reported by Green House® homes. In a field where turnover of direct care workers averages 71% this is a critical finding. Serious attention is needed to the issue of job quality and satisfaction if we are to have a sufficient workforce ready to care for a rapidly aging nation. The stabilization of staff in Green House® homes reflects the higher staff satisfaction reported by Shahbazim, nurses and other clinical support team members.
2. Just as important is the development of close, knowing relationships that grow out of this model. The Shahbazim and nurses get to know and understand elders well, which results in more immediate recognition of small, but potentially significant, changes in health status. The potential for minimizing acute health problems and avoiding expensive hospitalizations adds to the benefits of a person-centered model of care.
The Robert Wood Johnson Foundation is currently funding research to measure these outcomes as well as the efficacy of the Nurse/ Shahbaz relationship related to clinical outcomes, and a work flow analysis examining the universal worker model of care delivery.
Senior Care and Nursing Home Regulation and PolicyThe big question asked by providers and the public is: can a person-directed care model be fully realized within existing federal and state nursing home regulations?”
Financial Viability of Green House ProjectsInformation on the financial viability of this model is emerging as open projects track operating and capital costs over time. The good news is that it is viable for 15 organizations across the country and many of those providers are building more homes and campuses. Success to date means significant fund raising to off-set capital costs and limiting Medicaid funded residents particularly in lower reimbursing Medicaid states. Some providers with good direct-care staffing levels have found operating costs to be comparable to their traditional nursing home operations.
However, The Green House model’s operations require slightly more direct care staff than the industry average. According to data available on CMS’ Medicare Compare website, the national average nursing home staffing for Certified Nursing Assistants and licensed nurses (including those in administrative roles) is just under 3.5 hours per resident per day. By contrast, The Green House model calls on organizations to provide a combined total of direct care licensed nursing (exclusive of administrative nursing time) and Shahbazim time of 5 – 5.2 hours per elder, per day.
Identifying the Green House Challenges AheadThe Green House® Project and the Robert Wood Johnson Foundation are committed to making a person-centered model of care, specifically The Green House homes, available to those of all income groups needing skilled nursing care. This necessarily requires Medicaid reimbursement rates that adequately support a consumer-driven, humane model of care. Medicaid rates range from an average rate of $100 in Illinois to over $225 in New York in 2006. Currently, Green House® homes are serving elders receiving Medicaid funding only in states with higher reimbursement rates.
An additional challenge is the capital costs for building new buildings. In the 1960’s the Hill Burton Act provided funding for building many of the nursing homes that exist today. The capital costs were significantly defrayed so that only the operating costs needed to be covered for the nursing home to be viable. Today, many state Medicaid reimbursement rates cover only a small percentage of the actual capital costs of constructing a new skilled nursing facility. This problem is even more acute for Green House® providers due to the model’s focus on private rooms and home-like common areas as important features of improved quality of life.
Green House Project in CaliforniaGreen House Model Meets California Regulatory Requirements for Role of Certified Nursing Assistants
In October 2008, The Green House Project met with the California Department of Public Health (CDPH) to review the state’s requirements as they apply to the roles, responsibilities, and supervision of Certified Nursing Assistants (CNA’s). After careful analyses of the regulations and statues, the state’s Licensing and Certification Program concurred with The Green House Project’s interpretation that the model’s core principles and practices met the intent and requirements of California nursing home regulations fully in the areas of health and safety, staff dietetic service, and nursing services. We appreciate the support of the California Health Care Foundation, Aging Services of California, and our NCB Capital Impact colleagues in the Center for Long-Term Supports. Read the full CDPH letter, December 3, 2008 (PDF). Additional links to regulatory information regarding Green House models.
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