Figure. The Green House model is making nursing homes more homelike.
Excellent nursing care has always been available to those with enough money to hire private caretakers. Nursing homes made such care available to the masses by imitating the efficiency of hospitals, where patients eat, sleep, bathe and take their medications when it's convenient for the staff.
Alas, that's contributed to the widespread perception of nursing homes as dreadful places. Lurid expos's have revealed horrid conditions, with residents neglected and occasionally abused by low-paid staff. Even today, a visitor expects to be assaulted by the smell of urine and the moaning and screaming of residents. As a result, many adults who put their aging, infirm parents into nursing homes feel racked with guilt, and fearful that they too may have to live in one someday.
Now, however, nursing homes across the country are abandoning that hospital model in an attempt to improve quality of life for residents. And they are doing this without causing costs to soar.
Steve McAlilly, for one, set out to make nursing homes more homelike at a cost no greater than what Medicare reimburses. “That way it would be available to everybody,” says McAlilly, CEO of Mississippi Methodist Senior Services.
The result is four “Green Houses” in Tupelo, each with 10 residents who live as a family, maintaining as much autonomy over their lives as possible. They get up when they choose, eat when they choose, get dressed when they choose.
“The reaction people have when they walk in the door is, ‘This is the way it's supposed to be,’” McAlilly says. “They don't feel the hustle and bustle of the institution with medicine carts clattering down the hall.”
To achieve this effect, he reconceived the purpose of the nursing home. Instead of keeping large numbers of residents together for the staff's convenience, he divided them into smaller communities where they live under one roof in private bedrooms. There, they are sustained and nurtured by certified nursing assistants–each known as a “shahbaz,” a made-up word free of clinical associations.
This enables residents to develop close relationships with the same staff members and fosters a sense of familiarity and comfort, which is especially reassuring to the many patients with Alzheimer's disease.
“It's a calm and predictable environment that gives them cues of home, so they settle down,” says McAlilly. “The first two houses we built were for people with Alzheimer's disease. Amazingly, the behaviors we typically associate with Alzheimer's disease–yelling, agitation, frustration, wandering into wrong rooms–disappeared to a large extent within a few days.”
This is all the more important given that over half of nursing home residents have dementia.
So how does McAlilly maintain such a pleasant environment at such a low cost?
He admits that private rooms, which he considers essential, “cost twice as much, basically.” However, residential housing costs less to build than a traditional institution.
In addition, McAlilly eliminated many administrative positions and even whole departments. “We've pushed all those responsibilities down to the people who are certified nurses' aides,” he says. “They cook, do light housekeeping and personal laundry, and plan activities.”
By giving staff members more responsibility and more pay, the turnover, which averages 71 percent at traditional nursing homes, has plummeted in the Green Houses. Since staff training is very expensive, this accounts for a huge savings.
“In essence we've gone back to the way it was 40 or 50 years ago when skilled nursing home care was delivered in small mom-and-pop boarding houses,” says McAlilly. “I honestly believe that in 20 years the Green House model will be the way it's done in this country.”
Others across the country are attempting to transform the culture of traditional nursing homes, and in 1997 they created a loose association known as the Pioneer Network to share ideas and provide mutual support. While they pursue their goals in various ways, “they all have the same vision anchored in the same values,” says Rose Marie Fagan, executive director of the Pioneer Network. “We agree we should be creating a home for people so they can live in relationship to the community and to each other. They should have control over their lives. They shouldn't be forced to turn their life over to the home. The traditional industrial model of the nursing home that we're trying to overcome is focused on getting tasks done. In this new culture, we say the person should come first.”
Leslie Grant, a University of Minnesota professor who studies long-term care for the elderly, says these nursing homes are embracing a model that emerged in Sweden in the 1970s when traditional nursing homes started to be replaced with “service houses.”
Shortly after he came to the Twin Cities area in 1991, Grant helped organize an exchange program between residents in a St. Paul nursing home and a service house in Sweden. “When the Americans came back, they were all excited about how wonderful it was,” he says.
The Lyngblomsten Care Center in St. Paul hired a Swedish architect to carve out a small service house within its 237-bed facility. Fifteen private rooms were converted to nine efficiency apartments, plus a kitchen, dining hall, sitting room and laundry. Each private apartment has a kitchenette with a refrigerator, microwave and an accessible bathroom. The entrance to each apartment has a doorbell. Residents are encouraged to do as much for themselves as possible. That often means more work for the staff, but Grant found that the staff liked the new system. “They told me they would never want to go back to the old model,” he says.
The center has since added two more service houses, and the people who live in them pay no more than residents of its traditional areas. “Actually, they pay less,” says CEO Paul Mikelson. “They have one meal a day included, but they also buy their own food or their families bring in food, so their rate is discounted.”
He would like to see the service house model spread, but finds that laws and regulations need to change first. “I think it would be feasible if the government were a more willing partner,” he says. Although the Minnesota Health Department granted more than 50 waivers so the first service house could be built, it must enforce rules for Medicare and Medicaid reimbursement–rules designed for the medical model of nursing homes.
“I think in the future, long-term care will be provided in places like this,” Mikelson says, “but the payment system needs to catch up.”