HELPING SENIORS TO THRIVE: THE “GREEN HOUSE” MODEL

Volume 28, Issue 500 October 1, 2007

Matthew Gever

Long-term care is going green—as in “Green House.” Part of a culture change that seeks to provide long-term care recipients with greater autonomy, the Green House model eschews the traditional nursing home in favor of smaller, more intimate residences. The theory is that providing more choices and a more “home-like” atmosphere to residents can normalize their lives and combat learned helplessness.

“The institutional system of care for the aging in our country has evolved over the years based on faulty assumptions—assumptions that too readily dismissed the capacities of older adults to remain active and social, maintain some level of independence and contribute to their own well-being,” said geriatrician Dr. William Thomas, who developed the concept.

Green Houses are designed for people who might otherwise be in a conventional nursing home—frail individuals who require nursing care and assistance with daily activities. Whereas traditional nursing homes use a medical model of care, with facilities built around the nursing station, Green Houses use a social model of design, with facilities built around the kitchen. This is to encourage socializing among residents and staff and make the house look more like a home than a medical facility.

Green Houses take in no more than 12 residents at a time, each of whom has a private room and bath. Additionally, residents are free to eat, sleep and plan their days as they see fit, rather than follow a facility-controlled schedule. The homes also allow residents to keep pets on-site.

The concept has been endorsed by the Centers for Medicare & Medicaid Services (CMS), whose officials wrote in February 2007 that Green Houses fit CMS’ goals of making long-term care more “person-centered.” Houses that follow the model should qualify for reimbursement as nursing homes, CMS said.

State Actions

State lawmakers have taken notice of the model, and have been bringing it to their states. “This type of legislation addresses a basic issue—quality of life,” said Arkansas Representative Tracy Pennartz.

In its 2007 session, the Natural State passed two bills that seek to grow more Green Houses. HB 1363 allows the state’s Office of Long-Term Care (OLTC) to use money from its trust fund to support Green House projects. HB 1364 enables the OLTC to establish separate staffing guidelines and reimbursement categories for Green Houses.

“Our elders should be allowed to finish their lives with the same dignity they enjoyed as young people, and Green Houses provide it,” said Oklahoma Representative Jerry Ellis. The Sooner State’s Governor signed HB 1510 into law, giving the Commissioner of Health the authority to waive provisions of the state’s Nursing Home Care Act to create residences that are designed like private homes and house no more than ten individuals.

Wyoming enacted the Long-Term Care Choices Act (SF 89), making the typical Green House an eligible provider of services under Medicaid. Additionally, the act authorizes the Department of Health to provide grants for three pilot programs to study innovations in long-term care, including creation of a facility that provides a home-like atmosphere.

Obstacles and Benefits

Currently, Green House projects are being implemented in 18 states, according to the American Association of Homes and Services for the Aging. Supporters believe that the model can replace existing nursing homes, although so few houses have been developed that the jury is still out on whether this is feasible or wholly desirable.

Building a new house or changing an existing nursing home costs substantial sums of money, and requires the retraining of staff in the methods and culture of the Green House. Also, many current state regulations apply to standard nursing homes, and legislatures may need to adjust these rules, as the aforementioned states have done.

Do the homes actually provide better care? In a two-year study of the first Green House units (which opened in Tupelo, Mississippi, in 2003), researchers found that Green House residents had better emotional well-being and were more satisfied with their facility than residents of traditional nursing homes. Seniors living in Green Houses reported higher quality-of-life measures in privacy, dignity, meaningful activity, relationships, autonomy, food, enjoyment and individuality. The residents did engage in fewer organized activities on-site, but were more likely to participate in activities off-grounds.

Researchers cautioned that the results might be different if residents had moved to a Green House from their own homes rather than from a traditional nursing home. And the sample was too small for an analysis of mortality.

NCB Capitol Impact, a community development organization, is joining with other groups to establish 50 Green Houses across the country, with funding from The Robert Wood Johnson Foundation.