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Radical Redesign of Nursing Homes: Applying the Green House Concept in Tupelo, Miss.

In the Literature

Moving to a nursing home facility is a dreaded event for many older Americans. Nursing homes conjure up images of impersonal, uncaring institutions, where personal autonomy has no place.

Unfortunately, that image too often reflects reality. Despite the regulatory attention paid the industry, the more than 2 million individuals who reside in nursing homes do not consistently receive high-quality care. Perceiving they have little control over their surroundings and their lives, many residents develop a sense of learned helplessness, depression, and a progressive loss of function.

The people behind the Green House Project are seeking to "deinstitutionalize" long-term care. They have taken the traditional nursing home and radically transformed it—into a real home, a place where residents receive care, not just treatment. In The Commonwealth Fund-supported study, "Radical Redesign of Nursing Homes: Applying the Green House Concept in Tupelo, MS" (The Gerontologist, Aug. 2006), lead author Judith Rabig, R.N., M.A., former director of the National Green House Project, presents the goals of the initiative and reports on preliminary evaluation results pointing to positive outcomes for residents, family, and staff.

The Architecture of Care
The first Green Houses were built in 2003, on the campus of Mississippi Methodist Senior Services, an operator of nursing homes and assisted-living facilities, in Tupelo, Miss. At the time, executives at Mississippi Methodist had plans to renovate one of its nursing facilities. But then they heard about Green Houses—and decided to build four of them.

Each Green House accommodates between seven and 10 residents—a size that has been associated with reduced depression and anxiety, increased sociability, and improved mobility and independence. Residents have private rooms and are encouraged to bring their own furnishings and decorations. The Tupelo Green Houses feature large living rooms, fully equipped kitchens, a screened-in porch, and dining rooms with a single, communal table. To diminish the impression that the house is a medical facility, the nurses' station is housed in a study, which also serves as a break room for staff. Visitors must ring a doorbell before they can enter the homes.

From the Ground Up
The physical transformation is only one element of nursing home care that the Green House Project seeks to change. Staffing and organizational problems are also addressed. Specifically, the Green House creators seek "to decrease levels of bureaucracy and to recreate the role of the direct care worker by providing a safe working environment, higher levels of training, improved salary and benefits, and more empowerment." Under this model, care becomes the province of in-house certified nursing assistants, termed "Shahbazim" by the Green House Project. Each House is also served by a clinical support team of nurses, medical directors, social workers, and physical therapists, among others. These professionals are not situated within the Green House but visit according to a schedule. This realigned structure is intended to draw a clear line between treatment and care, with treatment defined as the "provision of competent, comprehensive therapeutic services" and care as "helping another person to achieve the highest quality of life given his or her condition and impairments."

Mississippi Methodist's Green Houses have experienced lower staff absenteeism and turnover than have the organization's other facilities, and no transfer-related injuries to workers. "Most Shahbazim," the authors say, "embrace the empowerment of their roles and visibly demonstrate increased skills, self-esteem, problem solving, and self-possession."

Participation, Not Passivity
Green Houses seek to reverse the loss of control that elders experience by emphasizing competence and participation in daily household activities. As such, the Green Houses impose no strict schedule, allowing residents to choose their activities, mealtimes, and degree of participation in household tasks. Elders are frequently outdoors, and when indoors, tend to cluster in common areas. In many cases the design of the house, with its short distances from bedrooms to common space, have increased resident mobility by reducing their need for wheelchairs.

Achievements and Challenges
Transforming roles proved to be a challenging aspect of the Green House model, as professional staff were resistant to losing power and concerned about potential patient vulnerability. However, when the professional staff were engaged as partners and saw that the Shahbazim were able to take responsibility for their new roles, their anxieties were quelled, report the authors.

In terms of financial consideration, the authors say that operating a Green House appears to require a "redistribution of resources, rather than more resources." The National Green House Project has developed financial tools to allow organizations to determine whether they can make the business case to move ahead with transforming their facilities.

Mississippi Methodist is more than satisfied with its experience, and in less than one year after its initial four Green Houses were occupied, broke ground on an additional six Houses. Many factors assisted in its success, say the authors: a corporation that needed to rebuild, a chief executive officer and corporate staff committed to the vision, technical assistance from the Green House Project, and foundation financial support.

In addition to the replication of Green Houses, the authors predict that practices inspired by Green Houses will likely be diffused into other residential long-term care settings, similar to the way hospice principles have become adapted into all end-of-life care. Both developments, say the authors, would be welcome and "would justify the exercise of thinking grandly rather than incrementally at the outset."

Publication Details



J. Rabig, W. Thomas, R. A. Kane et al., Radical Redesign of Nursing Homes: Applying the Green House Concept in Tupelo, MS, The Gerontologist, August 2006 46(4):533?39