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Resident Outcomes in Small-House Nursing Homes: A Longitudinal Evaluation of the Initial Green House Program

Green House

In the Literature

Reforms enacted in the late 1980s helped to improve the health care received by many nursing home residents, but for the most part these changes did not address the larger problem of quality of life. Since then, what is known as the "culture change" movement has gathered force. Its adherents advocate transforming the large, institutional nursing facility into smaller-scale housing with private rooms and baths; empowering frontline workers to be centrally involved in decisions about day-to-day resident care; and implementing the principles of individualized care.

One of the most innovative projects in the culture change field is the Green House®—a radical vision of deinstitutionalized nursing homes. In Green Houses, seniors enjoy privacy, community, and, perhaps most important, an environment designed to look and feel like a real home. In a study comparing health outcomes and quality of life for Green House residents with residents at two traditional nursing homes, Green House residents were found to experience better quality of life, with the same or better quality of care than those in the comparison homes.

The study, "Resident Outcomes in Small-House Nursing Homes: A Longitudinal Evaluation of the Initial Green House Program," (Journal of the American Geriatrics Society, June 2007), was led by researcher Rosalie A. Kane, Ph.D., of the University of Minnesota School of Public Health, and supported by The Commonwealth Fund and the Robert Wood Johnson Foundation.

About Green Houses

Green Houses are self-contained dwellings for seven to 10 residents requiring nursing home levels of care. They incorporate physical design changes such as private rooms and bathrooms, a residential-style kitchen, a communal dining area, and accessible outdoor space. Institutional elements, like medication carts, public address systems, and nurses' stations, are avoided. The model also transforms the hierarchy of the institutional staff, giving wider responsibilities to certified nursing assistants who are supervised by an administrator, or "guide." A visiting clinical team comprises all other professional staff members, such as nurses, doctors, physical therapists, social workers, and others.

For the study, Kane and colleagues interviewed residents, family members, and staff from the Green House in Tupelo, Miss., and two traditional nursing homes nearby (the remaining residents of Cedars Health Care Center, where the Green House was implemented, and Trinity Care). The research team also accessed records from the Minimum Data Set (MDS), which provides clinical data about nursing home residents. The study was conducted between 2003 and 2005.

Quality of Life

Interviewers gathered data on 11 aspects pertaining to quality of life: physical comfort, privacy, dignity, autonomy, ability to enjoy food, spiritual well-being, security, individuality, functional competence, relationships, and ability to engage in meaningful activities. The Green House residents reported better quality of life than Cedars residents on seven measures, and on four measures compared with Trinity residents. Green House residents did not report lower quality-of-life scores than either the Cedars or Trinity residents on any of the 11 measures.

Health, Satisfaction, and Functioning

There was no statistically significant difference in self-reported health, ability to perform activities of daily living (e.g., bathing, dressing, eating, using the toilet) or ability to perform instrumental activities of daily living (e.g., taking medicine, using the telephone, managing money) across the three facilities. However, Green House residents did report significantly higher scores on emotional well-being—indicators such as happiness, contentedness, and looking forward to the future—than did residents at Cedars.

Green House residents, furthermore, expressed greater satisfaction with their institution as a "place to live" than did residents at either of the other two facilities, and as a "place to get care" than did residents of Cedars. They were also more likely to recommend the facility to others. In terms of quality indicators measured by the MDS, Green House residents experienced lower rates of depression, bed rest, reduced activity, and decline in functional abilities than both the Cedars and Trinity groups. The Green House residents did fare worse than one of the comparison settings in terms of rate of incontinence.

Social Activity

With the increased emphasis on individuality and autonomy at Green House facilities, it is perhaps not surprising that residents there were less likely to participate in organized activities than were residents at Cedars and Trinity. Green House residents, however, were more likely to participate in social outings off the grounds. In addition, they were equally as likely to receive phone calls and visits, engage in solo activities, take privately arranged trips, or have overnight guests. "The findings that Green House residents equaled the comparison groups in seven areas of social activity allays concerns that the Green House model offers insufficient resident stimulation," say the authors.

Moving Forward

"The results strongly favor the Green House and suggest that it achieved its stated goals," say the authors. As the Green House model proliferates, more research will be needed to examine the processes of implementation and management for sustaining the innovation. There will likely be no shortage of opportunity for follow-up. Based on its positive experience with the first four Green Houses, the nursing home operator has added six more facilities. In addition, in 2005, the Robert Wood Johnson Foundation began a replication project to open 50 Green Houses within five years.

Facts and Figures

  • Green House residents reported significantly higher satisfaction with their facility as a place to live than did residents of the other two traditional nursing homes, and better scores on many dimensions of self-reported quality of life.
  • In terms of care and health outcomes, Green House residents experienced lower rates of depression, bed rest, reduced activity, and decline in functional abilities, but did have higher rates of incontinence than did one of the comparison settings.
  • Green House residents reported significantly higher scores on emotional well-being indicators.

Publication Details



R. A. Kane, T. Y. Lum, L. J. Cutler et al., Resident Outcomes in Small-House Nursing Homes: A Longitudinal Evaluation of the Initial Green House Program, Journal of the American Geriatrics Society, June 2007 55(6):832–39