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Case Study: Elder Homes Replace Nursing Homes in Tupelo, Miss.

By Artemis March, Ph.D.

Issue: Efforts to improve the quality of life in long-term care facilities through "culture change" have, for the most part, not gone far enough to transform care. Some have concluded that the physical environment of nursing homes—with their long corridors, nurses' stations, medicine carts, and fluorescent lighting—is an insurmountable barrier to achieving the desired magnitude of change. Redesigned nursing homes that deinstitutionalize care, including the Green Houses conceived by William Thomas, M.D., and explored in this case, aim to eliminate the loneliness, helplessness, and boredom rampant among institutionalized elders.

Organization and Leadership: The first Green Houses were built on Mississippi Methodist Senior Services' (MMSS) flagship campus in Tupelo. Thomas, founder of the Eden Alternative, an organization that seeks to transform assisted-living facilities into "vibrant centers of care and companionship," had the vision for creating Green Houses. Steve McAlilly, J.D., CEO of the 11-campus, multi-level, retirement community, spearheaded the Tupelo project. He worked closely with Thomas to flesh out the Green House concept and with Richard McCarty, an architect at The McCarty Company–Design Group P.A., to give it physical form. Jude Rabig, R.N., M.A., the first executive director of the Green House Project and currently an independent long-term care consultant, helped put Thomas' vision into practice, drawing on her experience delivering care to patients in their homes. To encourage replication of this model, the Green House Project team works with NCB Capital Impact, a national nonprofit organization, to provide access to capital and technical assistance to organizations that want to establish a Green House facility.

Objective and Intervention: Tupelo's Green Houses were designed to redefine long-term care in Mississippi by creating a "warm, smart, and green" environment in which residents feel at home and have the opportunity for continued growth, and staff are highly satisfied with their work. Green Houses have three key dimensions:

  1. A physical environment composed of small, technologically smart houses that function as people's homes rather than facilities where they come to die. Private rooms with private bathrooms are clustered around a central area with a shared kitchen, dining room, and living room. Although safety features and the necessary medical technology are built into their design, Green Houses contain few "medical signposts."
  2. An organization in which elders—a preferred term to "residents," as it connotes respect for their years and experience—and newly empowered certified nursing assistants (CNAs) make daily decisions about their lives and care. This includes, for example, choosing their menus rather than having them selected by a centralized dietary department.
  3. A shift in focus whereby necessary medical treatment—for which physicians and nurses retain responsibility and authority—is no longer the driver of daily routines but is incorporated into the context of elders' lives, much as happens in home care.
Implementation Date: MMSS decided to adopt the Green House concept in November 2001. By March 2002, the design was sufficiently defined to seek approval from state regulators and, by June, ground was broken on four, 10-person houses. The houses opened a year later, and 40 cognitively impaired elders chose to transfer from the older facility to the Green Houses.

Process of Change: In November 2001, MMSS was considering the fifth iteration of its plans to replace a 140-bed facility with a state-of-the-art building in which Eden Alternative principles would be implemented. After spending a long weekend in conversation with Thomas, however, McAlilly concluded his objectives could never be realized within an institutional setting that was designed to make it easier and more efficient to deliver medical services. His goal was to design a home that revolved around enhancing elders' quality of life. Thus, McAlilly told the MMSS board, "We are about to make a $12 million mistake." This led them to consider using the money allocated to the project to "make a bigger difference," he says. The board members agreed to a radical redefinition of their original plans which, McAlilly projected, would break even financially.

McAlilly insisted that the Green Houses be developed within current regulations, as the need to seek waivers would deter replication. He asked the state's Department of Health to bring together everyone needed to sign off and told them that MMSS wanted to build a new collaborative model for working with regulators. His guiding principle for their new design was: Would you have this in your home? There would be no nurses' station or medication carts, for example; how then to provide for these services and meet requirements (e.g., exit signs) in an inconspicuous way? They worked through 114 regulatory issues in a single day, agreeing to a new "nursing home" model that required no waivers.

A new role for CNAs was developed, necessitating a new title—shahbaz (shahbazim, pl.), a Persian word meaning "royal falcon," a bird with mystical powers—that did not carry the negative connotations, mainly of mistrust, many associated with the term CNA. The shahbazim were given 120 hours of additional training, an amount that greatly exceeds the federal mandate and most state requirements, in ways to protect, sustain, and nurture the elders and to take on a broader array of responsibilities, including cooking and light housekeeping. Their overarching responsibility, however, would be to build and foster relationships with and among the elders, so that the people who live and work at the Green House become a family.

Shahbazim work in self-directed teams with no on-site supervisor and as co-equals with members of the clinical team, who visit daily but must ring a doorbell for admittance to the elders' homes. A few shahbazim were not comfortable working without a boss or being the boss, and they opted out of the project. Most, however, embraced their new role and skills, gaining self-esteem and a sense of empowerment.

Early Results: Green House staff have documented many examples of elders who are eating again, gaining weight, and less reliant on their wheelchairs than they were before moving into their new environment. Visitors also respond positively to the Green Houses, as seen in stories of children who had refused to visit their grandparents in traditional nursing facilities but know the names and rooms of every elder in their new home. Researchers have found that, as University of Minnesota's Rosalie Kane, Ph.D., puts it, "the Green Houses blow away the old model on every measure: quality of life, family satisfaction, staff satisfaction," with no detriment to nationally used quality indicators that measure clinical conditions. With support from The Commonwealth Fund, Kane led an in-depth, 30-month study of the first set of Green Houses. Early results have found:

  • When Green House residents were compared with residents in two traditional nursing home settings, the former were equal to or exceeded the latter on all accepted measures of clinical quality. They also were less likely to experience decline in their functional capabilities, such as dressing and eating.
  • Quality of life measures indicate Green House residents were significantly more satisfied than both control groups with regard to dignity, privacy, autonomy, and food enjoyment. They also were more satisfied than residents remaining in the MMSS nursing home from which they had relocated with respect to their involvement in meaningful activity, sense of individuality and security, and spiritual well-being.
  • Relative to their counterparts, CNA-level nursing staff, i.e. the shahbazim, were much more satisfied with their jobs, believed they knew residents under their care better, and were more confident of their abilities to change resident outcomes.
It is difficult to identify the specific factors producing these results because, as McAlilly observes, "the elements that make it work cannot be isolated from each other. It's a home that fits into the neighborhood and creates space for relationships to grow. Design is only 30 percent [of the equation], but it is the keystone. If you pull it out, everything would fall apart."

Lessons Learned: Resistance to the Green House design was far greater than anticipated. Loss of power, confusion about roles, and distrust of the empowered CNAs—most of them poor, black women—led professionals of all levels to pushback. Two campus executive directors, two nursing home administrators, and two nursing directors could not make the switch. Given the direction the CEO and board were taking, with more Green Houses being planned at Tupelo and other MMSS campuses, they left the system. Some nurses, used to being in control and uncertain about how to behave in their new role, also could not make the transition.

The intensity of this resistance made project leaders recognize that they needed to give much more attention, coaching, hand-holding, and training to the clinical and administrative professionals whose roles changed dramatically with the Green Houses. "There is a chaos phase where everyone is undergoing an identity crisis, reworking their understanding of who they are and their role," says Rabig. "People on the inside want to calm the chaos, so it requires an outside coach to say, 'No, it's too soon.'" Coaching during this period, adds Rabig, should include three components: coaching the primary implementer, in this example, McAlilly; providing information and training to the organization; and "most important, instituting communication within the organization that is accurate, timely, and makes everyone feel informed."

MMSS demonstrated that it is possible to build collaborative relationships with regulators, reach joint decisions quickly, and build Green Houses within existing regulations. Researching and examining what the regulations actually say were key to this collaborative success. Too often, regulations are inaccurately interpreted; clarifying them can open up opportunities for exploring creative solutions with regulators.

Many clinicians, gerontologists, and regulators are skeptical about allowing cognitively impaired, frail elders living in a home-like environment to decide, for example, whether to stay in bed—potentially increasing their risk for pressure sores. But, Rabig explains: "You have to educate and coach people about how to help elders make choices that are safe and understand when [they] have to intervene.… Health is an interaction and balance between quality of life and quality of care."

Financially, the Tupelo Green Houses have been "cost neutral, but we get more bang for the buck," says McAlilly. In the old model, a large portion of nursing home expenditures supported departments and professionals: maintenance, nutrition, social work, activities, layers of nursing management, and nurses who were performing largely administrative functions. The Green House model eliminates many of those costs and reassigns dollars into building Green Houses, staffing at higher levels, and paying frontline staff at a higher rate. Decision-making is moved to the elders themselves and those closest to them, a change that is supported by reallocating dollars to direct support of elder quality of life.

Implications: Twenty-two Green House projects are under way in 15 states, and leaders of the Green House Project hope every state will have one or more within five years. Innovators and policymakers who want to help spread this model more broadly need to:

  1. Develop a business case for Green Houses, using institutions that have good baseline data. They should be able to compare a full range of factors affected by Green Houses, for example: the number of CNAs sustaining back injuries (so far, zero in Tupelo), the costs of CNA turnover, and reduced need for medications.
  2. Examine current reimbursement formulas that serve as disincentives to building Green Houses, as do health department regulations and misperceptions about what the regulations require, and consider adopting policies and regulations that promote Green Houses.
For Further Information: Contact Steve McAlilly, CEO, Mississippi Methodist Senior Services, at [email protected].

W. Thomas (2004) What are Old People For? How Elders Will Save the World. Acton, MA: VanderWyk & Burnham.

J. Rabig et al. (2006) Radical Redesign of Nursing Homes: Applying the Green House Concept in Tupelo, Mississippi. The Gerontologist 46, 533–539.

R. A. Kane et al. (2007) "Resident Outcomes in Small-Group Home Nursing Homes: a Longitudinal Evaluation of the Initial Green House Program." Journal of the American Geriatric Society, in press.

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