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Making a Nursing Home Where the Heart Is

By John Reichard, CQ HealthBeat Editor

July 23, 2008 -- The air was thick with buzzwords at a Senate Aging Committee hearing Wednesday on improving care for the elderly but the message delivered by witnesses testifying about "person-centered care" was nevertheless clear—it's possible to deliver long-term care in a place where residents love to live and where staff wants to work.

A recent survey by the senior lobby AARP "found that fewer than 1 percent of individuals over 50 with a disability want to move to a nursing home," noted Sen. Bob Casey, D-Pa., who was invited by Chairman Herb Kohl, D-Wis., to wield the gavel because of his nursing home oversight work as Pennsylvania's Auditor General. "There has to be a better way and in fact there is," Casey declared.

Casey used the hearing to give a big shout out to a type of care for the frail and disabled known as "the Green House model," described by Robert Jenkens, director of the Arlington, Virginia–based Green House Project as simply an approach that "reinvents nursing homes to make them real homes." The project is a nonprofit entity that works with financial assistance from the Robert Wood Johnson Foundation to spread the model.

"Picture elders waking up when they choose, to a breakfast of their choice, made fresh and hot just for them," Jenkens said in his testimony. "They spend their day according to their choices and preferences, with staff who know them very well. Their family and friends are welcome and feel comfortable visiting a place that is truly mom's, dad's or grandma's home."

The approach "combines small houses with the full range of personal care and clinical services needed by elders typically served in skilled nursing facilities." A Green House home "is a small, flexible environment, typically of 10 elders, organized around the central common area called the hearth. The hearth includes the kitchen, living area and dining area in an open plan and is intended to support . . . community and strong relationships.

"A core feature of the Green House home is a private bedroom and bath for each elder, to provide sanctuary and privacy. The open kitchen becomes a hub for elder and staff activity and normal social life. The aroma of fresh, home-cooked food stimulates appetite and makes meals comfortable and familiar again.

"The design creates a therapeutic environment, encouraging self-reliance through short distances and a safe environment for elders," Jenkens said.

The Green House home uses various tactics to shatter the stereotype of nursing home work as being low in prestige and heavy in subservience, witnesses said.

"The model reorganizes the staff and flattens the hierarchy," Jenkens said. Staffers involved in direct care are called "Shahbazim," a Persian word that means "royal falcon." Trained as certified nursing assistants, they handle all the duties of running the household—working in teams to cook the meals, do the laundry, and managing personal care "in partnership with elders."

Each house functions independently, with a "guide" acting as a "coach" and "mentor" to help the Shahbazim make decisions and solve problems about the running of the home.

Edna Hess, a Shabaz at Lebanon Valley Brethren Home in Palmyra, Penn., said that since beginning work in a Green Home "the most noticeable improvement I have witnessed is in the amount of socialization that occurs in our house. Several of my elders were hardly ever out of their rooms in the traditional nursing units; now they are frequently seen chatting in the living room, out on the patio, or lingering at the dinner table.

"Even the elders who have dementia are engaged in the activities and conversations around them, though they clearly don't understand everything that is going on. The second biggest improvement is in the dining experience. Every meal is home-cooked in our open kitchen, and the elders experience all the smells and sights of the meal preparation; they really chow down by the time the meal is served.

"The working life we now enjoy is very demanding, because we do cooking, cleaning, and activities in addition to nursing care, but it is so much more fulfilling. I no longer feel like I am working on an assembly line," Hess said.

A two-year study by the University of Minnesota of four Green House homes found fewer declines in independence on the part of patients, with less depression and fewer patients who were bedfast or otherwise inactive, Jenkens said.

He added that the Green House model is spreading, with 41 homes on 15 campuses in 10 states. "There are 120 additional houses in planning on 19 campuses, expanding Green House homes to 22 states. In time, the model is expected to spread to all 50 states."

But the concept faces funding obstacles. "Issue like Medicaid reimbursement rates, debt load, and the capital expense of constructing new homes impact the ability of a provider to build successful Green House homes," he said. "Economies of scale—where several homes can share costs and systems—are also critical to the model.

"Currently, Green House homes are serving elders receiving Medicaid funding only in states with higher reimbursement rates," he said. The model requires "slightly more direct care staff than the industry average." And "many state Medicaid reimbursement rates cover only a small percentage of the actual capital costs of constructing a new skilled nursing facility."

Jenkens urged lawmakers to spur creation of the homes through tax credits, targeted grants and interest rate reductions to make capital costs more manageable. He also urged fast-track federal review of state-based Medicaid payment revisions to increase the number of Green House homes.

Casey said he plans to introduce legislation to provide loan funding to long-term care nursing facilities that commit to the principles of person-centered care shown in the Green House model.

"Person-centered care" had another dimension explored by the hearing—the concept of a "medical home."

Melinda Abrams, assistant vice president at the Commonwealth Fund, explained the concept, which involves treatment of patients who aren't hospitalized or in nursing homes who typically have various chronic medical conditions. The home isn't actually a facility but a doctor's office that takes responsibility for all of the patient's health care needs or arranges care to be provided by other doctors and nurses.

"In a medical home, a patient could expect to obtain care from the physician practice on holidays, evenings, and weekends without going to the emergency room," Abrams said. "The patient could have medical questions answered by telephone or e-mail [message] on the same day that she contacts the office. Non-urgent care appointments could be scheduled one or two days ahead of time, instead of weeks or months."

"In a medical home, care coordination is vastly improved," Abrams added. "The primary care clinician helps the patient select a specialist and with support from staff proactively follows up with both the providers and the patient about test or examination results. In a medical home, the personal physician reviews treatment options with the patient and her family to help understand or resolve conflicting advice received from multiple providers."

Abrams said there is preliminary evidence that the approach reduces medical costs by preventing hospital admissions and lower readmission rates. But she said that the approach requires "fundamental payment reform that is intended to strengthen and reward primary care."

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