Small World
AARP Bulletin
October 2005

The Green House: It looks like home and feels like home. It’s a new way of living when you need long-term care.

By Beth Baker

At first glance, there's nothing unconventional about the house. A curbside mailbox on a cul-de-sac in a new Tupelo, Miss., development marks the single-story residence, painted cream with blue shutters. A tall picket fence encloses a tidy yard with a barbecue grill, wind chimes and beds of flowers and tomato plants.

To enter, you ring the front doorbell and wait to be greeted by Cynthia Dunn. "This is my home," says the cheerful woman, who gets around in a wheelchair.

Behind her opens a bright interior every bit as welcoming as the exterior. The living room has a fireplace, a sofa and easy chairs. Family photos decorate the bookshelves and the walls. In the adjoining dining area a long wooden table can seat a large family gathering. From the kitchen drift smells of ham and biscuits.

It feels like home, a comfortable place to live, and this very ordinariness is precisely what makes the house exceptional. As part of the first wave of residences from the Green House Project, it's a reinvented nursing home—or more accurately, a new way of living for people who need long-term care.

Developed by geriatrician William H. Thomas, M.D., the approach is part of a national effort to abandon large, impersonal institutions for small, intimate environments. In the 1990s Thomas' Eden Alternative concept called for replacing a medical model with a social model—infusing sterile institutions with plants, pets and children cared for by residents and staff.

Green Houses are the most far-reaching realization of the vision—family-size homes of 10 residents or fewer, each with private bedrooms and baths around a common area, each a "warm, loving, nurturing sanctuary," Thomas says.

Several years ago the nonprofit Mississippi Methodist Senior Services (MMSS) was planning to upgrade its 140-bed Cedars Health Center, a traditional nursing home in Tupelo. When CEO Steve McAlilly learned about Thomas' Green House concept, "we took his ideas and figured out how to put them into practice."

A cluster of the nation's first four Green Houses opened there in 2003, and two more came online this year. Just two blocks away, the Cedars offers a working contrast. There, an institutional environment holds sway. Residents slump in wheelchairs around a nurse's station. An aide wheels a frightened-looking man, covered only in a bed sheet, to the shower. Meals are a hectic affair, as residents are transferred at scheduled times down long hallways to a large dining room.

"We're pushed all the time," says nurse's aide Gail Wilson.

The Green Houses are among a new breed of nursing homes "centered on the idea of healthy human development," says Thomas, an AARP visiting scholar. For Cynthia Dunn, that means being surrounded by people who make her feel connected and who keep life both purposeful and fun. She joins staff members on frequent outings to yard sales or the mall, joshes with nurses and regularly volunteers to do the laundry. "But I don't do ironing," Dunn jokes.

To Clyde Biddle, 56, whose wife, Sara, 55, has multiple sclerosis, the Green House is "so much more private, with more dignity. We have a lot of support. They're really in tune not only to Sara, but to my needs."

Crucial agents of change are staff members who blend the roles of caregiver, homemaker and friend. Called "shahbaz" ("powerful falcon" in Farsi) in Green Houses, they are certified nurse's aides who train an additional 200 hours in first aid, cooking, listening, team building and other skills. Referring to herself as a shahbaz took some getting used to, says Rena Reid, but she likes what it represents—a radical departure from the old ways.

In a reversal of typical nursing home hierarchy, shahbaz manage the household, supported by nurses and therapists. They have risen from the lowest-paid, least respected workers to "these amazing professional people," says McAlilly. "I think it's because [as aides] they were stuck in jobs that were too small for them."

Do Green Houses deliver on their idealism? Rosalie Kane, a long-term care expert at the University of Minnesota's School of Public Health, has collected and analyzed data comparing Tupelo's Green Houses with the Cedars and another traditional MMSS nursing home. "The results favored the Green House at all times," Kane says.

While receiving comparable medical care, Green House residents were treated with more dignity and were more satisfied with their relationships, activities and meals. "Family members reported much greater satisfaction," says Kane. "Staff members were more empowered."

Consider 94-year-old Mildred Adams. At the Cedars, Adams, who has Alzheimer's disease, was bedridden, uncommunicative and had not fed herself in months. But wheeled into the Green House, she brightened. At her first family meal, Adams' son "fed her two bites," says daughter-in-law Becky Adams, "and she took the spoon from his hand. She fed herself the rest of the meal."

A year later, Adams has gone from a pureed diet to regular food, gaining 15 pounds in the process, Reid says. After gentle prompting from her daughter-in-law, Adams cheerfully sings hymns. When her voice chokes with emotion during "The Old Rugged Cross," she smiles and says, "I get filled up at times when I'm singing to myself."

What do private rooms and a staff-to-residents ratio double that of the Cedars do to operating costs? The national average monthly fee in a nursing home tops $5,000. In Tupelo, Green Houses cost about the same. Medicaid covers the cost for 90 percent of the residents.

According to McAlilly, savings come from streamlining jobs and shifting resources. Separate departments to deliver housekeeping, dietary and personal care services are not needed. Use of food supplements and incontinence products has been reduced. Costly staff turnover, endemic in nursing homes, has plummeted.

The nation's 16,000 nursing homes have reason to experiment: Their number has fallen by 800 in the last several years, and they still have an 11.5 percent vacancy rate. Though industry-wide change can come at a glacial pace, especially when it requires reinvestment, 20 facilities around the country have announced plans to build Green Houses. Even before the study results were out, nursing home personnel from across the country were coming to Tupelo for monthly training seminars.

Though he believes the idea will catch on, Hal Daub, former president and CEO of the American Health Care Association/National Center for Assisted Living, says many nursing homes may balk at the up-front costs of new construction. "Present [profit] margins are so slim that justifying that new space has a cost constraint," he says.

At the Cedars, long-term care is winding to a close. That's good news to Bea McBryde. She used to worry that one day she would have to give up her nearby independent-living apartment and move to the Cedars. But "the Green House is so pretty," she says, "and the shahbaz treat you so nice. That's where I'm going."

Beth Baker is a Washington-based writer working on a book about long-term care.