A Lot Like Home

The results of Rosalie Kane's studies on Green Houses--smaller, more personalized nursing homes--suggests that elder care may have a bright future.

By Erin Peterson

Sight unseen, nursing homes are expected to be large and impersonal, filled with residents who are bored and lonely. Fortunately, the nation’s first Green Houses demonstrate what happens with a major makeover.

The Green Houses idea was dreamed up by geriatrician Bill Thomas and made a reality in Tupelo, Miss., by Mississippi Methodist Senior Services. With a small number of elders in each Green House, meals freshly prepared in family-style kitchens, outdoor patios, and indoor fireplaces, the facilities resemble homes more than institutions.

“It’s a revolutionized concept of a nursing home,” says Rosalie Kane, a professor of health services research and policy in the School of Public Health. A collection of administratively linked Green Houses hold a nursing home license, and the central organization provides visiting clinical services such as nursing, therapies, and social work. As certified nursing homes, they must meet all quality standards of a highly regulated industry, serve elders with difficult health problems, and do so within the Medicaid reimbursement rates of states where they are located.

Kane is studying how Green Houses compare with traditional nursing homes with a grant from the Commonwealth Fund of New York City. The goal, she says, “is to build the program around individualized efforts to maintain each elder’s quality of life, with good health care as a backdrop rather than the organizing principle of the organization.”

Along with adding homey touches such as the smell of freshly baked cookies, Green Houses eliminate some of nursing homes’ typical rigid structures, including sleeping and eating schedules. “The goal is that residents should be free to live lives as normally as their disabilities permit,” says Kane. The Green House architects sought to exclude anything that wouldn’t be found in a typical home. With the exception of legally required exit signs, they succeeded.

The radical changes apply not only to facilities but also to staff. The key workers are resident assistants with nursing assistant credentials who also receive extensive additional training. Assigned to a single house, they cook, clean, provide personal care, serve as elder-development specialists, and interact with the visiting clinicians; they do not report directly to nurses. These workers have more opportunities to get to know the elders under their care and their jobs entail more responsibility, which may help translate to higher retention rates in jobs that typically see high turnover.

Kane has been collecting data to follow the progress of the residents, their families, and staff members since the first four Green Houses were occupied in Tupelo in 2003. A major marker of success are 11 measures of quality of life— including meaningful activity, relationships, and enjoyment—that Kane’s team developed in an earlier research project. Kane’s Green House study, which took place over the course of more than two years, discovered what proponents of the Green Houses had long known intuitively: Nursing homes that are more like homes and less like institutions help residents lead happier, healthier lives.

Kane says, even anecdotally, the differences are clear. “[The common perception within the nursing home community] is that you can’t let people sit for an hour and a half for a meal. But if the meal is good enough and life there is interesting enough, you might find that it happens,” she says. “Meals at Green Houses tend to be long.”

Although questions still remain to be answered, including Green Houses’ longterm economic feasibility, the results so far have been encouraging enough that similar facilities have started across the nation. There are currently 18 Green House projects in the planning stages in 15 states; four have already broken ground.

The reason is clear to Kane. “Daily life comes first [in a Green House],” says Kane. “It’s important to give the best health care you can, but you’re not living only for the health care.”