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‘Green House’ Nursing Homes Expand as Communities Reinvent Elder Care

January 23, 2008 at 6:30 PM EST
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Susan Dentzer reports on the "green houses" project, which seeks to reinvent traditional nursing home care and create close-knit communities of patients and caregivers. Some observers, however, question the homes' financial feasibility.
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SUSAN DENTZER, NewsHour Health Correspondent: Dr. Bill Thomas was already one of the nation’s most outspoken nursing home reformers when we first interviewed him six years ago.

DR. BILL THOMAS, Geriatrician and Nursing Home Reformer: What you’re seeing right now is the end of the American nursing home. It is finished. And the big question that really ought to be on the lips of the politicians, and the leaders, and the academics is: What comes next?

SUSAN DENTZER: At that time, Thomas had started down the road to the next phase, with something called the Eden Alternative. The approach revamped the nursing home in various ways, most visibly with plenty of green plants and even animals.

What Thomas came up with next was what he called “Green Houses,” small, homelike settings where care for elders, rather than the demands of the institution, came first.

DR. BILL THOMAS: This house really, for me, is a dream come true.

SUSAN DENTZER: Today, that vision is a reality, here at this Green House in Lincoln, Nebraska. It’s operated by Tabitha Health Services, a Lutheran-affiliated nonprofit focused on long-term care.

DR. BILL THOMAS: Hi, I’m Dr. Thomas.

SUSAN DENTZER: When Thomas visited for the first time recently, he talked with Eva Goldsby, one of nine residents here. She told him that the Green House feels much more like home than Tabitha’s other traditional nursing home.

EVA GOLDSBY (ph), Resident, Tabitha: This is a lovely place to be at.

DR. BILL THOMAS: Why is it different than the big house?

EVA GOLDSBY: Well, it’s just like being at home.

SUSAN DENTZER: At times, in fact, the Green House seems more like a clubhouse for seniors than a skilled long-term care facility. Two afternoons a week, for instance, there’s happy hour.

DR. BILL THOMAS: What do you like to have at happy hour?

EVA GOLDSBY: Beer, usually.

DR. BILL THOMAS: Beer? Yes, I think I’ll join you.

EVA GOLDSBY: Yes, red beer, sometimes.

DR. BILL THOMAS: Oh, red beer?

EVA GOLDSBY: Yes, do you like that?

DR. BILL THOMAS: I’ve never tried it.

EVA GOLDSBY: Oh, just tomato juice in beer.

DR. BILL THOMAS: Oh, whoa!

SUSAN DENTZER: There are now 35 Green Houses up and running on 13 campuses across the country. In partnership with a nonprofit, NCB Capital Impact, the Robert Wood Johnson Foundation is spending nearly $10 million to replicate the model nationwide. The foundation also funds the NewsHour’s Health Unit.

It’s cold here in Nebraska, and the ground is covered with snow, so you can’t really tell why this is called a Green House. The name is meant to invoke sunlight, plants, access to outdoor spaces, the opposite of the feeling you get inside the conventional nursing home.

That was part of the appeal for Joyce Ebmeier, who ran Tabitha’s traditional nursing facility here and went on to lead the project to build the Green House.

She first heard Thomas talk about the concept at a 2001 conference.

JOYCE EBMEIER, Tabitha Heath Care Services: He said, “I want you all to close your eyes, and I want you to think about, 10 years from now, what the nursing home would look like.” What came to my mind was I was putting a big padlock on the door, and I was smiling. I was happy. And I opened my eyes kind of fast and thought, “What in the world was that?”

High-tech and low-tech innovations

Bill Thomas
Geriatrician
We've always insisted in the Green House that there be one big table, because [...] that makes a meal into a community experience, where food and companionship come together.

SUSAN DENTZER: Ebmeier says she now realizes she was frustrated by the regimented feel of even a well-run nursing home, with its centralized food preparation and dining, certified nursing assistants bustling around to meet the needs of seniors, and residents themselves doubled up in frequently sterile rooms.

So, some six years, countless discussions with state regulators, and more than $1 million later, the result was the Green House. It can accommodate up to 12 elders, as the residents are called, in spacious, private rooms with their own baths.

Discreet lift technology installed on the ceilings means that severely disabled residents like Eva Goldsby aren't bed-bound. And with a few computer keystrokes, attendants like Thomas Cooper keep track of how the residents are doing through an electronic patient-care record.

THOMAS COOPER, Tabitha Health Care Services: It's a touch screen, so you go in and you find your name -- and that's me -- and then you log on with your thumbprint. So it's pretty high-tech, actually.

SUSAN DENTZER: Still, the real innovations of the Green Houses aren't high-tech, but low-tech, Thomas says.

DR. BILL THOMAS: We wanted there to be a heart, a center, a focus of the house. So, you know, what you have in the hearth is sort of food on one end, fire on the other, and a place to share convivium or the pleasure of a good meal sort of in the middle. And this house really does that.

SUSAN DENTZER: Even the common dining table is a critical part of the mix.

DR. BILL THOMAS: We've always insisted in the Green House that there be one big table, because that's how -- that makes a meal into a community experience, where food and companionship come together.

From nursing assistant to shahbaz

Wanda Temple
Daughter of Green House resident
They started working with [my mother], you know, and trying to get her to walk. And it wasn't very long before she could get up and take a few steps. And now, you can see she does pretty good with the walker getting around.

SUSAN DENTZER: Thomas told us the biggest difference between Green Houses and traditional nursing homes are these people, specially trained and empowered staff who assist the residents in everything from eating to toileting.

In traditional nursing homes, they're called certified nursing assistants, but Thomas coined a new word for the elevated position here, "shahbaz," or the plural, "shahbazim."

DR. BILL THOMAS: It's a Persian word, and it means "royal falcon" or the "king's falcons," the mightiest, the bravest, the fastest, the most courageous of all the falcons. And I thought, "Now, that's a model I can build on."

SUSAN DENTZER: When Bill Thomas first uttered that word "shahbaz," what did you think?

JOYCE EBMEIER: I'm a Bill Thomas fan, you know, "Shahbaz!" I just really -- it took me about a year to get it trippingly off my tongue.

SUSAN DENTZER: At the Green House, the role of shahbaz turns upside-down the traditional nursing home staffing model, where administrators and nurses call the shots while the certified nursing assistants, or CNAs, do the grunt work. Here, by contrast, nurses like Cindy Kohn (ph) visit to attend to clinical matters, like dispensing medication.

CINDY KOHN (ph), Nurse: You can tip your chin like this and kind of clear your throat a little bit, too. That'll help.

SUSAN DENTZER: But it's the shahbazim who run the show. Shahbaz Thomas Cooper was a CNA at a traditional nursing home before coming here to work at the Green House.

THOMAS COOPER: We cook. We clean. We do their laundry. We do their ambulation, which is exercises, and their FMP, which is functional maintenance program.

SUSAN DENTZER: Wanda Temple credits the shahbazim with the fact that her 95-year-old mother, Ruth Rush (ph), once bedridden with severe osteoporosis, is now up and walking again.

WANDA TEMPLE: They started working with her, you know, and trying to get her to walk. And it wasn't very long before she could get up and take a few steps. And now, you can see she does pretty good with the walker getting around, you know.

SUSAN DENTZER: Shahbazim are paid $13 an hour, about 40 percent more than the going rate here in Nebraska for CNAs. What's more, the ratio of staff to residents is about a third higher than in the average nursing home.

That's produced something atypical for long-term care institutions, says Ebmeier.

JOYCE EBMEIER: At the Green House, we have 100 percent retention of the shahbazim who originally started as full-time shahbazim.

SUSAN DENTZER: That contrasts with the typical nursing home, where annual turnover of CNAs can range as high as 100 percent.

Concerns over financial feasibility

Bill Thomas
Geriatrician
I acknowledge that there are financial strains and stresses in this model. It's not easy. It's of interest exclusively at this point to nonprofits.

SUSAN DENTZER: Still, the economics of running Green Houses, where staffing levels and wages are higher, makes some in the nursing home industry question just how replicable the idea really is.

The average charge for Green House residents at Tabitha is $242 per day. That's comparable to the cost of traditional nursing homes. Medicaid pays all but about $25 a day of that for the roughly two-thirds of Green House residents eligible for the program.

But those rates produce only narrow margins for the institutions operating Green Houses. As a result, the model may make financial sense mainly for the 30 percent of the nation's 16,000 nursing homes that are nonprofit and for multi-site providers like Tabitha, that can spread some costs across a number of facilities.

DR. BILL THOMAS: I acknowledge that there are financial strains and stresses in this model. It's not easy. It's of interest exclusively at this point to nonprofits.

And we are the tip of the arrow. We're out there showing what can happen when you really do provide, you know, recommended levels of care in a new model, with a new philosophy, with more energized staff.

SUSAN DENTZER: The best argument for the model may be that it appears to produce real results. A study of the first group of Green Houses, built in Tupelo, Mississippi, showed that residents got equal or better quality of care than they did in comparable nursing homes. They also reported a higher quality of life.

Both staff and family members of those living in Green Houses said they, too, were more satisfied.

Creating a "place that can love"

Joyce Ebmeier
Tabitha Health Care Services
Death gets harder in a Green House because, [...] when you are engaged in the way that the shahbazim are engaged in the lives of the elders they love so much, it is like losing your dearest family member.

SUSAN DENTZER: There is, it turns out, one downside to this model. Ebmeier and the shahbazim tell the story of one former Green House elder, Mary Valentine (ph), who celebrated her 101st birthday in the Green House.

JOYCE EBMEIER: One of the shahbazim went to her and said, "Well, Mary, what do you want to do? What shall we do so that you have a great birthday?" And she looked at the shahbaz and she said, "You know, what I really want is a margarita and a cigarette."

SUSAN DENTZER: And that's what she got, as seen in this picture, taken as she and her daughter celebrated on the Green House's front porch. When Valentine died soon after that memorable day, the shahbazim were crushed. They told us that was the downside of life in the Green House, saying goodbye.

THOMAS COOPER: The night after that she had passed, my dog went into her room, and jumped up on her recliner, and sat where Mary used to sit. That was really emotional for me, and for the whole group of shahbazim, and the whole team.

JOYCE EBMEIER: Death gets harder in a Green House because, when you are smaller and when you are engaged in the way that the shahbazim are engaged in the lives of the elders they love so much, it is like losing your dearest family member.

SUSAN DENTZER: All this reminded us of something else Thomas had said back in 2001 about the central problem with nursing homes.

DR. BILL THOMAS: In long-term care, love matters. And the heart of the problem is institutions can't love.

SUSAN DENTZER: Do you think you've finally helped to create a place that can love?

DR. BILL THOMAS: Yes. In fact, I think it's the signal achievement of the Green House: making a place where love matters.

SUSAN DENTZER: Here in Lincoln at Tabitha, there are now plans to have three more Green Houses up and running within the next five years. About 100 more are under development across the country.