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The Green House is a model of skilled long-term care designed to transform traditional skilled nursing facilities into homes providing meaning and growth for the people who live and work in them. The story of Mildred Adams illustrates this transformation—see Sidebar.
Instead of a large facility with many elderly residents, Green House projects create homes for six to 10 residents. Each resident gets a private bedroom and bath opening off a central area for cooking, eating and gathering. Nursing assistants play a much broader role in the care of patients.
William H. Thomas, M.D., creator of the concept (see Sidebar for a profile of Thomas), and Judith (Jude) Rabig, M.A., R.N., at the Center for Growing and Becoming in Sherburne, N.Y., promoted implementation of the Green House model through various communications strategies and provided technical assistance and other support to organizations interested in building Green Houses.
RWJF supported the work of the Center for Growing and Becoming from January 2002 through January 2006 with three grants totaling $1,003,118. The first grant was solicited, the second and third unsolicited.
RWJF's support for the replication initiative is a solicited five-year $9,584,202 grant awarded in November 2005. Thomas is collaborating as a consultant to this ongoing program.
In the early 1990s, William H. Thomas, M.D., began practicing medicine in an upstate New York nursing home that seemed to have everything. The building was modern and well maintained; the staff was dedicated, and the operation met all regulations.
In his book What Are Old People For? How Elders Will Save the World, Thomas adds,
"There were just three problems at the nursing home:
From his firsthand experience, Thomas concluded that even with the best of intentions, the traditional nursing home leaves elders dependent and socially isolated. "To understand nursing homes as they truly are, you have to see them as instruments of terror designed, funded and operated by adults," he writes in his book.
Often called a visionary although he prefers the term iconoclast, this Harvard-trained physician is not one to accept the status quo. He set out to transform long-term care for the elderly. See Sidebar for a profile of Thomas.
His first creation was the Eden Alternative—a prescription for encouraging meaningful relationships among nursing home residents by improving the physical and social environment. A key ingredient of nursing home "Edenization" is the addition of plants, animals and contact with children. The idea is to provide elders with opportunities to give care instead of just receive it.
Thomas and his wife and partner, Judith Meyers-Thomas, built an organization to spread adoption of this approach and after 10 years counted more than 200 "Edenized" nursing homes in the United States, Canada and Australia.
While continuing to spread the Eden Alternative principles, Thomas become convinced that significant, permanent reform of long-term care required a radical redesign of nursing home architecture and organization. By 1999, he was ready—in his words—to bulldoze the nursing home.
The result was a concept he named Green House—signifying life and continued growth. Instead of a large nursing home facility, Thomas envisioned a community of small homes, each housing six to 10 elders.
Each elder would have a private room and bath, but for meals, meetings and recreation, the residents of the house would come together in the "hearth" in the living room, at the kitchen counter or at the large table in the dining area. The hearth would be the center of life in the Green House. Staff would join in as well.
In short, the Green House homes would be real homes in appearance and function. As with a home, there would be no such thing as a nursing station. Clinical services would be available at the level, and within the rules, of nursing home regulations, but the medical model would be de-emphasized.
In a Green House home, certified nursing assistants—the workers on the bottom rung at the traditional nursing home—would be the key staff members. Armed with special training and a self-managed work team, they would play a far broader role than in the typical nursing facility.
In addition to cooking, cleaning and managing logistics of their Green House, they would be responsible for nurturing the residents—bringing forth the skills and capacities, no matter how latent, that Thomas believes every elder possesses.
Dissatisfied with the ability of any English word to convey the function of this new staff position, Thomas settled on Shahbaz (plural Shahbazim), a Persian term that he says means royal falcon. The Shahbaz would be, in Thomas's vocabulary, the "midwife of elderhood."
Along with being good for the residents, Thomas believed this new staffing structure would address one of the nursing home industry's major problems: high employee turnover, especially among nursing assistants. (A survey by the American Health Care Association in 2002 estimated annual turnover among nursing assistants to be greater than 70 percent.)
Thomas took his Green House idea to Mary Jane Koren, M.D., who had helped him get the Eden Alternative program off the ground when she worked for the New York State Department of Health.
Koren had since joined the staff of the Fan Fox and Leslie R. Samuels Foundation in New York City. She encouraged Thomas to spend time talking to experts and nailing down the architectural, regulatory, staffing and other components of his concept. To support Thomas in this process, the Samuels foundation provided a $52,000 planning grant in 2000 followed by a supplement of $50,000 in 2001.
The grant recipient was the Center for Growing and Becoming in Sherburne, N.Y. Thomas, who lives in Sherburne, formed the nonprofit organization and is president.
Koren had hoped that the Samuels foundation itself would eventually fund implementation of the Green House model. However, the foundation's decision in 2002 to restrict its health care grants to helping the elderly specifically in New York City closed off that possibility.
Meanwhile, Thomas received an invitation to speak to the program staff at RWJF.
Thomas's RWJF audience included program officer David C. Colby, Ph.D., a member of what was then the foundation's Supportive Services Team.
The team's portfolio included long-term care, and Colby was on the lookout for promising new approaches that might—with a little financial boost from RWJF—blossom eventually into alternatives to the traditional nursing home. In Colby's words, he wanted to seed the field.
Colby saw promise in Thomas's concept but was under no illusions. Turning the concept into reality would not be easy, and any payoff was likely to be years away. Still, he considered it a risk worth taking and invited Thomas to apply for a grant to help get the Green House concept from idea to reality. Colby expected RWJF's investment to be limited in both dollars and duration.
Although nursing home reform has not been a major focus of RWJF, RWJF over the years has funded many initiatives to improve the quality of long-term care for the elderly. These include:
In 2003, as part of a new framework for RWJF grantmaking, the Supportive Services Team disbanded, and long-term care issues became the responsibility of a staff group created to focus on the nation's vulnerable populations, including older adults.
Thomas and the executive director of the Center for Growing and Becoming, Judith (Jude) Rabig, M.A., R.N., promoted implementation of the Green House model through various communications strategies and provided technical assistance and other support to groups interested in building Green Houses.
A major focus of the project was helping a long-term-care organization in Tupelo, Miss., build and open four pilot Green Houses.
RWJF supported the work from January 2002 through January 2006 with three grants totaling $1,003,118 awarded to the Center for Growing and Becoming (ID#s 043280, 047239 and 051241). The first grant was solicited, the second and third unsolicited.
The goals of the three grants differed slightly, but the overall objective was to stimulate development of the Green House model as an alternative to the traditional long-term-care facility.
The Green House model may be licensed as a skilled nursing home or, depending on discharge requirements, assisted living or adult foster care. Green House homes transform long-term-care practices and outcomes for the most impaired residents within existing regulatory guidelines and reimbursement levels.
The principals at the core of the model are:
Near the end of the third grant, the RWJF Board of Trustees approved a national Green House replication effort. This $9,584,202 project (ID# 053217), which runs through October 2010, is called the Green House Replication Initiative. Its goal is to stimulate development of 50 or more Green House projects by the end of that year.
NCB Development Corporation administers this new initiative. In October 2006, NCB changed its name to NCB Capital Impact. Thomas is participating as a consultant to NCB Capital Impact. For details of this ongoing program, see After the Grant.
In addition to the Fan Fox and Leslie R. Samuels Foundation's funding of the planning phase, other Green House supporters include:
Thomas was project director for the first two grants, Rabig for the third. Rabig, a gerontologist in the process of earning a Ph.D., headed the Oneida County (N.Y.) Office for Aging and Continuing Care before joining Thomas's organization shortly after RWJF awarded the first grant. She later became a vice president at NCB Capital Impact. See After the Grant for more information.
Assisted by several part-time administrative employees and technical consultants, Thomas and Rabig engaged in two broad categories of activity:
Originally the pilot Green House site was to be Utica, N.Y. At the time of the first RWJF grant award in January 2002, Thomas was working with a nonprofit health care system in Utica—Faxton-St. Luke's Healthcare—to build seven six-person Green Houses. He anticipated construction would start later that year.
No RWJF money was to go into the construction itself, but a major purpose of the grant was to support Thomas while he helped Faxton-St. Luke's develop architectural plans, satisfy zoning requirements and take other steps necessary to get the homes up and running.
However, soon after the grant began, the Utica organization decided against moving forward with its Green House plans—at least in part because of financial concerns, according to Thomas and Colby.
The decision was potentially a serious blow. Even with a good salesperson like Thomas, successful diffusion of the Green House model required an operating prototype that nursing home operators could observe, says Colby.
However, just as the door shut in Utica, a new one opened, this one leading Thomas and Rabig to Tupelo, a city of 35,000 in northeastern Mississippi and home of Mississippi Methodist Senior Services (formerly United Methodist Senior Services of Mississippi).
This nonprofit corporation—an affiliate of the Mississippi Annual Conference of the United Methodist Church—operates housing for the elderly on 11 campuses across the state, including the Traceway Retirement Community in Tupelo.
Along with independent and assisted living facilities, Traceway has a 140-bed skilled nursing home, the Cedars Health Center. Plans for replacing Cedars, which opened in 1978, with a new $12-million structure had been underway for several years.
In fall 2000, Steve McAlilly, president of Mississippi Methodist Senior Services, heard about the Green House concept. McAlilly already knew Thomas; a year earlier, as McAlilly's organization was implementing the Eden Alternative principles, he had brought Thomas to Mississippi to address the staff.
McAlilly looked into Thomas's new concept of group homes and liked what he saw. Not only did he think Green Houses would be affordable, it seemed to him that they would offer a better environment than the planned new nursing home.
McAlilly, as he explains in an appendix to Thomas's book, began pushing his architects and board of directors to adopt the group-home model, and in 2002 McAlilly's nursing home administrator took floor plans to a national Eden meeting to show Thomas.
Shortly afterwards, when Thomas learned that the Utica project had fallen through, he knew where to find a substitute. He telephoned McAlilly and offered to help him implement the nation's pilot Green Houses.
McAlilly and his staff proceeded to develop four 10-person Green Houses on the Traceway campus. Thomas and Rabig provided assistance, including the following, according to a report to RWJF:
The technical assistance provided to Mississippi Methodist Senior Services and the sponsors of three other early Green House projects—in Redford, Mich., Powers, Mich., and Lincoln, Neb.—was free of charge.
However, as the last of the three RWJF grants neared an end, the Center for Growing and Becoming began charging organizations a consulting fee. New sponsors adopting the Green House model and receiving assistance were to pay $10,000 when signing a contract and another $15,000 at a later date.
Funded by the Commonwealth Fund, a University of Minnesota School of Public Health research team headed by Rosalie A. Kane, Ph.D., studied the impact of Tupelo's four pilot Green Houses during the first two and a half years.
Through interviews and observation conducted at six-month intervals, the team compared Green House home residents with two groups of nursing home residents:
See Appendix 2 for a description of the study methodology.
RWJF grant funds to the Center for Growing and Becoming supported design of the research plan and collection of the residents' baseline data. However, the bulk of the evaluation funding came from the Commonwealth Fund through a two-year, $259,997 grant awarded to the University of Minnesota in the summer of 2003.
Koren, who had moved to Commonwealth from the Samuels foundation, oversaw the grant. An assistant vice president of Commonwealth, she was working on improving nursing home quality and viewed the Green House evaluation as an opportunity to do evidence-based work in that area.
The following were the key results of the three RWJF grants to the Center for Growing and Becoming:
When RWJF made the first Green House grant, Colby, the program officer, did not expect that in a just a few years the Foundation would be supporting a large-scale Green House replication effort. That, however, is what happened.
In October 2005, the Board of Trustees approved a five-year, $9,584,202 grant (ID# 053217) to NCB Development Corporation to spur development of more than 100 Green House projects across the nation. RWJF named the new effort the Green House Replication Initiative. NCB Development Corporation changed its name to NCB Capital Impact in October 2006; to avoid confusion, the remainder of the report uses the organization's new name, even through the grants were awarded under the old name.
NCB Capital Impact is a Washington-based, nonprofit organization that provides capital and technical assistance to low- and moderate-income communities. Its office in Oakland, Calif., administered the national RWJF Coming Home® program. See also the Grant Results on Coming Home®.
In addition to the grant to the grant, RWJF set aside $620,486 to promote the Green House model through outreach and communications activities managed by the RWJF Vulnerable Population Team's communications officer.
The positive preliminary result of the Kane evaluation was one factor in RWJF's decision to support replication—but not the only factor, according to Colby. It did not take a study to know that an elder would be better off in a Green House than in a regular nursing home, he says.
Colby visited the Tupelo project with program officer Jane Isaacs Lowe, Ph.D., head of the Foundation's Vulnerable Populations Team and program officer for the current replication initiative. Other RWJF program staff, and its trustees, viewed the informational video and were moved by what they saw, especially the positive reactions of the seniors pictured.
Also, the favorable attention that the pilot project received in the national media helped underline the potential value of the Green House model.
Before funding the replication, RWJF awarded NCB Capital Impact two grants to inform the planning process:
In an unpublished report to RWJF, the project team summarized the advantages and disadvantages associated with each model and concluded: "All of the models have the potential for replication and good arguments can be made for their replication."
The 29-page report (entitled Models of Care for a Nursing Home Eligible Population) was influential in RWJF's decision to limit the replication effort to Green House, according to Barrand.
Because of NCB Capital Impact's administrative capability, financing expertise and Coming Home role, RWJF invited the organization to run the new Green House replication initiative in collaboration with Thomas.
RWJF structured the grant as a five-year award to provide sufficient time for the initiative to become fully self-sustaining. The goal for the first 30 months is to have 50 Green House projects in development or operating. NCB Capital Impact recruits sponsoring organizations and assists them with all phases of development, including feasibility analysis and regulatory approval—in a similar manner to the organization's work to develop affordable assisted living in rural areas in the Coming Home program.
These 50 early adopters pay a fee—but not enough to cover the cost of the assistance they receive. In the second half of the grant period, NCB Capital Impact expects to start development of 50 or more additional Green House projects on a full-fee basis.
To help attract sponsors, the replication initiative includes access to unsecured, low-interest loans of up to $125,000 to cover architectural, engineering and other predevelopment expenses.
The loan funds come from a revolving fund administered by NCB Capital Impact as part of the Coming Home program. To be eligible, a sponsor must be a nonprofit, put up a $10,000 cash match and be approved by NCB Capital Impact underwriters.
When it started, the replication initiative had two co-directors. One was Robert Jenkens, an NCB Capital Impact executive in Washington and director of Coming Home. The other was Rabig, who became an NCB Capital Impact vice president and co-director of the Green House project. She lived in New York City and worked in a Green House office set up for her there. Thomas was involved as a consultant to NCB.
The co-directorship arrangement, however, soon proved unsatisfactory. In April 2006, Rabig left NCB Capital Impact. Jenkens continued as sole director of the Green House replication initiative. Thomas is a consultant to NCB Capital Impact and remains a close partner in the Green House Project.
As of October 2006, four Green House projects were open and in operation, and another 20 projects were under construction or in preconstruction development, according to Jenkins at NCB Capital Impact. The total included projects that began during the initial RWJF grants to the Center for Growing and Becoming.
See Appendix 3 for the location of the 24 projects.
Most of these projects involved multiple houses, several as many as 12. The projects included Green Houses licensed as assisted living facilities as well as nursing homes.
Organizations contracting for NCB Capital Impact's assistance agree to abide by Green House policies and procedures and in return receive permission to use the Green House name. Thomas retained ownership of the Green House trademark but licensed its use to NCB Capital Impact.
The purpose of the licensing control, says Jenkens, is not to limit diffusion of the model but to ensure that all Green Houses have a core set of principles and attributes to permit the evaluation of the model's impact on quality of life, improved care outcomes, employee satisfaction and costs.
In May 2006, RWJF awarded the Michigan Public Health Institute in Okemos, Mich., a one-year, $102,407 grant (ID# 057114) to test an online tool that NCB Capital Impact planned to use to screen potential Green House sponsors.
The tool, which was designed by the National Council on Aging, consists of 100 computerized questions aimed at measuring an organization's willingness and capacity to adopt the Green House model.
In October 2005, RWJF gave Mississippi Methodist Senior Services a one-year, $50,000 grant (ID# 055938) as part of the Foundation's effort to assist the Gulf region's recovery from hurricane Katrina.
The grant was among a number of special awards made to current and former RWJF grantees in communities affected by the storm. Although Mississippi Methodist Senior Services was itself not an RWJF grantee, the Foundation treated the organization as such since it was implementing an RWJF-supported model.
Center for Growing and Becoming (Sherburne, NY)
William H. Thomas, M.D.
NCB Capital Impact (Washington, DC)
(formerly NCB Development Corporation)
Additional Communications Activities
Project staff and consultants used a number of communications tools and strategies to stimulate interest in Green House replication. The team:
The University of Minnesota evaluation team compared the experience of the Green House residents with that of elders who remained at the Cedars nursing home in Tupelo and with residents of a Columbia, Miss., nursing home also operated by Mississippi Methodist Senior Services.
The team reasoned that any unsettling impact on the Cedars sample from the Green House move would not extend to nursing home residents in a different city, explains Rosalie A. Kane, Ph.D., the team's director.
Although not random samples—random assignment to the Green Houses was considered to be impractical—the study groups were comparable in all key areas, including disability, gender, cognitive ability and length of nursing home stay, according to Kane.
The initial 40 Green House residents included all 20 elders from the locked dementia unit of Cedars. The other 20 volunteered to move to a Green House after they and family members heard a presentation about the concept.
To collect baseline data, the team conducted interviews and observations just before or—in some cases—just after the Green House move. Follow-up interviews and observations took place at six-month intervals.
The team interviewed the resident or, when that was not practical, relatives who could speak on the resident's behalf. The team also interviewed family members about their own experiences with the Green House or nursing home staff and interviewed the Shahbazim in the Green Houses and nursing assistants in the nursing homes about their job experience and satisfaction.
Some residents died during the study period. In those instances, the evaluation team added the replacement resident to the sample, using a statistically valid method to account for the change, Kane says.
The team calculated quality indicators for the three groups using the Minimum Data Set, an assessment tool required by the federal government for use in nursing home reimbursement and regulation.
Green House Projects Underway as of October 2006
The following 24 Green House project were in operation or development in October 2006, according to NCB Capital Impact. Unless noted, the project is licensed as a skilled nursing home.
Green House projects Open and in Operation:
Projects in Construction
Projects in Development
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
Thomas WH. What Are Old People For? How Elders Will Save the World. Acton, MA: VanderWyk & Burnham, 2004.
Rabig J, Thomas W, Kane RA, Cutler LJ and McAlilly S. "Radical Redesign of Nursing Homes: Applying the Green House Concept in Tupelo, Mississippi." Gerontologist, 46(4): 533539, 2006. (An abstract is free on the journal's Web site; the full text is available for a fee.)
Thomas WH. "What Is Old Age For?" Yes magazine, Fall 2005. Available online.
"Models of Care for a Nursing Home Eligible Population," report by NCB Capital Impact to RWJF. Oakland, CA: NCB Capital Impact, 2005.
The Green House Project Report, a newsletter about activities related to the Green House project, published periodically during the project period. Sherburne, NY: Center for Growing and Becoming.
Weaver A and VanLiere J. Market Assessment and Business Strategy for the National Center for Housing with Services. Brookline, MA: ICA Group, 2004.
AAHSA-Future of Aging Services Conference-4/03-DC, a 105-minute audiotape. Hawley, PA: Conference Copy Inc., 2003.
Audio CD of presentations to a symposium entitled "Green House and the Regulatory Issues." Sherburne, NY: Center for Growing and Becoming, 2005.
Green House Financial Feasibility Model, an Excel worksheet for project feasibility analysis. Sherburne, NY: Center for Growing and Becoming, 2003.
The Green House: Elder Homes for the Twenty-First Century, a 20-minute informational video on the Green House pilot project in Tupelo, Miss. Santa Monica, CA: Wiland-Bell Productions LLC, 2003. Available for a $20 fee from NCB Capital Impact (firstname.lastname@example.org). (The project also distributed edited versions, including a DVD entitled The Green House Project: Tupelo, MS.)
www.ncbcapitalimpact.org/default.aspx?id=146. NCB Capital Impact Web site about the Green House Project. The Center for Growing and Becoming (Sherburne, NY) developed a Web site devoted to providing information about the Green House concept of long-term care for the elderly, but it is no longer in existence.
Judith Rabig, "The Green House Project: Solutions for Keeping Elders at Home for Life," invited testimony to the Schmieding/ILC Solutions Forum on Elder Caregiving, White House Conference on Aging, June 2, 2005, Springdale, AZ. Available online.
Judith Rabig, invited testimony to the National Commission for Quality Long-Term Care, July 22, 2005, Washington. Available online.
Report prepared by: Michael H. Brown
Reviewed by: Kelsey Menehan
Reviewed by: Molly McKaughan
Program Officer: David C. Colby
Program Officer: Jane Isaacs Lowe
Program Officer: Nancy Barrand
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