Returning Control and Dignity to Elderly Residents

    • December 9, 2007

The problem: Many frail elders seek an alternative to the typical institutional-style nursing home setting and would prefer a smaller, community-based home that offers the services they need to support their health and daily living.

The proposal: The Green House project is a model for small-group, self-contained houses for 10 elders with substantial disabilities that provides skilled nursing home services. Residents each have their own private bedroom and share a living room, and dining and kitchen facilities. Green Houses are designed to return control, dignity and a sense of well-being to the residents and care staff. NCB Capital Impact of Oakland, Calif., under the leadership of Robert Jenkens, has received funding from RWJF to replicate the Green House model on a national scale.

Grantee perspective: Joyce Ebmeier knows a little something about nursing homes, having worked in them for 24 years. She currently is administrator of a 205-bed nursing home in Lincoln, Neb. But she also serves as a "guide" for a nine-person home that is part of the Green House project, a nontraditional alternative to nursing homes.

"I'm not the boss here. I am here to make sure that the elders are always safe and to make sure that we live up to the rules and regulations that govern care at this level," says Ebmeier, "and to make sure that the self-managed work team that are the 'shahbazim' are successful." Shahbazim (plural of shahbaz) is an amalgamated word with roots in Hebrew and Persian languages and "intentionally foreign to institutional nomenclature such as nursing assistant," says Ebmeier.

"The old [nursing home] setting is based on economies of scale and medical treatment," she says, "and the Green House is based on deep relationships; nurturing, sustaining and protecting each person. It is about creating a home clearly dedicated to supporting who the residents are and what they want to accomplish. Excellent medical treatment is a key component of life in a Green House, but it is delivered discretely and supportively, with respect to the rhythm of each elder's life. In a traditional setting, medical treatment governs nearly everything an elder does; it rules."

"Whatever it is you need—and even if you need everything, to move through each day—the Green House and shahbazim are prepared to support you in an environment that is home and that is not constantly reminding you that you are sick," Ebmeier says.

Results: In addition to the more pleasing aesthetic characteristics of a home, the Lincoln Green House has shown improvements in residents' health, according to Ebmeier. "When we take the same clinical measurements that we use in a traditional setting and hold them up against each other, the Green House wins. Nine out of the 10 elders that we served in the first year have had significant clinical improvements. They are walking, they are eating better, they are gaining weight. That is pretty significant," she says.

What's more, says Ebmeier, the Green House home saves money. "The cost for our Medicaid clients who lived here in the first year was actually reduced by over 7 percent, cost per client day. We are saving the Medicaid program while improving the quality of life for our frail elders. What Green House does is recognize that we can do this for the same cost; and we can achieve better results; and we can offer an option that is not dehumanizing."

Says Ebmeier: "It is exciting to think that this is the new face of long-term care."

RWJF perspective: Support for the Green House project emanated from the Foundation's historic work to improve long-term care for frail vulnerable adults, according to Jane Isaacs Lowe, Ph.D., senior program officer and Vulnerable Populations team leader.

"We decided we were going to focus on creating home- and community-based service systems for older adults so they can age in their homes and communities for as long as possible," she says.

"This model was attractive for the Foundation as a way to begin to think differently about how we conceptualize care for frail older adults and to try to get rid of the medical model of a nursing home," Lowe says. "Older adults who are frail do not have to live in institutions. There is a better way to preserve the dignity and autonomy and provide equally as good, if not better care—and keep people connected to a community as they age. They can live in Green Houses."

The grantee organization, NCB Capital Impact, offers technical assistance and pre-development loans to assist organizations interested in implementing the Green House model across the country with the goal of 50 such homes by 2010. RWJF decided to use the expertise of the NCB Capital Impact to make the project market-driven. According to Lowe: "People are going to demand for themselves and their family members a different place to be in rather than a 200-bed nursing home where you are lined up in the hallway in a wheelchair and have no ability to choose the time of day you get up or when you eat or what you eat.

"The Green House takes the whole idea of care for elderly and turns it upside down and creates a structured home environment that can support and care for very old people," says Lowe.