A Nursing Home Shrinks Until It Feels Like a Home

Joshua Bright for The New York Times

By LAURIE TARKAN

Published: October 31, 2011

Toni Davis spent much of her childhood roaming the corridors of a nursing home in West Orange, N.J., where her mother was the director. Even now she recalls the pleas of the residents there: " 'Please help me, please take me home with you,' they'd beg," Ms. Davis said. "I remember asking my mom, 'Why can't we take them home for dinner for just one night?'"

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Joshua Bright for The New York Times

WARMTH Toni Davis, right, director of the Green Hill Retirement Community in West Orange, N.J., played bingo last week at one of the four Green Houses on the campus.

Following in her mother's footsteps, Ms. Davis is now director of Green Hill Retirement Community, a nursing home and assisted living facility, and she is determined to make it into a place where residents feel little reason to leave. She has added fish tanks and bird cages, hung pictures on the walls carpeted the corridors, and brought in dogs for pet therapy.

Still, the nursing home looks like... a nursing home. "No matter what you do, you can't get that homelike feeling in an institution because it's too big," she said.

So now Ms. Davis, along with two dozen other nursing home operators across the country, is trying something different. This year, behind two large institutional buildings on the Green Hill campus, she has opened four small Arts and Crafts-style houses for elderly residents.

Just 10 residents live in each so-called Green House, which looks nothing like a traditional nursing home. The front door opens onto a large living and dining area; on one side is a hearth surrounded by upholstered chairs, and on the other is a long communal dining table where meals are served. An open kitchen faces the table, so caregivers can chat with elderly residents while preparing meals.

Private bedrooms and baths surround the main living area. The house has a front porch and back deck with tables and chairs. There are no corridors, no nursing stations, no medicine carts (each room has a locked cabinet containing the resident's medications) and no trays of food delivered to the rooms.

There are 117 Green Houses across the United States now, part of a quiet but intriguing effort to de-institutionalize elder care. The movement has its roots in the 1987 Nursing Home Reform Act, which declared that residents of long-term care have the right to be free from abuse or neglect. Nursing homes across the country have tried a variety of strategies to become more "resident-centered."

"It's happening all over the country, in a lot of different models," said Sarah Wells, executive director of the National Consumer Voices for Quality Long-Term Care, an advocacy group based in Washington.

The Green House concept is the most comprehensive effort to reinvent the nursing home, experts say - including the way medical care is delivered. In traditional nursing homes, employees typically have narrowly defined jobs: Some give baths, some cook, some do laundry. It's a system based on efficiency that tends to ignore individuals' preferences and needs.

In a Green House, each home is staffed with two certified nursing assistants who perform all of these jobs, but for fewer residents. In addition, one registered nurse typically supports two or three houses.

"If you have one person doing everything, they can spend more time with the residents and get to know somebody as a real person," said Robert Jenkens, a director at NCB Capital Impact, a nonprofit community development finance institution that has partnered with the Robert Wood Johnson Foundation to provide consulting and loans for organizations developing many Green Houses.

"You're also less locked into a rigid 'wake, meal, bath' schedule, and you can reorganize someone's day based on her preferences," he said.

If nurses' aides aren't feeling rushed to dress and bathe residents, the thinking goes, they're more likely to let them perform more of these tasks themselves, fostering independence.

Erika Dickens, a certified nursing assistant, worked in the traditional nursing home at Green Hill for 20 years but recently was transferred to the new Green House.

"I used to feel like my hands were tied. I had to get the elders out of bed at a certain time, even if they didn't want to," she said. "Now if someone doesn't want to get out of bed for breakfast one day, I'll bring her a milkshake."

The notion that elder care should be de-institutionalized is a popular one. According to a poll released in September by NPR, the Robert Wood Johnson Foundation and the Harvard School of Public Health, 82 percent of pre-retirees (adults over age 50 who have not retired but plan to) and 78 percent of retirees are somewhat or very concerned about being in an institutional environment that is not as comfortable as a home.

"Loneliness, helplessness and boredom are the three plagues of nursing homes," Mr. Jenkens said. "Arguably, much of the institutionalized practice induced this."

Still, it's not clear that the Green House model can be widely duplicated. Though the day-to-day costs are no greater than those of larger nursing homes, the homes are typically built in clusters of two or more and require comparatively large initial capital investments. "It would increase long-term costs if it were implemented to replace every nursing home in the country," said Dr. Catherine Hawes, director of the program on aging and long-term care policy at Texas A&M Health Science Center.

Perhaps more important, whether the Green House model improves care for the elderly, compared with institutional settings, is not known. Several small studies, none particularly rigorous, have found that Green Houses deliver similar care for no more money than traditional nursing homes. The homes do this largely through reducing supervisory positions and training certified nurse assistants to take on more responsibility.

Green Houses also have a lower vacancy rates than conventional nursing homes, and they accept patients on Medicare and Medicaid, making them an option for low-income elderly. On average, about 54 percent of Green House residents are on Medicaid, while the rest pay for the care privately.

Residents of Green Houses experience fewer bed sores than those in conventional nursing homes, according to one survey, and each day they get 24 minutes more of direct and personalized care and 1.5 hours more of nursing staff time than those living in traditional nursing homes. Residents say they feel like they have deeper relationships with the staff, and family members report higher satisfaction with the physical environment, privacy, their own autonomy, health care and meals. Employees, too, report less stress. The turnover rate is significantly lower than in a traditional nursing home. Green House certified nursing assistants are paid on average about 5 percent more than those in institutional settings.

Even if this model of elder care turns out to be impractical on a large scale, Ms. Wells said, "we can learn a lot from what the Green House is doing and can translate these methods into things that existing nursing homes can use."

Many residents and their families find the Green House to be a substantial improvement over standard nursing home care. Diane LoCicero moved her 88-year-old mother, Evelyn, from the traditional nursing home into one of Green Hill's Green Houses this year. Her mother is far more relaxed now, said Ms. LoCicero, and she actually enjoys visiting the place.

"Before, it was like a hospital and I hated to visit," Ms. LoCicero said. "Now, I'll stay here for hours."

On a recent day in September at Green Hill, Jane Larkin, 82, a retired home economics teacher who suffered a stroke in 2007, sat in her wheelchair at the long dining table and marveled at the differences between this residence and the traditional nursing home in which she'd once lived.

"There's more opportunity to be social here. We can get outdoors easily, and people like to visit more," she said. "Sometimes, I give the girls advice when they're cooking, like I'm their teacher. There was no opportunity to do that in the other place, because we were isolated in our rooms."

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