Evidence Behind the Green House and Similar Models of Nursing Home Care

Sheryl Zimmerman; Lauren W Cohen

Disclosures

Aging Health. 2010;6(6):717-737. 

In This Article

Abstract and Introduction

Abstract

The Green House and similar models of nursing home care offer a solution to the institutional nature of nursing homes. In The Green House model, small houses are home to 6–12 residents in which care is given as much attention as treatment and is provided by a consistent, self-directed team of staff who are responsible for all care, including preparing meals in a centrally located open kitchen. Residents have private rooms and bathrooms that open onto a central living area. Although a nurse is available 24 h a day and the clinical care team is nearby and visits the home to provide care, the sense is that one is receiving care in a family-type setting. While these homes are expanding rapidly and seem to embody a better culture of nursing home care, their future growth may depend on the evidence that supports or refutes the quality of care that they provide.

Introduction

At any given time, 1.5 million individuals reside in nursing homes (NHs). Unfortunately, for most of these individuals, the NH is a setting of last resort because despite the care provided there and the improvements that have been witnessed in recent years, their ambiance is essentially one of an institution.[1] Fortunately, the future is not grim in this regard. A most promising development in NH care is encapsulated by the culture change movement, which seeks to change the organizational culture of NHs while attending to residents' healthcare needs. The best known example of NH culture change is the Eden Alternative, which encouraged companionship with children, adults and pets, promoted meaningfulness and control, and recast medical treatment as secondary to caring.[2] However, the limitation of this and many other models of culture change is that they do not address the fundamental structure of NHs as an institution.

A relatively recent and rapidly growing new culture of NH care is that of small-house NHs, best typified by The Green House homes that grew out of Eden principles. Their very intent is to combat the institutionalization of NHs by deinstitutionalizing them. As of July 2010, there were 89 Green House NHs in operation across 14 states in the USA, and more than 125 in development across 11 states. In The Green House model, small houses are home to 6–12 residents in which care is given as much attention as treatment and is provided by a consistent, self-directed team of staff who are responsible for care ranging from preparing meals in a centrally located open kitchen, to assisting with activities of daily living (ADLs), to engaging in social activities. Residents have private rooms and bathrooms that open onto a central living area, and they reflect the range of impairments seen in traditional NHs. The staffing hierarchy in traditional NHs is flattened in these homes, and although a nurse is available 24 h a day and the clinical care team is nearby and visits as needed, the sense is that one is living in a home receiving care in a family-type setting.[3] The Green House is a registered trademark that can be used only by settings that have a license to do so.

Viscerally, these settings seem to embody a better culture of NH care, and the few outcome studies conducted to date (using a quasi-experimental design in four Green House homes and two comparison sites) found better reported quality of life in four of 11 domains (privacy, dignity, autonomy and food enjoyment), less decline in late loss ADLs, less family involvement in providing assistance, and more activities outside the NH and satisfaction reported by residents and families. However, there were no consistent results related to health, no change in the social environment and less participation in organized activities.[4,5] An examination of workflow conducted in 14 Green House homes in comparison with 13 traditional NHs found the former did not require more staffing; in fact, they had slightly less overall staff time (nursing plus non-nursing; 0.3 fewer h per resident day [HPRD]), composed of 1.6 more HPRD of certified nursing assistant time but 2.0 fewer HPRD of housekeeping, laundry, dietary, dietician, activities and staff education time. The certified nursing assistants spent almost 0.5 more HPRD in direct care in The Green House homes and 0.3 more HPRD engaging outside of ADL care.[6]

Findings related to the Swedish model of group living are informative to this model of care because these settings similarly house up to ten residents and workers have consistent assignment and universal roles. In studies that compared matched residents with dementia in small group homes to those in NHs, over 1 year residents in the smaller settings had better preserved function, less aggressiveness, anxiety and depression, and a lower use of neuroleptics, tranquilizers and antibiotics.[7,8] Staff differences were that group living staff were more in favor of independent activities for residents, were more satisfied and felt more strongly that they were providing quality care, and less often reported that they needed to spend more time with residents.[7,9] In another study, group living favored longer length of stay and less family burden.[10] Considering that these studies represent the bulk of outcomes research that has been conducted in The Green House and similar homes, it is evident that much is yet to be understood regarding the benefits and limitations of this model of care.

The rationale to increase the evidence base on The Green House homes is that by having emerged from within the practice community, they represent a feasible innovation. However, to be adopted sufficiently to actually change NH care, their structures and processes must be shown to have advantage, be able to be broken down into manageable parts so as not to be overly complex and be able to be modified to suit individual needs.[11] Failing these conditions, a promising innovation may fade into oblivion. Consequently, this article examines existing evidence related to the essential elements of The Green House and similar models of NH care gleaned from research conducted in other NHs or related settings. Since these homes did not arise in a vacuum, it is a disservice to restrict the evidence base to the few studies that are specific to the model.

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