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

Sheryl Zimmerman; Lauren W Cohen


Aging Health. 2010;6(6):717-737. 

In This Article


Essential Elements of the Green House Model

The expert panel identified six elements as essential to The Green House model, related to the physical structure (small size, private rooms and bathrooms, access to the outdoors); dining (noninstitutional, with an open, residential-style kitchen accessible to the elders); staffing (consistent assignment and broadened universal role of certified nursing assistant direct care staff [named shahbazim] who function as a self-managed team, and a nearby and readily available clinical team); diverse and stable elder case mix; elder-centered care; and normalized engagement ( Box 1 ). A qualitative operational synthesis and the related literature for each of these elements follows.

Physical Structure: Small Size, Private Rooms & Bathrooms & Access to the Outdoors

Physical Structure, Operational Synthesis The Green House homes are intended to be similar to homes in which elders live in the community. In urban communities, they look like apartments or duplexes, while in rural areas they resemble freestanding single-family homes. The majority of The Green House homes are on a campus with a traditional NH and/or other Green House homes, and so may be conceived of as a small unit on a larger campus. Each home is fully independent from other homes or buildings on the campus and accommodates no more than ten elders (or up to 12 with a financial hardship exception). A Green House project in a high-rise building may include one or more independent Green House homes, each with a separate entry and no physical connections except for a shared elevator, lobby and/or corridor; that is, they do not share service space, kitchens or other areas. A typical home averages 6400–7000 square feet. Required design features include:

  • An open-plan great room area (referred to as the 'hearth') encompassing living space, a dining area and an open kitchen;

  • A single dining table large enough to seat all elders, the shahbazim and two guests;

  • A private bedroom and full bathroom for each elder;

  • A readily accessible, secure outdoor space for use at any time.

Physical Structure, Literature The expert panel identified three physical structures as essential elements of The Green House homes: small size, private rooms and bathrooms, and access to the outdoors. Studies that examine differences by NH size have not compared NHs with fewer than ten beds to larger NHs, but they do examine whether resident status, care and outcomes vary by size. While the data are primarily from descriptive and comparative (Grade C) studies, many favored smaller NHs, finding that they exhibit: better staff rapport with residents;[13] less abuse;[14] more activity involvement for impaired residents;[15] better outcomes in quality indicators;[16] less resident agitation/anxiety, depression, withdrawal, behavioral and mood disturbance, delusions, hallucinations, psychosis, aggression and phobias;[17,18] less pressure ulcers and restraint use;[19] as well as less infection.[20] For example, a study of 92 NHs randomly selected from all NHs in Missouri, USA, found smaller homes (median size 60 beds) had better quality indicators (an aggregate of 28 items such as new fractures, falls, depressive symptoms and infection) than those with a median size of 134 beds; the authors hypothesized that smaller size is beneficial because staff know the residents better.[16] Similarly, studies of smaller NH units found they were favorable in terms of resident anxiety and depression,[21] and that there were fewer resident conflicts over space and less aggressiveness.[22] On the other hand, studies have also favored large NH size, finding it related to specialty care,[23] reduced costs,[24] less likelihood of closure[25] and less resident decline. More specifically, compared with NHs with 30–51 residents, those in NHs with more than 101 residents showed an 18% decreased odds of functional decline over 3 months.[26] Studies that found no relationship between size and other variables examined it in relation to social interaction[27] and neuropsychiatric symptoms,[28] although in these cases, it was not evident that the studies were powered to detect differences by size. On balance, smaller size favors psychosocial care, behavioral outcomes and some medical outcomes, while larger size conveys more resources, financial stability and better ADL care.

The second important physical structure element of The Green House homes is private rooms and bathrooms. The majority of studies related to private rooms are hospital based, in which comprehensive reviews found privacy relates to lower operating costs (but higher initial costs); higher occupancy; shorter length of stay; fewer medication errors; lower rates of nosocomial infections (although some reports were conflicting), disruptive behaviors and transfers to other rooms; less noise and sleep disturbances; and higher levels of patient satisfaction, sense of privacy, dignity and control.[29,30] In addition, hospital nurses favor single-occupancy rooms as more amenable to care and accommodating the family.[31] Still, some studies found isolation relates to more falls, less documented care and longer length of stay,[32] and that narcotic use is variably more or less in private rooms.[33] Studies in NHs found reduced infection and hospitalization for infection for residents in private versus shared rooms,[34,35] such as one wherein 86% of residents who developed acute nonbacterial gastroenteritis during an outbreak shared a room, compared with 14% of those afflicted who resided in private rooms,[36] and another in which those in shared rooms had more than a threefold risk of acquiring influenza A compared with those in private rooms.[37] Additional data supporting private NH rooms are that they are highly desired by residents and preferred for family visitation, during the dying process and for improved sleep; in addition, operational costs are less, and they require less time to market, clean, manage conflict (due to not having a roommate) and handle transfers.[38–40] On the other hand, while private rooms related to more time in the common area they also related to less interaction,[41] and while 59% of NH residents considered a private room and bathroom as important, they more highly rated the importance of seven other features, including safety, medical care, food and the staff.[202] The construction and debt costs are more for private rooms, but this difference may be recouped in less than 2 years if the NH charges US$23 more a day for a private room, and in less than 3 months if one of the two beds in the shared room were empty and not providing revenue.[39] In reference to behavioral disturbances, data are controversial whether privacy is related to less anxiety/aggression, withdrawal, depression and psychological problems.[28,42] Considering these data together, there are strong benefits of privacy for infection control and overall management, as long as the additional costs can be managed.

The third important physical structure element of The Green House homes is access to the outdoors. Evidence of the therapeutic benefit of the outdoors has been noted regarding light, as sleep and behavioral symptoms can be improved with bright light.[43] Residents who spend more time outdoors sleep less during the day,[44] and those exposed to bright light sleep more during the night.[45] However, there is also evidence that bright light increases agitation among residents with dementia[46] and is not effective in treating depression.[47] On the other hand, one study found violence was less in NHs with outdoor environments, and residents walked more often in a NH that had a therapeutic garden.[48] Similarly, residents appear to enjoy the outdoors, as evidenced by a simulation in which residents with dementia spent nonsignificantly more time in a simulated outdoor corridor than a bare one, exhibiting a trend toward less trespassing, exit-seeking and other agitated behaviors, and also a significant increase in interest and pleasure and less anger and anxiety.[49]

Of course, the real matter related to access to the outdoors is whether the outdoor space is used. In one study, while almost all 40 NHs had an outdoor space, direct access to it was most often locked. Approximately 22% of able residents used the space every day, with another 16% using it several times a week and 17% using it once a week.[203] A survey of 320 NHs that had special care units for persons with dementia and outdoor spaces found 77% were used every day and 98% were used several days a week in the summer; in the spring and fall, these numbers were closer to 50 and 90%. Almost two-thirds of respondents felt the area could be used more, with hindrances relating to weather (31%), accessibility (25%), design (23%) and residents not being accustomed to going outdoors (24%). Fewer than 15% of outdoor spaces had handrails and easy access to a bathroom and only 28% used gazebos for shade protection. The most problematic feature was considered to be concrete walkways because they threatened safety, and the primary safeguard for safety was that the staff accompanied the residents outdoors (69%). While all respondents rated the outdoor space as useful, more than a half reported having experienced problems, including safety (58% of problems), problems with residents or staff (26 and 10%) and being too costly (6%).[50] In a study not specific to special care units, residents were found to be exposed to only 10 min of outdoor light levels per day.[51] If residents do use the outdoors, caution is advisable in that because outdoor light is 100–1000-times greater than interior daylight, it may take up to 35 min for the eyes of NH residents to adapt to the change.[52] Overall, there are behavioral and health-related benefits of outdoor space, but special considerations for its development and use are required.

Dining (Noninstitutional, Residential-style Kitchen)

Dining, Operational Synthesis

In The Green House model, food is much more than nourishment. The kitchen and dining table are also essential sources of enjoyment, activity and community, with the term for engagement around food and dining being 'convivium'. Principles associated with food and mealtimes include: preparation of all meals in the house kitchen; selection of menus based on elder preference and choice using fresh, local ingredients; the preservation of traditions to foster community; and a fully stocked residential-style kitchen accessible to elders at all times. Related practices include: the development of house cookbooks with recipes contributed by elders and their families; elders' involvement in food preparation, cooking, setting the table and related activities; use of music, table linens, flowers and decorations to enhance the environment; and including all staff and any others in the house at mealtime at the common table.

Dining, Literature The effects of age on food and fluid intake are well documented, in that hunger declines with age and results in reduced caloric intake.[53] Protein energy malnutrition is as high as 65% in NHs,[54] and relates to increased infection, hospitalization and mortality.[54–58] A substantial body of evidence indicates that eating with others stimulates intake, a finding that has been documented across age groups,[53,59] in rehabilitation settings,[60] and in NHs.[61,62] Furthermore, staff are more satisfied when NHs do not deliver food on trays,[63] and evidence exists that residents' table manners are improved in these instances.[64]

An additional benefit of having meals in a communal setting is that staff are available to assist. When asked how to improve meals and mealtimes, NH residents request more staff to provide assistance (as well as better menu variety and tastier food).[65] In a study of more than 130 residents in ten NHs, 44% of residents received physical assistance, 47% received verbal assistance and 74% received monitoring support during mealtimes;[62] another study of 91 residents with low intake found 60% of residents required extensive physical assistance at mealtimes.[66] The benefit of such assistance is evident in one study of 134 NH residents in which intake significantly increased when residents received physical assistance or verbal prompts. However, the assistance required 29 additional minutes of staff time per meal per resident (35 vs 6 min).[66–68]

Along with communal dining, another essential element is the open accessible kitchen, which conveys social activity and produces appetite-stimulating aromas.[69,70] To the extent that this accessibility extends to the availability of snacks, providing easily accessible snacks is associated with increased intake and in one study provided residents an additional 300 calories.[56,68,71] In addition, a study in 53 Alzheimer's special care units found resident-accessible kitchens (among other factors) were associated with decreased agitation.[18]

Finally, in a randomized controlled trial to improve NH mealtime ambience, which included enhanced table dressings (i.e., tablecloths, napkins and flowers), family-style meals, staff presence at the table, beginning meals only when all residents were seated and a devoted, home-like meal setting during which time no other activities were allowed, residents significantly increased their caloric intake.[61] Of note, the residents were seated at more than one table, so this intervention did not exactly mirror The Green House homes. Taking all of these findings into account, there is good support for communal eating arrangements and the convivium encouraged by The Green House model.

Staffing (Consistent Assignment, Self-managed Teams & Clinical Staffing)

Staffing, Operational Synthesis The Green House model reorganizes staff, flattening the traditional hierarchy. Each house functions independently with consistent and dedicated staffing by specially trained certified nursing assistants in an expanded role referred to as shahbaz (plural: shahbazim). A consistent team of shahbazim staffs each home, taking responsibility for personal care, activities, meal preparation and service, light housekeeping and laundry. Shahbazim operate within a self-managed work team. They are coached by and are accountable to the Guide (a role often assumed by a NH administrator). Nurses are present in the homes on a daily basis. Expected staffing includes 4 h per elder per day of shahbazim time and 1–1.2 h per elder per day of nursing time (licenced practical nurse [LPN] and/or registered nurse [RN]). A nurse generally staffs two homes during days and evenings and up to three homes overnight. Other clinical professionals (e.g., therapists, dietician, physicians, social workers and activities professionals) visit the home on a routine basis and as required to provide resident assessment and treatment and coaching to the shahbazim.

Staffing, Literature The experts identified three important elements of The Green House model related to staffing: consistent assignment, a universal role within self-managed teams and clinical staffing (having a clinical team in place nearby but not always in the building). The rationale underlying consistent assignment is that it allows staff to become more familiar with residents' needs and preferences, that the affective quality of their relationship is improved and that resident confusion is lessened by having fewer staff providing care. On the other hand, the rationale underlying a rotating model of staff assignment is that it more evenly distributes burden and more staff know more residents. Many of the studies in this area are not pure examinations of consistent assignment however, because it often is conducted in consort with other changes, such as a team model of care.[72] Looking at projects that examined consistent assignment in and of itself, findings are contradictory. Two studies found staff disliked consistent assignment due to boredom and having demanding residents.[73,74] However, two other studies reported staff preferred consistent assignment so they could know the residents better,[75,76] and two others found residents preferred consistent assignment;[72,73] in addition, families preferred consistent assignment so staff can better know the residents and they can better know the staff.[77] Findings are also contradictory regarding the outcomes or correlates of consistent assignment. In regard to staff turnover, studies that suggest consistent assignment is favorable have methodologic flaws,[78] while two that were more robust found either no relationship between assignment and turnover[79] or that consistent assignment related to more turnover.[78]

In terms of other outcomes, a comparative study in four NHs found consistent assignment did not relate to differences in resident–staff verbal interactions, resident disruptive behavior or effect, or quality of care, although it did relate to more staff absenteeism. Of note, workers in the consistent assignment condition were matched to residents only 50% of the time (although this was twice the rate found in rotating assignment) so it must be considered that consistent assignment does not itself indicate the amount of time a given staff person spends with a given resident.[76] Also on the negative side, one study in 45 settings found consistent assignment related to lower ratings of resident quality of life,[80] and another in 35 settings found that it related to lower adherence to a new clinical procedure (i.e., hip pad protectors), presumably because rotating workers were more attentive to care plans due to less familiarity with the resident.[81] Data from the 2004 National Nursing Assistant Survey obtained from 2252 respondents found consistent assignment did not relate to satisfaction.[63] Thus, the evidence supporting consistent assignment is not strong, although it seems assignment should be consistent enough to allow familiarity between the staff, resident and family.

The second staffing element determined essential to The Green House model is having a broadened universal role within self-managed work teams. Self-managed work teams (also known as self-directed or autonomous work groups or teams) allow nonmanagement employees to manage many aspects of their work. The rationale for such teams is that they presumably increase morale, satisfaction and commitment, and reduce absenteeism and turnover; research conducted in the manufacturing industry supports those assumptions.[82] In general NH practice, the involvement of certified nursing assistants (CNAs) in teams and perceptions of teamwork are not common. An analysis of 135 NHs in New York, USA, found less than 16% of CNAs were part of either formal teams (8.4%; assigned by management) or self-managed work teams (7.4%; those that self-organize in teams). Up to a certain level there were cost savings associated with having formal teams of approximately $174,000/year due to fewer medical costs incurred, whereas no such savings were achieved by self-managed teams.[83] A smaller study in 15 NHs presumed to offer good care found only 37% of CNAs reported often or always having coworkers they could count on to help with assignments; in this study, teamwork did not relate to job commitment above and beyond awards such as wages, benefits and advancement possibilities.[84] In another study, no relationship was found among more than 3000 CNAs between turnover and either being supported to work in teams or being enabled to decide how to do their work.[85] Extending this concept to patient outcomes, a hospital-based study of those treated on self-managed nursing units found no differences related to perceived health, function, needs or unmet needs for care, unplanned healthcare or readmission.[86] Finally, a study of 1500 NH residents in ten NHs found more levels of supervision were associated with better resident function when there were more heavy care residents, presumably due to the need to process more information.[87]

Research specific to self-managed work teams in NHs is limited. One study that established 21 teams in five NHs found that CNAs in self-managed teams reported a modest 0.2-point increase (on a 5-point scale) in feelings of empowerment and modest benefit in six out of 21 other outcomes: nurses' perceptions of CNAs' behaviors and coordination; family members' perceptions of choice related to bed, meal and shower routines; and CNA satisfaction with scheduling. Results related to CNA turnover were promising but inconclusive. The authors hypothesized the modest results were due to increased CNA expectations regarding the merits of consistent staffing. In reference to team management, approximately 60% of CNAs reported they learned about residents and how work should be carried out from each other during their team meetings, meaning a substantial minority did not agree with these statements. Furthermore, meetings required 30 min per week, and this time was difficult to free from providing direct care. Dissatisfaction with time demands and the manner in which the meetings were run were considered the reasons these teams did not have a positive effect on absenteeism, job attitudes, satisfaction, commitment and self-esteem.[82] One solution to the time issue may be having impromptu 'stand up' meetings of approximately 5 min duration, as an observational study found these to be most efficient.[88] On the other hand, there are anecdotal reports that having a team approach resulted in more efficiency and so more time to spend with the residents in noncare activities.[72] Of note, qualitative findings indicated that decision-making did not always remain within the purview of the team, especially when management determined that decisions needed to be made quickly or simply failed to include the team.[89] In summary, the data on self-managed work teams are not overwhelmingly supportive, but nor are they damning, which may reflect the limited experience with such teams.

In relation to clinical staffing, a more unique feature of The Green House is that the clinical care team is not always located within the home; however, they are nearby, typically based elsewhere on the campus. While this staffing model has not been directly evaluated, findings related to physician presence in the NH shed light on the role of clinician presence and outcomes. Physicians have been described as 'missing in action' in NHs. In one qualitative study of end-of-life care, family reported that increased physician presence in the NH was needed in order to improve care;[90] other work has shown residents are more satisfied and perceive care as better when the physician is onsite,[91] and families rate communication as better when they meet with the physician.[92] Increased physician presence in the NH is also associated with reduced infection and hospitalization rates, as well as improved satisfaction with end-of-life care.[90,93–95] It is important to stress, however, that clinical staff in The Green House homes are nearby if they are not actually on site, such as in the traditional NH building on the same campus.

The physician model of care does not differ between traditional NHs and The Green House homes, but the model for other clinical staff (e.g., nurses, social workers, activity and dietary staff) differs in that in The Green House homes they share their time between multiple homes. The national average of clinical nursing time in traditional NHs is 1.4 HPRD (36 min RN and 48 min LPN).[204] Increased licensed nursing time is widely associated with improved resident outcomes, including pressure ulcers,[96–98] infections,[98] abuse,[99] discharge,[100,101] hospitalizations[98,102] and mortality.[100,101] There are also reports to the contrary, including that increased nurse time relates to more CNA dissatisfaction,[63] is unrelated to resident functional outcomes[103] and has minimal benefit for chronic residents.[100,104] These mixed findings may be attributable to differing data sources[105] or resident profiles because staffing must be considered in the context of need;[103,104,106] therefore, they signify the importance to consider not only the number of staff, but also their organization and the characteristics of the residents and setting. Furthermore, because several reports found that LPN time (as opposed to or in relation to RN time) may be associated with increased infection, pressure ulcers and health-related deficiencies,[35,96,107] the skill-mix (RN:LPN ratio) must be considered.

With regard to other clinical staff, little rigorous research has explored issues related to their availability. One large analysis of NH survey data found fewer HPRD of dietary, activity and therapy staff were associated with deficiencies in quality of life, but had no significant effect on care quality.[106] Other research has shown increased therapy staff relates to increased hospitalizations (which is not necessarily indicative of poor care or outcomes).[35] Finally, related to administration, less administrative time is associated with deficiencies in administrative duties,[106] although hands-off, consensus management may be beneficial in reducing turnover and improving outcomes.[108]

Extensive literature has found increased CNA time relates to improved outcomes, including infection,[35] pressure ulcers,[96,98] abuse,[14] quality of life,[106] resident satisfaction,[27] and staff satisfaction[63] and turnover,[109] and better care in engagement, nutrition and documentation.[105] Furthermore, a more favorable staff:resident ratio is associated with less resident verbal aggression and lower apathy but not neuropsychiatric symptoms.[28,42] Other studies with inconclusive or negative findings have shown CNA time does not relate to outcomes such as hospitalization or urinary tract infection,[98] is associated with a greater decline in function,[103] increases the likelihood of incontinence,[96] is unrelated to discharge[104] and, in relation to RN staffing, is associated with more ambulatory-care sensitive hospitalizations.[94] Thus, while the literature on clinical, administrative and direct care staffing has some findings to the contrary, the preponderance supports the benefit of more staffing, although none, other than that related to physicians, speaks to staff who are based 'on' versus 'off' the unit.

Elder Case Mix (Diverse & Stable)

Elder Case Mix, Operational Synthesis Most Green House homes are dually certified under Medicare and Medicaid and are able to offer care to elders needing postacute rehabilitation, as well as those with chronic care needs. Generally, however, Green House homes primarily serve elders with chronic needs rather than a high volume of short-stay elders, consistent with the goal of creating a stable and close-knit intentional community for whom the residence becomes a home. All skilled services, including physical and occupational therapies, can generally be provided within a Green House home. Some sites in development plan to target short-stay clients or to meet the unique needs of sub-groups, such as persons with multiple sclerosis. Elders living in The Green House homes represent the spectrum of different payor sources seen in long-term care, including private pay, Medicare and Medicaid. The first Veteran's Administration-sponsored homes are now in development.

Elder Case Mix, Literature The expert panel identified two essential elements of The Green House model as relating to a diverse and stable resident case mix – meaning residents who represent those in traditional NHs and also residents who tend to be long-stay. There are advantages and limitation of different types of case mix. Settings with higher proportions of nonwhite residents are rated as lower in environmental comfort and relationships between and among residents and staff,[13] and have more feeding tube use[110,111] and health-related care deficiencies.[112] Private pay status is associated with greater use of antidepressants[113] and better structure and process quality indicators;[114] similarly, residents whose primary payer is Medicaid have a 30% increased likelihood of functional decline[115] and are less likely to adhere to the use of hip protectors[81] than residents whose payment source is private or Medicare.[116] In addition, a higher Medicare case mix is associated with increased risk of infection but not hospitalization for infection.[35] In terms of dependencies, resident function is better when fewer residents require heavy care,[87] a lower percentage of skilled nursing beds relates to better quality care and outcomes,[16,114] and residents who have been readmitted to a NH tend to have more service needs and a longer length of stay.[117] However, case mix does not relate to physical restraint or antipsychotic medication use.[118] Thus, racial, payer, and clinical case mix have implications for care and outcomes.

The intent behind The Green House homes primarily serving residents with long-term care needs is to achieve stability so that relationships may be formed among residents and with staff. NH residents desire these meaningful relationships, and they are important to psychological and physical health and may be protective against mortality.[119–124] Unfortunately, one study found that although the majority of NH residents (63%) prioritize making new friends in the NH, few (25%) achieve this goal.[120] Barriers to relationship formation relate to the environment (e.g., long corridors separating residents, little privacy and inaccessible outdoor seating), as well as interpersonal features (e.g., lack of shared interests or common backgrounds, and high numbers of residents with emotional needs or cognitive, visual or hearing impairments).[125–128] The literature describing the relationship between stable resident tenure and resident–resident friendship formation is mixed. Of the minimal data available, one study found longer-stay residents had fewer close relationships than those with shorter tenures; other work indicates that length of stay is associated with better perceived social support from friends and less disruption in relationships. However, others have shown length of stay has no relationship to life satisfaction or feelings of 'home'.[124,125,127,128] Research related to tenure and resident–staff relationships is more consistent, which is important considering that 36% of NH residents identify a staff member or volunteer as the person with whom they feel close.[125] Residents report building trust with staff members based on staff reliability and knowledge of and familiarity with shared routines.[119,121,124,129] Thus, on balance, the literature supports the benefit of longer tenure to develop supportive, interpersonal relationships.

To set the case-mix issue in context, Table 1 provides statistics based on the 2004 National Nursing Home Survey (NNHS).[205] The data indicate the stability of NH residents, showing that of those aged 64 years or older, 56% have been resident in the NH for 1 year or more, and 19% for less than 3 months. These data are helpful for comparative purposes to determine whether The Green House homes achieve similar case mix and stability as traditional NHs. Of note, the NNHS presents prevalence data (i.e., related to current residents), which undercounts short-stay Medicare residents. As noted in the operational synthesis, while most Green House homes are certified to provide rehabilitation, they primarily serve elders with long-term needs. Thus, comparisons of their case mix with national prevalence data must recognize that similarities do not accurately reflect the number of NH residents who receive postacute rehabilitative care.

Elder-centered Care (Not According to Fixed Schedules)

Elder-centered Care, Operational Synthesis The Green House model builds upon the principles of The Eden Alternative, and places each elder at the center of the home and his/her life. The natural daily rhythms of each individual drive the flow of all activities and relationships, such that elders direct their own waking, sleeping, meals and leisure, and the shahbazim are encouraged and empowered to support the choices of each elder.

Elder-centered Care, Literature At the core of elder-centered care is the concept of choice and control. Countless studies across different populations and situations have demonstrated the importance of perceived control.[130–132] However, there are changes in perceived control as an individual ages, with some studies indicating more perception that external forces shape life as one gets older, which may affect expectations regarding control.[133] More so, with age there is more variability in preferred amounts of control, and in some instances more control results in stress, worry and self-blame.[132] Furthermore, the ability to exercise choice is variable; for example, more choice relates to more resident-initiated activities for higher functioning residents, but less activity engagement for more impaired residents.[15]

Cross-sectional studies in long-term care settings indicate a relationship between involvement in facility policies and administration and resident wellbeing.[134] However, studies that examined choice and control as distinct from other components of care are few, and quasi- or experimental studies are even fewer. One such study used a cluster randomized trial design in one NH in which the administrator talked with some residents about the influence they have over their care, and talked with other residents about the attentive care the NH provides; control also differed in that the first group was given the option of which days to watch a movie, while the second group was told what day the movie would be shown. Despite being a weak intervention, more residents in the first group watched the movie and 3 weeks later reported themselves to be happier and more active; in addition, they were considered more alert and engaged.[135] There was some indication that beneficial results continued through 18 months,[136] although the information to affirm this is insufficient.

Another cluster randomized trial explored the difference between control and predictability in allowing older adults to determine if, when and for how long they had a visitor. Those who had control over the number, time and duration of visits as well as those who knew when visitors were coming (but could not control the number, time nor duration of the visit) exhibited better outcomes 2 months later in social engagement, activity and change in number of medications taken compared with those who had visitors who came without warning or had no visitors.[137] Thus, while there is evidence that control relates to outcomes, this study suggests that it is the predictability of the events that transpire that is most important, rather than the choice itself. This conclusion has important implications because it is markedly more simple to make care predictable for all NH residents than it is to allow each one to control his/her environment. This conclusion is consistent with those from other NH studies which found that what is central is that the opportunities for control be maintained because the loss of control is more detrimental than the lack of control, and that expectations for control must be reasonable in terms of the capacity of the environment.[132]

Additional important considerations arise when examining the activities that NH residents consider most important regarding control. A study of 135 residents from 45 NHs found more than two-thirds considered it important to have choice and control over leaving the facility, telephone and mail, while fewer (one-half to two-thirds) found it important to be in control of care routines, NH activities, money, food, roommate selection, getting up in the morning and going to bed; still fewer (less than a half) felt it important to have choice and control over visitors. Nursing assistants rated the importance of telephone and mail significantly lower than did residents, and rated NH activities, food and visitors significantly higher than did residents.[138] Therefore, residents were more concerned with their ability to control contact with the outside rather than the inside world (although they found both to be important), but these priorities were not understood by staff. In summary, it is beneficial to allow residents choice and control, but doing so must be elder-centered, realistic and consistently maintained.

Engagement (Normalized Rather Than Organized Activities)

Engagement, Operational Synthesis The Green House model supports elders to spend their days in ways that are relevant and meaningful, and allow them to find purpose and joy. The concept of 'meaningful engagement' encompasses all activities that are social, leisure, physical, self-care, intellectual and spiritual. The term 'activities' is avoided because of the connotation it has to the standard 'activity schedule' within traditional NHs.

Engagement, Literature Social engagement – above and beyond that to address the needs of residents with dementia or depression – is recognized as an appropriate goal of NH care, although little research has been conducted on this subject. Six items of the Resident Assessment Instrument collected for all US NH residents provide a telling picture of social engagement. Among 1848 residents from 268 NHs in ten states, the percentage of individuals rated positively were as follows: at ease interacting with others (59%); at ease doing planned or structured activities (38%); accepts invitations into most group activities (35%); at ease doing self-initiated activities (33%); establishes own goals (28%); and pursues involvement in the life of the facility (23%).[139] These items were associated with the amount of time actually spent in social activities, and so present a potential focus for interventions.

In relation to the amount of time actually spent in activities, data from more than 376,000 residents indicated that 8% participated in activities most of the time, 42% some of the time, 44% a little of the time and 7% none of the time over a week.[140] Not surprisingly, those with more impairment spent less time in activities.[139–141] Putting the matter of social engagement in perhaps the most salient light, a study of more than 30,000 NH residents who did not have serious communication problems found more engagement related to reduced mortality independent of risk factors; causal explanations relate to psychological benefits of engagement, such as a sense of belonging and support that result in a stronger will to live, physiological factors, such as resistance to disease, and interpersonal factors, such as the ability to more readily identify a change in a resident's condition.[142–144]

Thus, the intent for The Green House homes to facilitate engagement is grounded in the literature, with the question being the manner in which to do so. Numerous studies have documented that engagement is increased when equipment and materials are provided and residents are encouraged to participate. One study found an increase from 20% of residents being in a common area when activities were not available to 74% spending time there when equipment and materials were provided and residents were prompted to participate.[145] Another study found baseline engagement of 29% increased to 61% with materials and prompting to participate in individual activities, and to 74% with materials and prompting to participate in group activities.[146] Of note, an analysis of approximately 2500 residents found that those in NHs with more organized activities were approximately 40% less likely to die or decline over 6 months.[115]

Looking further at these group activities, a study of more than 1400 residents of congregate care settings found those who were less impaired were more likely to participate in self-initiated activities, whereas those who were more impaired were more likely to participate in facility-organized events. Furthermore, involvement in organized activities was higher when others participated, suggesting an additive effect of encouraging attendance in organized activities. This same study found resident characteristics did not relate to likelihood to participate in facility-organized activities, and the authors concluded it could be the egalitarian nature of those activities that makes them appear impersonal and institutional. It also found that rapport – perceptions of warmth and supportiveness – related to more involvement in facility activities.[15] Finally, a study conducted in Sweden found more than 60% of cognitively intact residents felt it important to have a nice time with other residents and to make new friends, although almost 40% said their expectations had not been met in this regard.[120] Thus, it is clear that social engagement is necessary, and that facilitation and group activities may be especially beneficial, especially when residents are more impaired.


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