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

Conclusion & Future Perspective

In drawing conclusions based on the literature that addresses the essential elements of The Green House and similar homes, it must be noted that the literature derives primarily from cross-sectional studies, a small number of quasi-experimental studies and an even smaller number of randomized controlled trials. Thus, associations among variables may not be assumed to indicate causal relationships, and small studies may not be assumed to be generalizable. Still, the preponderance of data in some areas, especially in light of the importance of the topic and the limited data that exist about The Green House homes to date, allow certain conclusions to be drawn, with implications for the future.

The Green House Model Elements for Which Changes are Suggested Based on the Literature

Since NH residents do not generally engage in normative activities and literature indicates that providing materials for and promoting activity participation increases engagement that is beneficial to well-being, more structured activities and a stronger role for activities personnel are indicated as The Green House and similar models of care evolve.

The Green House Model Elements That Merit Further Examination as Priority Areas

Since there is not a nurse continually on-site in each Green House home and data indicate that more nursing is beneficial, resident health-related outcomes, including hospitalization, should be studied (because many hospitalizations are avoidable with proper care and because if hospitalization rates are less in The Green House homes, a case may be made for the financial viability of these settings). At the same time, it should be noted that the amount of nursing time did not differ between The Green House homes and other NHs studied.[6,208] An examination of health outcomes will inform the extent of resident acuity that can safely be managed in The Green House homes, including whether this is a suitable environment for postacute care. In examining this topic, consideration should also be given to optimal nursing models, how emergencies and medication issues are handled, and communication between shahbazim and nurses (e.g., do they consistently know when to involve a nurse?) and shahbazim and physicians (e.g., whether they are an effective point of contact for physicians).

A second priority topic meriting examination relates to the financial viability of The Green House homes because smaller homes are usually disadvantaged from diseconomies of scale. The extent to which this is true in The Green House homes is unclear given that they are typically part of a larger campus. In examining this topic, costs for homes that cater to different levels of resident acuity should be considered, because such homes may require different staffing models while enabling more resident homogeneity. This is a priority topic because if financial viability is not assured, a potentially promising new model of care may be at risk of extinction.

The Green House Model Elements That Merit Further Examination & Some Likely Modification

The literature on consistent staff assignment, self-managed teams and outdoor spaces suggest that these elements of The Green House homes may not yet be functioning as optimally as desired.


In considering the implications of the evidence presented, two caveats are indicated. The first is that while this article examined elements of The Green House homes considered to be essential by an expert panel, it may not have captured elements considered essential by others. The second is that this article addressed elements that are not specific to The Green House model. Even large NHs may incorporate small units that function similarly to what is envisioned in The Green House homes and other small NHs. Thus, what has been examined in regard to the physical structure of NHs (e.g., dining, staffing, case mix, elder-centered care and engagement), can inform virtually any existing or emerging model of NH care. This is a strength that should not be overlooked, and it is one that must be underscored.

Perhaps the most salient matter related to The Green House homes is not the evidence per se, but that they constitute an innovative vision of what NH care and living can be. Their mere existence is a tremendously important contribution in a field in which talk of culture change is the norm rather than the exception; that is, The Green House homes convey the possible. Developers and supporters of this model hope that its rate of adoption will grow exponentially, and if these homes are shown to be preferable and cost effective, this vision may be realized. Alternately, it may be that future innovations in NH care embody some rather than all of The Green House components and related principles, and that The Green House model itself evolves over time. In the end, the goals are to provide optimal NH care and enable an optimal quality of life for elders who live there; the most certain predication is that these are goals toward which our society will continue to strive, with increasing success.


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