The Green House Model of Nursing Home Care in Design and Implementation (2024)

PMCID: PMC5338211

Lauren W. Cohen, M.A.,¹ Sheryl Zimmerman, Ph.D.,² David Reed, Ph.D.,¹ Patrick Brown, B.S.,³ Barbara J. Bowers, R.N., Ph.D.,⁴ Kimberly Nolet, M.S.,⁴ Sandra Hudak, R.N.,⁵ Susan Horn, Ph.D.,⁶ and the THRIVE Research Collaborative^†

David Grabowski

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Objective

To describe the Green House (GH) model of nursing home (NH) care, and examine how GH homes vary from the model, one another, and their founding (or legacy) NH.

Data Sources/Study Setting

Data include primary quantitative and qualitative data and secondary quantitative data, derived from 12 GH/legacy NH organizations February 2012—September 2014.

Study Design

This mixed methods, cross‐sectional study used structured interviews to obtain information about presence of, and variation in, GH‐relevant structures and processes of care. Qualitative questions explored reasons for variation in model implementation.

Data Collection/Extraction Methods

Interview data were analyzed using related‐sample tests, and qualitative data were iteratively analyzed using a directed content approach.

Principal Findings

GH homes showed substantial variation in practices to support resident choice and decision making; neither GH nor legacy homes provided complete choice, and all GH homes excluded residents from some key decisions. GH homes were most consistent with the model and one another in elements to create a real home, such as private rooms and baths and open kitchens, and in staff‐related elements, such as self‐managed work teams and consistent, universal workers.

Conclusions

Although variation in model implementation complicates evaluation, if expansion is to continue, it is essential to examine GH elements and their outcomes.

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*The values, elements, and practices are defined by The Green House Project (2012).

Structured Interviews

Structured interviews were completed with administrators (or their designee) in 12 GH/legacy organizations. These interviews asked questions separately for the GH and legacy home except for areas that did not differ between the two (e.g., ownership status, religious affiliation). Questions addressed the presence of select structures and practices indicative of GHmodel implementation, and included those that create real home (e.g., unit size, outdoor access), meaningful life (e.g., resident control over bed times, availability of group activities), and staff empowerment (e.g., self‐managed workteams).

In addition to individual questions, two established subscales were administered in GHs, namely those from a modified version of the Policy and Program Information Form (POLIF) (Lemke and Moos 1980; Zimmerman, Eckert, and Wildfire 2001). These questions addressed components in the Individual Freedom and Institutional Order domain (i.e., Policy Choice and Provision for Privacy) and addressed whether residents are encouraged, allowed, discouraged, or prohibited from exercising 11 various forms of freedom, ranging from skipping breakfast to sleeping late to choosing the furniture in their room. Scores represent the percent of the 11 behaviors encouraged or allowed, and theoretically range from 0 to 100 percent. Fifteen other items assessed the extent to which residents are involved in decision making in areas such as planning menus, making decisions about pets in the home, and choosing new residents. Scores represent the percent of the 15 areas in which residents make decisions either independently or with staff input, and again theoretically range from 0 to 100 percent.

Semistructured Interviews

Qualitative data were collected during visits to nine of the GH/legacy organizations selected to represent a range of organization size, length of operation, and resident clinical outcomes. During these visits, two members of the research team interviewed 250 GH/legacy staff, including direct care staff (nursing assistants and Shahbazim), directors of nursing and other licensed nurses, therapy staff, administrators (referred to as Guides in GH homes), and other department heads (social work, dietary, environmental services, human resources, medical director), and nurse practitioners. The semistructured interviews included questions relevant to the elements of the GH model, such as “Tell us how you make this a homelike environment for the elders” and “What parts of the model have been more difficult to implement or sustain?” Interviews began with open, nondirective questions about implementing the GH model and the impact of the model on care processes; as data were analyzed, interview questions were iteratively refined, becoming increasingly focused on emerging themes.

Secondary Data

To determine the representativeness of GH/legacy organizations in relation to NHs nationally and in their respective state, minimum dataset (MDS) 3.0 staffing and quality measure data for all licensed NHs were downloaded from Nursing Home Compare (Centers for Medicare and Medicaid Services 2014). The staffing and quality measure data for GH/legacy organizations are combined in this dataset. MDS 3.0 staffing data represent the January 1, 2011—June 30, 2013 period, while quality measure data reflect the April 1, 2011 through June 30, 2012 reporting period, as these were the data that were available.

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Notes:

Noninteractive tasks include ordering and stocking resident food, cooking resident meals, planning activities for residents, handling resident laundry, setting and clearing dining tables, performing light housekeeping duties, and performing deep housekeeping duties; interactive tasks include serving resident meals, helping residents to eat meals (i.e., feeding), helping residents with exercises, taking residents on trips, ensuring residents are engaged in activities that they enjoy, leading group activities, participating in group activities, helping residents stay in contact with family and friends, weighing residents, taking blood pressures, and checking blood sugars. The medical care services are X‐ray, bladder scanner, catheter and drain care, tracheotomy management, wound care, IV capabilities, and tube feeding. Differences between site types in the availability of individual services were not statistically significant for any of the services.

*p<.05; **p<.01.

Small Scale

Consistent with the model's emphasis on small‐scale design, GH homes had between 10 and 12 beds; far fewer than the legacy homes’ units, which ranged from 24 to 50 beds. Respondents from GH homes considered the small scale to be an advantage related to staff responsiveness and efficiency, noted in a statement saying “We're in a close vicinity where we can hear if something is going on … we're not, you know, down another wing in another hall”; to the elders’ safety and confidence, about which a staff member said: “[Elder] feels pretty good about herself that she can walk … she doesn't have that far to walk . … it kind of builds their self‐esteem, makes them feel good they can walk versus having to be in a wheelchair;” and to staff and resident relationships, noted as: “… they recognize you, because there's only a few of us, and there's only a few of them. And they become friends, and they, you know, when we're busy, it's funny how patient they are. They don't say, I got to go, I got to go. They see that we're helping this person …”

Private Space

Also consistent with the GH model, all of the rooms in GH homes were private, while only 36 percent of those in legacy units were private.

Residential Feel

A lower proportion of GH homes (17 percent) had overhead paging systems installed, compared to the legacies (42 percent), although this difference was not significant. Still, contrary to the GH model, two (17 percent) GH homes did have overhead paging installed, and staff indicated it was used in some circ*mstances. Respondents from GH homes reported other characteristics of the homes provided a ‘homey’ feel, for example: “We have a big table where all the elders can sit. It's not little. It's beautiful. You'd want one in your own home . … Some of the elders and families have brought in trinkets or, you know, furniture that they've donated … And having little things like that really make it homey.”

Open Kitchen

All GH homes included an open kitchen, and 75 percent of these permitted families and elders access. This proportion was significantlyhigher than that reported by legacy homes, where 25 percent of homes allowed families and residents to access the kitchen (p=.03). Despite the ready access in GH homes, respondents reported kitchens were infrequently used by elders, citing reasons such as health or cognitive status (i.e., frail or cognitively impaired residents were unable or unaware), and expectations (i.e., some expected to be “waited on” and/or had no interest inpreparing food). Staff believed that families did sometimes use the kitchens to prepare food for their family member, and noted that planningand organization were important: “If it's for their [elder] and other things aren't being prepared at the same time, that's fine. If it's for other [elders], or if they are in the kitchen while the Shahbazim are cooking foreveryone, we have to plan it out. We need to make sure it's safe for everyone, like with how things are cooked and textures. We have to follow our guidelines.”

Outdoor Space

Protected outdoor space was provided in 75 percent of GH homes and 33 percent of legacy units. In GH homes, outdoors spaces varied considerably in their design, access, and use. Some were large areas with adequate seating and protection from the weather; others contained only small “overhangs” and caregivers worried that residents might get sunburnt or overheated. There was also variation in whether staff could easily observe residents using the outdoor space. In homes where staff noted having clear visibility to outside areas, doors were left unlocked, allowing elders to come and go as they pleased. But, in homes where they could not be easily observed in outside areas, staff were often reluctant to let them go outside unaccompanied. This reluctance limited outside access and staff members explained: “I think they would need help to get in and out, but then we also have to look … at safety and can the person do that independently.” One GH home Guide also noted that the outdoor spaces were not consistently successful saying: “Some houses do great at it. I've got one house that … you go over there, and they're always outside on the porch, whether they're drinking margaritas, whether they're doing exercises, or just sitting there talking. That's an activity. So it's hit and miss.”

Location

The commitment to creating a home‐like environment in a “residential” area led many GH/legacy organizations to build GHs at some distance from the legacy homes. Respondents noted both benefits and limitations of this arrangement. One reported benefit of the residential location was that it created the sense of the GH homes being part of a neighborhood; as one respondent explained: “… they [elders] can sit out there … watching, being on your street and cars and your neighbors are coming home. And they can see the people walking … and oh, there goes the mailman …”

From an organizational perspective, the distance contributed to some GHs describing support services and oversight processes as inconsistent and insufficient, however. One administrator indicated: “The support was not as strong as we'd like to it have been. The support staff does not go down to the [GHs] as much as we'd like.” At some sites, where administrators sought to increase the integration between GH and legacy homes, there too were challenges, as it led to decreased autonomy of GH homes and was perceived by some staff as inconsistent with the intended autonomy of the GH model and its staff.

Resident Control

Residents in GH homes had significantly more choice in awakening (67 percent vs. 8 percent) and bed (83 percent vs. 8 percent) times than did those in legacies (p=.016 and .004, respectively); GH homes also allowed more choice around bath times than legacies (33 percent vs. 8 percent), but this difference was not significant. All four GHs with constraints on awakening times also constrained choice of bath times, and two GHs placed constraints on awakening, bath, and bed times. These two homes reported that elders must choose awakening, bath, and bed times within “a predefined window of time.”

Staff who had worked in both the GH and legacy home reported that they found it challenging to make the shift from accustomed routines in the legacy home to unconstrained resident choice: “One [caregiver] came to me the other day and she's been in the Green House 3years. She said, ‘It's like it is in the legacy, when that [resident] leaves, whoever comes in their spot gets the bath, right? I said ‘No way! He doesn't have to take the dead man's bath.’ That's not the way it works. I said, ‘When does he want his bath?’ and she said, ‘Well I don't know, I haven't asked him.’ And I told her that's the first problem. ‘You ask him what he wants and you all figure out how to accommodate him.’”

In some GH homes, therapy staff were challenged to support elder choice. Although therapists regarded GH homes positively overall, having to schedule around elder preferences led to time lost while waiting for them to awaken, or making multiple trips to determine the preferred time: “Therapy has a schedule they need to go by to be productive, and therapy is very important. And they have to walk [to the GH]. But we have taught the Shahbaz and the nurses very well that [the elders] have the right to sleep when they want to and go to bed when they want to and do what they want to…. We've had to educate the therapists on the philosophy of the Green House and to say you need to call the Shahbaz and work with them about when might be good time to do therapy and then fix your schedule accordingly.” Some, but not all, homes were able to successfully resolve this challenge.

GH homes reported that elders had complete choice and privacy in 70 percent of the areas measured by the POLIF (data not shown). Areas where they most often had choice were in having their own furniture in the room, moving furniture around the room, skipping breakfast to sleep late, and having a glass of wine or beer with meals (92 percent of GH homes reported that elders were either encouraged or allowed to do these things). They were less often allowed to choose to have a hot plate or coffee maker in their room; 83 percent of homes stated these practices were prohibited, and the other 17 percent reported they were discouraged. Similarly, the majority (83 percent) of homes reported that residents were not allowed to lock their bedroom doors, and in fact, all stated that the doors were not equipped with locks.

Elder Decision Making

Nearly all of the GH homes (92 percent) had standing resident council meetings (data not shown). Despite these forums, GH elders made decisions independently or with staff input in only 24 percent of the 15 policy areas assessed on the POLIF. The two decisions elders made independently in the majority of homes were those related to visiting hours for families and friends and whether pets were allowed in the home (8 [67 percent] of homes reported elders made these decisions). The remaining and majority of policy decisions were made either by staff or by staff with input from elders; decisions in which elders were least involved were about new elders being admitted (11 [92 percent] of homes said staff made these decisions without input) and changes in staff (100 percent of homes excluded elders from these decisions).

Engagement

GH homes were significantly less likely than legacy homes to have prescheduled daily activities (33 percent vs. 100 percent; p=.008), relying instead on spontaneous, naturally occurring activities. One caregiver's description was indicative of the unstructured, elder‐directed life of many GH homes saying: “They get to dictate what they want to do, so sometimes we'll have three people playing cards, and somebody else wanted to go take a nap. Or we'll have a craft. Some of them join in. Some of them don't. Exercises, on some days they feel up to it. Sometimes they don't. So we do try to accommodate them and find what they like to do, is the goal.”

Some elders preferred having a consistent schedule of activities where they could interact with others (e.g., music groups, crafts). A department head from a legacy home said: “The biggest thing that I've heard is that if it's someone who likes lots of activities, [the GH home] isn't usually as, isn't something that they like as well as being in the [legacy] where they have more, you know, big activities….” GH caregivers found it difficult to regularly offer activities or provide meaningful engagement within the house, and identified activities as the first thing to drop when it was a busy day, or when resident acuity was particularly high. Challenges were also identified related to outings, particularly when trying to support choice about whether to participate: “The [legacy] building does more of the outings, because now we have to have two people [Shahbazim] here at all times [to meet staffing requirements for remaining residents]. Obviously, you can't take two people and leave the other eight and take off.”

Half of the GHs used staffing strategies to assist caregivers with activities, such as having a caregiver scheduled exclusively for activities 3days per week, having a dedicated therapy aide from the legacy home visit the GH each day to supervise an activity, and selecting Guides or caregivers who had a background in activity provision.

Self‐Managed Work Teams

All GH homes used self‐managed work teams to assign work responsibilities; none of the legacy homes did so (p=.001). However, there was variation in what tasks were “self‐managed” by the caregivers in the GH homes. For example, while most reported that caregivers created their own schedules and self‐managed absences, in others, the schedules were created or managed by staff in the legacy home. In one organization, the responsibility was spread among several staff described as: “Well, they're [the GH Guides] overseeing the scheduling. We have the schedulers [a designated Shahbaz], but you know, they're not here all the time …” Scheduling was consistently described by Shahbazim as the most undesirable task: “I think it's a scary thing for some people, just because of the, they think, oh, my gosh, I have to fill these holes, and I have to call all these people. Because it's really, it's more time‐consuming probably now than most of the other roles.”

Some GH homes reported hiring caregivers to fill specific roles, such as cooking or organizing activities. Although such a specialized worker is not in accordance with the GH model, one administrative staff explained: “Our satisfaction with our food was not great, because, again, you have 19‐, 20‐year‐old CNAs cooking. Not everybody can cook … . it has actually worked out beautifully. It ensures food preferences were spot on. You know, after 40hours a week cooking for your elders, they get to know exactly what each likes.”

Versatile Universal Workers

In the GH homes, caregivers were responsible for an average of seven noninteractive tasks (e.g., cleaning, cooking meals) and nine interactive tasks (e.g., participating in activities, taking blood pressures), all of which were more prevalent in GH than in legacy homes. Areas of greatest difference included ordering and stocking food and cooking meals (staff in 100 percent of GH homes and 0 percent of legacy homes did these tasks); handling resident laundry (100 percent GH, 8 percent legacy); deep housekeeping (75 percent GH, 0 percent legacy), and planning resident activities (83 percent GH, 8 percent legacy). GH and legacy caregivers had similar responsibilities in areas such as helping residents eat meals and taking resident blood pressures (100 percent in both home types), weighing residents (100 percent GH, 92 percent legacy), serving meals to residents (100 percent GH, 75 percent legacy), and helping residents with exercises (75 percent GH, 67 percent legacy).

There was substantial variation in caregiver responsibilities between GH homes as well. While caregivers in 64 percent of GH homes took elders on trips outside the building, in the other GHs trips were infrequent or were taken only in partnership with the legacy home and its activities staff. One caregiver explained: “You know, with all the house duties, it's [taking resident's on outings] too much.”

Consistent Assignment

Compared to legacy homes, GH homes reported greater consistency in the caregivers assigned to elders each week; GH homes reported that one elder was cared for by an average of 8 (range 6–10) different people across all three shifts in a week compared to 11 (range 6–15) in legacies (p=.011). Caregivers in GH homes felt the consistency in staffing was crucial in creating a team and a home, but also acknowledged the challenges associated with working so closely. As one explained: “… We are a close team. You know, there's only a few of us. There's three on days, three on evenings, and… one and a half at night. So working as a team, when you have a new person come in, the dynamics change. So it's hard for some …”

GH and legacy homes shared administrators and reported having an average of two different administrators within the previous 3years. The number of different administrators varied from one to three; 58 percent reported one, 25 percent two, and 17 percent reported three different administrators during that time period. Similar variation in stability was seen among the directors of nursing; 60 percent of GH/legacy homes had one, 33 percent had two, and one (8 percent) had three directors of nursing over this period. The one GH/legacy home with three different directors of nursing also had two different administrators.

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