A few weeks ago, I had the privilege of being invited by NCB Capital Impact to learn more about The Green House Project, which is led by Robert Jenkens, and to celebrate the opening of the 100th Green House home in West Orange, New Jersey. The Green House home is an alternative model to the traditional nursing home and is designed to transform the way skilled nursing care is currently delivered. It is differentiated by the interior design, the staffing pattern, and the philosophy of delivering skilled care, all of which are designed with individualized and personal care for elders in mind.
When I first saw the Green House from the street, I thought it looked like a typical home. A Green House is designed to blend in with the neighborhood and is generally located in clusters. The scale is kept small so it doesn’t overwhelm the individual. In general, each Green House accommodates six to twelve people, each of whom has a diverse set of needs and may require a different level of care.
Inside the home, the first things I noticed were the smooth lines and open spaces, the abundance of light flowing in and out, and easy access to the garden areas and outdoor space; the environment is free of the traditional institutional trappings. There are a number of special features, including an open kitchen, a dining area, and a shared living room at the center of every home. Because the homes are small, they allow people to get around without wheelchairs. Each person has a private bedroom and a private bathroom.
As I learned, the organizational structure of the Green House follows a circular model with the residents at the center, surrounded by the people who provide the daily care and who, in turn, partner with the clinical support team and the leadership of the organization.
The homes are staffed by a self-managed team of direct care workers known in Green House parlance as the Shahbazim (singular: Shahbaz). The term, I was told, derives from an ancient Persian word meaning the “King’s Falcons.” As the primary caregivers, the role of the Shahbazim is to nurture, protect, and sustain the residents. According to a study published in the Journal of the American Geriatrics Society, Shahbazim spend on average 24 more minutes each day on direct-care activities than certified nursing assistants in traditional nursing homes. They also spend more time on indirect care activities and direct engagement with residents.
In preparation for their role, the Shahbazim receive special training and education. At the core of that training is the program developed by the Paraprofessional Healthcare Institute (“PHI”), a Hartford grantee, called the Coaching Approach. In fact, early on in the development of the Green House model, PHI was enlisted to embed the Coaching Approach in the educational offerings for all Green House staff—including the formal leadership team, nurses, and the Shahbazim. This program builds five essential skills: active listening; self-reflection/self-management; clear communication without blame or judgment; collaborative problem solving, and participative leadership.
The Shahbazim provide basic services within the home, such as cooking, housekeeping, and laundry; they are the homemakers and managers of the household. They create a flexible daily routine in order to meet the needs and preferences of individual residents. Unlike the traditional nursing home, there is no predetermined schedule of events. Rather, the focus is on individual preferences and natural rhythms. Residents are free to pursue their interests and activities, and schedule the day as they see fit. As a result, the relationship between direct care workers and the residents can be deeper and more involved.
Nursing services are of course provided as in other nursing homes. However, there are no nursing stations. Instead, the nurses use a small area to do their work. This set-up encourages mingling and interaction with the residents. Nurses serve each home on a 24-hour basis, with one nurse typically covering two homes during the day and evening and up to three homes at night.
All this has helped to create an environment that’s inviting for the residents and supportive and respectful of the people who work there. Anecdotally, turnover rates are very low in comparison with the traditional nursing home. (For more on the financial implications of the model, click here.) Geriatrician Dr. William Thomas created the concept of the Green House, which was supported early on by the Robert Wood Johnson Foundation. The vision came to Dr. Thomas on a tour, where he saw that the country’s nursing home buildings were “aging faster than the people living inside them.” This led him to re-envision the approach to long term care. As Dr. Thomas put it, “The Green House makes the elders the stars of the show. The doctors and nurses are backstage where they ought to be.”
The growth of the Green House model has been phenomenal. In 2003, the first four Green House homes opened. In early 2008, there were 41 Green House homes operating in 10 states. Currently, hundreds of Green House homes are planned to open or are under construction in rural, suburban, and urban areas across the country, including one in my very own neighborhood. I look forward to watching the continued expansion of Green House homes.
Dan Timmel: "This is what people should have for long-term care" from The Green House Project on Vimeo.