Rebooting the nursing home

Laura Voegeli - Wednesday, October 24, 2018


Rebooting the nursing home

A bold idea takes root: What if you built a house where seniors really enjoyed spending time?





PALMYRA, PA—On a rainy January day, Grace Williard, 86, was absorbed in a jigsaw puzzle in the living room. A fire glowed in the hearth, and three of her housemates dozed in comfy chairs. In the open kitchen, chicken was baking, and noodles and succotash simmered on the stove. The doorbell rang, announcing the arrival of family visitors.

Welcome to the Green House, a reimagined nursing home near Hershey, Pennsylvania. Williard and her nine elderly housemates are beneficiaries of a growing movement to transform nursing homes from medicalized institutions to places that feel much more like home.

“It’s very nice,” says Williard, who has lived there for four years. “I like the ladies. We can go anytime and talk to them. They’re very kind.”

The “ladies” are known as shahbazim (plural of shahbaz), who combine the skills of certified nursing assistants and homemakers. (Shahbaz, meaning “royal falcon” in Persian, is a term that Green House founder Bill Thomas coined to elevate the position.) Working two per shift (one at night), they run the household on behalf of the elders, as Green House residents are called. Nurses, therapists and physicians come as needed.

Another satisfied resident is Roy Keller, 84, a portly man who tools around on a motorized scooter. Keller worked 42 years at the nearby Hershey chocolate plant, first making candy before rising to manager. “If you want the best of life, come to a Green House,” says Keller. “They treat you the very best. It’s your choice when to get up. They ask you what do you want to wear. I say, ‘What do you want to see me in?’” He was bundled up in a warm hat and sweatshirt, a small oxygen tank propped on the back of the scooter. He was going over to the “Big House,” as he calls the main building on the campus of the Lebanon Valley Brethren Home, which runs the Green House. There, he would greet friends and drop by the gift shop to replenish his stash of snacks.

“We try to encourage healthy eating,” says Jeff Shireman, Lebanon Valley president, who led the Green House effort there. “But they know their residents’ rights, and they can choose what they want.”

survey found that just 4 percent of respondents would choose a nursing home if they were old and needed long-term help.


The Green House Project, by setting a high bar, seeks to change that view. The most obvious difference is the building. All Green House residents have private bedrooms with bath. (Lebanon Valley also has a few adjoining bedrooms for couples.) They eat together family style, across from the open kitchen. Comfortable chairs, family photos, a fireplace and a den for family gatherings or movie-watching are standard features. So, too, is access to a spacious (and secure) patio which residents freely use.

With major support from the Robert Wood Johnson Foundation, the Green House Project has helped providers open 211homes in 30 states in a decade. That number will grow to 300 by the end of 2018, according to Susan Ryan, a registered nurse and senior director of the Green House Project. “It’s starting to catch on,” she says. “While it’s still predominantly the not-for-profit provider that is adopting the model, we are starting to see the for-profit segment increase.” Seventy percent of nursing homes are for-profit.

Studies have found that Green House elders have physical and cognitive problems similar to those of other nursing home residents, yet they enjoy a higher quality of life, as measured by things like privacy, dignity, meaningful activity and relationships. They maintain their physical abilities longer and have lower levels of depression. Similarly, staff and family satisfaction are higher. A 2012 online survey of 1,065 adults caring for an elderly family member or friend found that 97 percent viewed the model favorably, with majorities thinking that it was better than home care or other residential options. Sixty percent were willing to pay more for their loved one to live in a Green House.

In addition, “The docs are big fans,” says Shireman. “They get quicker and better information from the shahbazim.” That can mean fewer costly hospital admissions and emergency room visits.

Lebanon Valley was an early adopter, opening its first Green Houses in 2007. A longtime nursing-home administrator, Shireman was drawn to the model in part because of his father’s experience in a top-rated traditional nursing home. “The care was so institutional,” he recalls. “He had no outdoor access. He was bored out of his mind.” Unable to speak due to aphasia, his father was labeled with dementia, seen as a troublemaker and drugged to keep him calm.

50 percent nationally for certified nursing assistants in nursing homes, runs 8 percent to 10 percent in Lebanon Valley’s Green Houses. Green House revenues are also higher, with full occupancy.


Lebanon Valley charges the same for the Green House as for private rooms in the traditional nursing home—$389 a day, higher than the median of $320 in Pennsylvania but “competitive with the higher-quality nursing facilities in our market area,” says Shireman. For those without funds, Lebanon Valley accepts the daily Medicaid rate of $200 to $210, and no one is ever asked to leave because of money. (Many Americans without deep pockets wind up in nursing homes because Medicaid will pay only for skilled nursing care, rather than assisted living or home care, although this is changing in some states.)

Nationally, the Green House Project finds that the closer providers hew to the model, the more affordably they can operate. This means empowering the shahbazim to run the houses, thus reducing the costs of nurse managers and activities, housekeeping and dietary staff. In addition to being experienced nursing assistants, the shahbazim receive three weeks of extra training, including one week of culinary. At Lebanon Valley, they are paid $1.50 an hour more for their additional responsibilities.

“What you must do as a leader is to support [the shahbazim] and empower them and hold them accountable,” says the Green House Project’s Ryan. “That is where you’ll see the efficiency.”

The shahbazim are important in other ways. Having them cook on site—rather than trundle food over from a central kitchen to be warmed in steam tables—is key. “We have found immeasurable benefits with the elders smelling and seeing the food being cooked,” says Shireman. “If you smell bread in the oven, you know it’s time to chow down,” he says. Unwanted weight loss, common in nursing homes, is greatly reduced.


Jeff Shireman, President of the Lebanon Valley Brethren Home (right) talks with a visitor in the living room of a Green House. Every Green House has a hearth, family-style dining, an open kitchen—and no nurse’s station or other institutional trappings. | Scott Goldsmith for Politico

Activities unfold naturally. “You never bat around balloons in your living room or play bingo with 15 people,” says Shireman, referring to common nursing home practices. Instead, an “activity” might be breakfast on the patio, with a shahbaz reading aloud the morning paper and discussing the advice in “Dear Abby.” Elders may help fold warm laundry, prepare food or Skype a relative.

Edna Hess, a veteran nursing assistant who is now a shahbaz, thought Shireman had lost his mind when he explained the Green House model. But once the training began, she was hooked. After nine years, she says she would never want to go back. In 2008, Hess testified about the Green House before the U.S. Senate Special Committee on Aging, along with Thomas. She is proud of a photograph of the event displayed in the Green House living room.

“In a traditional nursing home, everything is scheduled,” she says. She used to roust people out of bed at 5:30 a.m. to be ready for the breakfast trays. “Now it’s always breakfast time,” she says. A shahbaz will scramble eggs at 3 a.m. if that suits an elder.

“You get to know the person, their personalities, their families,” she says. “It’s totally different. People probably think we’re nuts, but it really does feel like home.”

Daryl Rice of Little Rock, Arkansas, who was visiting his mother, agrees.
“We’ve gotten to know the shahbaz,” he says. “They sort of become like family.”

Having his mother lose her independence after a massive stroke was hard, he says. “But this has helped. If I had to leave her in a traditional nursing home, I’d feel a lot worse.” Rice and his wife and sister make themselves at home. After sitting with his mother at lunch, they pitch in and do the dishes.

“If I had my druthers, I would have built an addition on my house and paid for full-time care,” says Rice. On further reflection, however, he wonders whether his mother is better off in a Green House. At his house, “she would have only had me and my wife,” he says. “Here she has friends.”

15,600 nursing homes in the U.S.—1,400 more than the number of McDonald’s. Thousands of facilities are owned by for-profit corporations, such as Genesis HealthCare and HCR ManorCare, whose headquarters are far removed from those who live and work in nursing homes.


“[Change] will require that the corporation—or whoever the owners are—are committed to building and operating these new models,” says Cathy Lieblich, director of network relations for the Pioneer Network, which has been working to transform nursing homes for 20 years. “Because if it doesn’t come from the top, it’s not going to happen.”

Lieblich says that the early adopters of models like the Green House did so because they “thought it was the right thing to do. But that’s not going to make for broad-scale change.” Strong incentives need to be in place to push transformation, she says, such as regulations requiring small homes and organizational change, extra payment, a strong business case and consumer demand.

In the meantime, says Ryan, the foundation has been laid. “This is a model that has the staying power to go into the future,” she says. “I think about the boomers and where all of us will be. Is this a model I could live in? Absolutely.”

Beth Baker is a freelance journalist who covers aging. Her most recent book is With a Little Help from our Friends: Creating Community as We Grow Older(Vanderbilt University Press, 2014).

200 SW 14th Street, Newton, Kansas 67114 | (316)283-4770 | Copyright 2014

200 SW 14th Street, Newton, Kansas 67114

(316)283-4770 | Copyright 2016