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The Green House Model and Outcomes
Individualized Care is Better Care
Nursing Home History

• 1965 - Passage of Medicare/Medicaid
– Offered a Nursing Facility Benefit
– Began the rise of “Conv...
OBRA 87 requires
each nursing home to
provide care and services to:
attain or maintain
the highest practicable
physical, m...
Highest Practicable =
No “avoidable” decline

Unavoidable =
natural progression of a
resident’s disease or condition

© B ...
Health Promotion

Institutional
Care

Highest
PracticableWell
-being

Individualized
Care

Iatrogenesis

Risk Prevention

...
A Broken System
“So many of the systems in traditional settings
foster dependence. The systems make people
shut down and f...
Green House Transformation
• Shift within current nursing home
regulatory and organizational
structures
• Transformation:
...
Real Home

8
Real Home
• Warm, Smart and Green
• Similar to surrounding community
• Private rooms and baths
• Residential Finishes
• In...
Real Home
•

Home to10 – 12 elders –

•

Small scale, intimate spaces

•

Internally organized for public
to private progr...
Key Elements: Hearth

Open plan Living, Dining, & Kitchen
Kitchen
• Open access to elders

except at busiest times
• Elders can prepare
food with supervision
• Built-in safety feat...
Private Bedrooms
• Elders encouraged
to bring own furniture
• Provide a sanctuary

Bedroom: 210 NSF
Private Baths
In-Room Medication Cabinets
• Key locked

• Key with nurse
• Refrigerated meds

and narcotics
locked in office
• All meds ...
Easy Access to Outdoors
Overhead Lifts

• No manual-lift
environment
• Creates safer work
environment
Office
• Qualifies as nurses’

station
• Paper and electronic
charting location
• Open to elders and
family
Life & Fire Safety
Meets institutional life safety
standard, including:
– Automatic Sprinkler
System
– Emergency Lighting
...
Urban Green House
Typical Residential Floor Plan
Porter Hill’s Green House home, Grand Rapids, MI
Urban Green House
Typical Residential Floor Plan
Living Room
“I want to go home.”
“Often when a resident says - “I want to go
home” - they are not necessarily referring to
the house t...
Empowered Staff

26
CNA Participation - Evidence
• Satisfaction with involvement in decision
making and professional growth =
Greater intent t...
The Hierarchy Structure
Administrator

Director of Nursing

Dietary Supervisor

ADON

Cooks

RN Supervisors

Dishwasher

L...
Organizational Redesign

29
Organizational Redesign
• Elder at the heart of the
organizational chart
• Shahbazim – versatile worker
– Prepare meals, h...
Training: Shahbaz
• CNA – required as a foundation
• 128 Hours additional training:
–
–
–
–

Safe food handling
CPR / Firs...
Nurses in The Green House Homes
• Care Role Model
• Gerontological Expert
• Care Partner
• Mentor and Teacher
Role of Nursing/Clinical Care
“…if anything, the nursing care is better [in
a Green House home] than in a
conventional nur...
Direct Care Staffing – 10 Room Green House
• Shahbazim
– 2 Shahbazim – am shift
– 2 Shahbazim – pm shift
– 1 Shahbaz - nig...
Work Flow Study
Further Benefits:
Transport: .77 hours less transportation
time per elder
per day in GH homes
Waiting for ...
Self-Managed Work Team
• Group of Shahbazim who
are responsible and trusted
to manage the Green
House home
• Work collabor...
Meaningful Life
Living, Growing, Thriving
• Structure decision-making
with elders
• Facilitate deep knowing
• Support a life worth living:...
Meaningful Life
• Resident participation and input in all aspects of care

• No Schedules – Breakfast cooked to order and ...
Satisfaction & Clinical Research
Kane: JAGS 2007 – Satisfaction and Clinical
• Significant improvements in satisfaction
• ...
NIC Article - Financial Benefits
• Occupancy increases:
• GH homes average 96%
• National average 85% and falling
• Privat...
Case Study – Re-Position and Gain Market Share
Before • 120 bed SNF, 60 semi-private rooms
After • 3 Green House homes of ...
Consumer Research
Edge Research 2012 – Caregivers
•
•
•
•
•
•

97% say GH model addresses their greatest concerns about NH...
5-Star Nursing Home Rating System

83% of Green House
Homes are 4 or 5
Stars compared to
42% of nursing homes
nationwide!
Short-Term Rehab in GH Homes
A real home is the best place to recover and get back
home:
• Home layout
• Medication manage...
Other Innovations
• Repositioning CCRC

• Assisted Living
• Dementia Care

• PACE

46
Spread
Operating
• 150 homes
• On 35 campuses
• In 24 states
In Development
• 120 homes
• On 19 campuses
• In 9 additional...
Barriers to Faster Replication
• Regulations – our surveyors won’t allow it

• Economics – operating costs, access to
capi...
Green House Technical Assistance
•
•
•
•
•
•
•
•
•
•
•

Project management
Financial feasibility
Design
Regulatory navigat...
Financing Your Green House Project
NCB Capital Impact
• AARP PRI
• RWJF PRI
• New market tax credits
• Weinberg Foundation...
The Green House Model Differentiation
Brand
• Reputation
• Research
• Consumer Demand

Education & Training
• Tools
• Reso...
Contact Information

David Farrell, MSW, LNHA
Senior Director
The Green House Project
510-725-7409
Upcoming SlideShare
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ATX14 - “Bringing a 'GREEN HOUSE HOME' to your Texas Community”

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  • Radical Transformation: More than physical change (only 1/3 or less)– organization and philosophyThe whole is greater than the sum of its parts – we must change the way we think about the paradigm of aging to change the way we act– this creates DEEP, slip resistant changeAccessible to all people: fits within current regulatory/reimbursement structureImplementing the full Green House model has proven to create positive outcomes in a variety of settings– rural, urban, suburban, veteran– doesn’t have to be perfect to be good
  • Through supportive consultation of design process, The Green House team ensures that the home is built to be warm, smart and green. All people deserve meaningful lives in real homesMeaningful lives require control, being known, and reciprocal relationshipsControl requires that decisions are placed with the elders and the staff who know them best Supporting choices requires very flexible operations that can respond to individual preferences Becoming known requires clear strategies for intentionalcommunityReciprocal relationships require deep relationshipsRight to live as a valued member of the community regardless of care needs change– acuity/ability to pay
  • Deep Culture ChangeHierarchy Flattened Elders Rule!!Over 200 hours of education equip team members with skills to communicate, coach and create sustainable systems for changeShahbazim work in a Self-Managed Work TeamGroup of CNAs who are empowered, responsible and trusted to manage The Green House homeWork collaboratively with leaders and members of the clinical support team
  • Elder’s Rule, and are at the center of the organizational chartLeadership changes from a telling approach to a coaching approach– balance support and accountabilityPartnership of clinical professionals with the deep knowing of the versatile worker
  • Essential practices to ensure that this value is being lived. Look different, but we feel are the building blocks to meaningful life.
  • Transcript of "ATX14 - “Bringing a 'GREEN HOUSE HOME' to your Texas Community”"

    1. 1. The Green House Model and Outcomes Individualized Care is Better Care
    2. 2. Nursing Home History • 1965 - Passage of Medicare/Medicaid – Offered a Nursing Facility Benefit – Began the rise of “Convalescent Hospitals” – “Convalescent Hospitals” designed like hospitals • Quality of Life concerns – 1960’s - “depersonalization” of nursing home life – 1970’s - “custodial care” – 1980’s - “psychic despair” – 1990’s - “loneliness, helplessness and boredom” Frank, B. 2004
    3. 3. OBRA 87 requires each nursing home to provide care and services to: attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident © B & F Consulting, Inc. 2012 www.BandFConsultingInc.com
    4. 4. Highest Practicable = No “avoidable” decline Unavoidable = natural progression of a resident’s disease or condition © B & F Consulting, Inc. 2012 www.BandFConsultingInc.com
    5. 5. Health Promotion Institutional Care Highest PracticableWell -being Individualized Care Iatrogenesis Risk Prevention © B & F Consulting, Inc. 2012 www.BandFConsultingInc.com
    6. 6. A Broken System “So many of the systems in traditional settings foster dependence. The systems make people shut down and feel incapable. A normalized environment can liberate them.” Dr. Al Powers
    7. 7. Green House Transformation • Shift within current nursing home regulatory and organizational structures • Transformation: • Physical Design: Real Home • Organizational Redesign: Empowered Staff • Philosophy: Meaningful Life 7
    8. 8. Real Home 8
    9. 9. Real Home • Warm, Smart and Green • Similar to surrounding community • Private rooms and baths • Residential Finishes • Intentional Community 9
    10. 10. Real Home • Home to10 – 12 elders – • Small scale, intimate spaces • Internally organized for public to private progression • Good sight lines • Lots of natural light • Exterior space immediately accessible
    11. 11. Key Elements: Hearth Open plan Living, Dining, & Kitchen
    12. 12. Kitchen • Open access to elders except at busiest times • Elders can prepare food with supervision • Built-in safety features allow open kitchen to be part of elder’s life
    13. 13. Private Bedrooms • Elders encouraged to bring own furniture • Provide a sanctuary Bedroom: 210 NSF
    14. 14. Private Baths
    15. 15. In-Room Medication Cabinets • Key locked • Key with nurse • Refrigerated meds and narcotics locked in office • All meds prepared in room
    16. 16. Easy Access to Outdoors
    17. 17. Overhead Lifts • No manual-lift environment • Creates safer work environment
    18. 18. Office • Qualifies as nurses’ station • Paper and electronic charting location • Open to elders and family
    19. 19. Life & Fire Safety Meets institutional life safety standard, including: – Automatic Sprinkler System – Emergency Lighting – Exit doors/smoke compartments – Comprehensive staff training – Generator – Emergency egress door lock releases
    20. 20. Urban Green House
    21. 21. Typical Residential Floor Plan Porter Hill’s Green House home, Grand Rapids, MI
    22. 22. Urban Green House
    23. 23. Typical Residential Floor Plan
    24. 24. Living Room
    25. 25. “I want to go home.” “Often when a resident says - “I want to go home” - they are not necessarily referring to the house they came from, but rather to a state of being that was comfortable, ordered, and fundamentally orienting.” Caulkins, M. 2003
    26. 26. Empowered Staff 26
    27. 27. CNA Participation - Evidence • Satisfaction with involvement in decision making and professional growth = Greater intent to stay • Involvement in decision making and care planning = Decreased turnover • Influence on resident care decisions = Increased social engagement • High morale, teamwork = Parsons et al., 2003 Leon et al., 2001 Barry et al., 2005 Commitment, higher resident satisfaction Sikorska-Simmons, 2005 and 2006
    28. 28. The Hierarchy Structure Administrator Director of Nursing Dietary Supervisor ADON Cooks RN Supervisors Dishwasher LPN’s C.N.A.’s Diet Techs Environmental Supervisor Housekeeping Supervisor Housekeepers
    29. 29. Organizational Redesign 29
    30. 30. Organizational Redesign • Elder at the heart of the organizational chart • Shahbazim – versatile worker – Prepare meals, housekeeping, laundry • Additional education hours = 128 • Redefines roles and responsibilities of the direct care worker, nurses and the clinical support team
    31. 31. Training: Shahbaz • CNA – required as a foundation • 128 Hours additional training: – – – – Safe food handling CPR / First Aid Culinary skills Home maintenance/ management skills – 48 hours Green House Training:  Dementia care  Critical Thinking for Clinical Excellence  Communication  Teamwork skills  Policies & Procedures
    32. 32. Nurses in The Green House Homes • Care Role Model • Gerontological Expert • Care Partner • Mentor and Teacher
    33. 33. Role of Nursing/Clinical Care “…if anything, the nursing care is better [in a Green House home] than in a conventional nursing facility. Things don't get overlooked at a Green House, as they might be in a nursing home, where caregivers don't work so closely with each other. If an elder stumbles at a Green House, every caregiver knows it and starts watching that person’" (Barbara Bowers, Associate Dean for Research, School for Nursing, University of Wisconsin, Dallas Morning News, 2/3/09).
    34. 34. Direct Care Staffing – 10 Room Green House • Shahbazim – 2 Shahbazim – am shift – 2 Shahbazim – pm shift – 1 Shahbaz - night shift – Total = 4.0 HPPD • Universal worker role • Nurses – One Nurse per two houses am shift – One Nurse per two - three houses pm shift and night shift – Total: .80 – 1.0 HPPD 34
    35. 35. Work Flow Study Further Benefits: Transport: .77 hours less transportation time per elder per day in GH homes Waiting for Meals: 1.1 hours less waiting time for meals per elder per day in GH homes & more interaction in GH homes while waiting Breakfast Flexibility: 1.3 hours longer breakfast period in GH homes (1 hour vs. 2.3 hours) Direct Engagement: Over 4 times as much direct engagement in GH homes vs.. traditional per elder per day (23.5 mins. vs. 5.2 mins.)
    36. 36. Self-Managed Work Team • Group of Shahbazim who are responsible and trusted to manage the Green House home • Work collaboratively with leaders and members of the clinical support team
    37. 37. Meaningful Life
    38. 38. Living, Growing, Thriving • Structure decision-making with elders • Facilitate deep knowing • Support a life worth living: engagement, enjoyment, pur pose
    39. 39. Meaningful Life • Resident participation and input in all aspects of care • No Schedules – Breakfast cooked to order and served all morning – Residents wake up as they please – No classic across-the-board staffing pattern
    40. 40. Satisfaction & Clinical Research Kane: JAGS 2007 – Satisfaction and Clinical • Significant improvements in satisfaction • Better clinical outcomes Sharkey: JAGS 2011 – Staff Time and Clinical • Acuity the same between settings • Fewer total hours in GH homes • Better clinical outcomes • 4 times more engagement between staff and elders Grabowsky: Working Paper – Medicare and Medicaid • Slower late loss ADLs • Lower rehospitalization rate Bowers: Working Paper – Nursing Quality • Seamless communications and deep relationships • Nursing care as good or better than traditional
    41. 41. NIC Article - Financial Benefits • Occupancy increases: • GH homes average 96% • National average 85% and falling • Private pay occupancy increases: • GH homes increased private pay days by 24% • Nationally, NHs lost 8% private pay days in same period • Private pay rates increase with private rooms • Short-term Medicare, HMO occupancy increases with all private rooms 41
    42. 42. Case Study – Re-Position and Gain Market Share Before • 120 bed SNF, 60 semi-private rooms After • 3 Green House homes of 12 people • Move 36 residents to Green Houses • Convert 36 rooms to private in current SNF • Total 72 private rooms and 24 semiprivate rooms • Less congestion in older SNF • Re-purpose space 42
    43. 43. Consumer Research Edge Research 2012 – Caregivers • • • • • • 97% say GH model addresses their greatest concerns about NHs 90% think it is important or very important for providers to build more GHs in their community 68% of caregivers believed GH better for relative than being cared for at home 73% would drive 15-60+ miles to receive GH services 60% would pay 5% - 25%+ more
    44. 44. 5-Star Nursing Home Rating System 83% of Green House Homes are 4 or 5 Stars compared to 42% of nursing homes nationwide!
    45. 45. Short-Term Rehab in GH Homes A real home is the best place to recover and get back home: • Home layout • Medication management • Private rooms with private bathrooms • Home cooked meals • Access to fresh air and sunlight • Rehab in a real home • Lower ratios and consistent assignment Leonard Florence Center for Living • Length of stay – 19.2 days • Re-hospitalization rate – 9.6%
    46. 46. Other Innovations • Repositioning CCRC • Assisted Living • Dementia Care • PACE 46
    47. 47. Spread Operating • 150 homes • On 35 campuses • In 24 states In Development • 120 homes • On 19 campuses • In 9 additional states 47
    48. 48. Barriers to Faster Replication • Regulations – our surveyors won’t allow it • Economics – operating costs, access to capital, covering the debt • Model is too prescriptive – too many specific requirements 48
    49. 49. Green House Technical Assistance • • • • • • • • • • • Project management Financial feasibility Design Regulatory navigation Fundraising and financing Pre-development loans Operational planning Staff education Leadership development PR and marketing Legacy Blueprint 49
    50. 50. Financing Your Green House Project NCB Capital Impact • AARP PRI • RWJF PRI • New market tax credits • Weinberg Foundation capital grants • Pre-development loans • Construction loans • Gap financing 50
    51. 51. The Green House Model Differentiation Brand • Reputation • Research • Consumer Demand Education & Training • Tools • Resources Project Management / Consultation • Regulatory • Architecture & Design • Leadership / Team Development Peer Network • Peer to Peer connections • Monthly webinars / ongoing support • Annual Conference
    52. 52. Contact Information David Farrell, MSW, LNHA Senior Director The Green House Project 510-725-7409
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