hill country observerThe independent newspaper of eastern New York, southwestern Vermont and the Berkshires


News February-March 2016


A nursing home revolution

Village of elders pioneers a new model of care


Contributing writer



Administrator James Farnan shares a laugh with one of the residents of Eddy Village Green, a facility built a decade ago to replace an older nursing home in Cohoes. The complex is the first in the region designed to meet the standards of the Green House movement, a radical rethinking of elder care.Scott Langley photo

When senior managers at The Eddy were trying to make decisions more than a decade ago about renovating or replacing the nonprofit organization’s large nursing home and rehabilitation center, its new long-term-care administrator, James Farnan, posed a strategic question.

Farnan asked whether his colleagues would want to live in the new or renovated facility they were planning. Their answers became the catalyst for a radical rethinking of their mission.
“I started asking this after a tour I did with a board member,” Farnan recalled. “He asked me how much it cost to live in the nursing home, and when I told him, the response was simply, ‘For this?’ This made me start to question whether we were doing right by the people we cared for.”

Farnan’s seemingly simple question cut to the heart of the choices faced by the Eddy and many other organizations that in recent years have faced the task of modernizing or replacing a generation of nursing homes built in the 1960s and ‘70s.

But what’s at stake goes much deeper than simply choosing a renovation plan. Is it enough to care for the physical needs of old people? Or do they deserve to have autonomy, purpose and quality human relationships in the waning years of their lives?

Are large institutions, whose employees spend their shifts scrambling to complete required tasks, the best places for old people who need nursing care? Or would elders do better in small, home-like settings where their individuality is better respected?

As the Eddy managers continued their internal conversation about what they wanted to achieve in the future and how they would accomplish it, they found out about an innovative approach to skilled nursing care called the Green House Project. This movement, launched more than a decade ago by a doctor from central New York, rests on three core values for elder care: a meaningful life, a real home and an empowered staff.

“When we found the Green House model, it aligned with what we were trying to do,” explained Farnan, who became the first and only administrator of Eddy Village Green, the complex that replaced the Eddy Ford nursing home and the Eddy Cohoes rehabilitation hospital.

The Village Green became the first Green House project in the state – and it remains the only facility of its kind in eastern New York, Vermont or western Massachusetts.


Changing the paradigm
The Eddy began opening new freestanding Green House homes on its campus in 2008. By 2011, it had completed its transition into 16 new single-level houses in place of the hulking institutional buildings of the past. Eddy Village Green is now the largest Green House project in the nation.

In this intentional village, each of the single-level houses functions as a “home for life” for 12 elderly people. The central architectural focus of each house is the dining room and living room, common spaces where people congregate. Twelve private bedrooms, each with a shower, radiate out from the common space. Adjoining the dining room is a large open kitchen where all meals are prepared.

In contrast to the traditional nursing home, where every wing is dominated by the nurses’ workstation, these houses don’t feel like medical institutions.

In his previous role as an administrator in a standard nursing-home setting, Farnan said he received many complaints about roommates or roommates’ families, because most residents had to share what the industry calls “semi-private” rooms. The Eddy’s new houses do away with that source of stress. And with rooms of their own, elders are more able to keep familiar furnishings from their previous homes.

In another departure from the industry norm, the Green House movement relies on an empowered work force and a democratic workplace organization. Direct-care workers, who are certified nursing assistants with additional training, plan their own workdays. As a team, they coordinate all aspects of the management of their house.

The staff team in each house is responsible for functions ranging from laundry and cooking to budgeting, staff scheduling and enrichment activities.

“We have flattened the workplace hierarchy, so everyone has a voice and a role in making each home function well,” explained Susan Ryan, a registered nurse who is director of the national Green House Project organization.

Eddy Village Green’s nursing director, Diana Lloyd, said she has seen for herself how this new organizational structure allows staff to flourish.

“You can tell,” she said. “Their caring comes out.”


Alternative vision
The Green House movement is the brainchild of William H. Thomas, a doctor who began to rethink the prevailing elder-care model more than 25 years ago when he was serving as the part-time medical director of a rural nursing home in the central New York of New Berlin. He has since written several books on elder care and formally organized the Green House Project in 2003.

Thomas, who has described himself as a “nursing home abolitionist,” was propelled onto his path as a reformer in New Berlin when a woman he was treating for a rash confided that she was very lonely. Realizing that medicine alone couldn’t help her, he began to consider how to counter what he described as the three plagues affecting nursing-home residents: loneliness, helplessness and boredom.

To enliven the institution where he worked, he convinced administrators and regulators to let him try integrating birds and other companion animals, gardens and even children into the facility’s daily routine. These efforts appeared to have significant benefits for the home’s residents.

Building on that success, in the early 1990s Thomas and his wife began organizing the Eden Alternative, an international movement to implement their program for fostering social wellbeing by deinstitutionalizing nursing homes.

As he toured the country to promote this effort, Thomas began to realize that the aging of many nursing homes’ physical structures offered an opportunity to rebuild or replace these institutions with something different.

The Green House model is the result of his effort to radically re-envision the care environment for elders. The first Green House project opened in 2003 in Tupelo, Miss. Two years later, the Robert Wood Johnson Foundation funded a major initiative to establish Green House projects in all 50 states.

Today, there are 185 Green House projects operating in 28 states, and another 185 are under development.

The Green House model is defined by 25 quality standards that cover such issues as in-home meal preparation, architectural review, self-managed work teams and a prohibition on the use of physical restraints.

Thomas trademarked his model, in an effort to protect it from being diluted, and individual Green House projects around the country pay a licensing fee for use of the trademark. The homes’ yearly dues give them membership in a network of their peers and access to a range of support services. Each Green House project also does annual self-assessments to monitor its fidelity to the model.


Workplace teams
In conceiving the Green House model, Thomas set out to elevate the position of direct-care workers and organize them as self-managed teams. Instead of calling them aides, a job classification that doesn’t accurately reflect the importance of their work, he borrowed the Persian word “shahbaz.” The shahbaz, literally a royal falcon who oversees the kingdom, functions as a leader as well as a servant.

Anyone who works in a Green House home in any capacity must first complete a five- or six-day course called the core training. The class orients people to the model and their roles within it and also fosters self-awareness and interpersonal skills. Participants learn how to draw on their individual strengths and styles to work collaboratively toward their shared goal of caring for the elderly people who live in the homes.

The training provides the basis for democratic decision-making as well as for forging strong relationships with the elders.

In many standard nursing-home settings, direct-care workers are discouraged from forming too much of a personal bond with the patients in their care. But requiring the staff to maintain this emotional distance can add to the sense of isolation felt by nursing-home residents, and in contrast the Green House movement encourages staff members to befriend and get to know the elders in their care.

Lloyd, the nursing director at Eddy Village Green, said the “Green House magic” is in large measure a result of direct care workers’ detailed knowledge of the homes’ elderly residents and their personalities and preferences.

Yadicka Mohamed of Schenectady worked in traditional nursing homes for many years before becoming a shahbaz at Eddy Village Green.

“This is my family away from home,” she said, adding that she had been looking for a long time for a nursing home where she could form a more meaningful bond with the residents in her care.
As a CNA at traditional nursing homes, Mohamed said she was “always in a rush” because there were so many residents and there was always a task to complete with each of them.

“You feel sad at the end of the day, because you want to make a difference but you don’t have the time,” she said.

But at Eddy Village Green, Mohamed said she doesn’t feel the same pressures.
“You go home feeling happy,” she said. “We have more time, and you can be patient with people.”


Fostering compassion
Stephanie Thomas, who has been a shahbaz at the Green House project in West Orange, N.J., since it first opened in 2011, said an essential qualification for a shahbaz is “that compassion piece ... that thing that can’t be taught.”

Each shahbaz receives ongoing support from a guide, who acts as a coach. They report to their guide, rather than being supervised by a nurse as is customary for most CNAs. Each guide works with from two to five Green House teams.

“Guides are there to hold us accountable and also to help us work through problems we have as a team,” explained Thomas, who’s no relation to William Thomas.

Being asked to make decisions can feel difficult or even scary for people – especially when they’re used to being subordinates in a traditional institutional hierarchy. But the Green House model puts resources into supporting their growth. And this empowerment translates into quality care for residents.

“You know what’s best for your elders, but now you’re able to speak up and have your opinions heard,” Stephanie Thomas explained.

One of the components of a shahbaz’s job is engaging the elders. Where traditional nursing homes may try to fill the day with bingo and exercise, the Green House model takes a different approach.

“Instead of the word ‘activity,’ we talk about engagement,” Thomas said. “You’re finding things that they want to do and doing them with them.”

One woman in her care likes to listen to classical music, while another spends her mornings reading the newspaper from front to back.

In some cases it takes more effort to figure out what will capture an elder’s attention and be enjoyable for them.
“I have a lady who, when it’s nice out, will sit on the porch and watch everything,” Thomas said. “When she comes inside, she’ll give me a full report.”


Allowing time for independence
The Green House model expressly aims to help elders maintain their independence and abilities for as long as possible. By comparison, Farnan said many traditional nursing homes are, intentionally or not, “forcing people who live there to become more dependent.”

For example, the sheer scale of the typical nursing home, coupled with the large number of residents under the care of a single aide, makes it hard for staff to keep a watchful eye on residents at risk of falling or wandering off. That’s why restraints and alarms were commonly used in these institutions in the past, Farnan said.

Ryan, of the national Green House Project, said she lately has gotten to see firsthand the dependency-inducing role of the traditional long-term-care facility – after her own mother-in-law was hospitalized at Christmastime and subsequently discharged to what Ryan described as a “very good” nursing home.

“In order for my mother-in-law to go to the dining hall, she must use a wheelchair because it’s too long a distance for her to walk,” Ryan said. “But she doesn’t like riding in a wheelchair. She says she would feel embarrassed. So now she’s sitting in her bed, having her meals brought to her on a tray.”

Other efforts to meet the basic needs of nursing-home residents within unrealistic time constraints also may lead to a cascade of undesirable outcomes.

“They’ve got to get all the trays back, so they don’t permit her to enjoy her meal,” Ryan said. “Then some well-meaning aides will say, ‘Let me help you,’ and they’ll start feeding her. They even butter her bread. She should be able to do it herself.”


Cost, quality comparisons
As the first Green House development in New York, the Eddy worked closely with the state Department of Health to gain regulatory approvals for its new approach. Although the organization had to address a number of safety issues, such as concerns about having an open kitchen among a group of elders, Farnan said the state was “very vested in our success.”
“We had a very good relationship with the state Department of Health, and they wanted the Green House model to happen in New York and for the Eddy to do it,” he said.

The Eddy began as a 19-bed nursing home in Troy in 1928. It was founded by Elizabeth Hart Shields Eddy with funds from a fortune amassed by her husband, James A. Eddy.
Construction of the Eddy Village Green, with 16 houses for 192 residents, cost $42 million. This figure compared favorably with the estimated $60 million price tag for renovating the two old facilities that were on the site.

It took a lot of fund raising to produce the upfront capital, however, Farnan said. The local Industrial Development Agency came through with a $30 million bond, and The Eddy Foundation, set up by the organization’s founding family, also made substantial contributions.
In terms of staffing, the requirement of Eddy Village Green, as measured in full-time equivalents, is identical to that of the old Eddy-Ford Nursing Home it replaced, Farnan said.
But the distribution of staff time couldn’t be more different.

The Green House model has a significantly higher ratio of direct-care staff to residents than a traditional nursing home. For 12 residents, each Eddy Village Green house has two or three shahbaz staff on the day shift, two on the evening shift and one overnight. (In addition, Eddy Village Green employs many nurses and has a full-time physician and nurse practitioner on staff.)

In a traditional facility, many employees work behind the scenes in support services such as food preparation or housekeeping. But by integrating these functions into a more home-like setting, residents at Green House homes have considerably more interaction time with caregivers. Even when the caregivers are preparing food or making a bed, they are often engaging with residents.


Slow to take flight
Farnan admits that Eddy Village Green is not cheap; it has a daily rate of $433, slightly higher than the cost of a good traditional nursing home. The Eddy accepts Medicaid, and 57 percent of its current residents are on Medicaid. The rest pay for care with their own funds.

From a national perspective, Ryan said she wants the Green House model to be available to all, regardless of their means.

“A personal mission of mine is that we are not creating something only for the ‘haves,’” she said.
In a 2013 survey she conducted of Green House homes, Ryan found that Medicaid paid for the care of 42 percent of the homes’ residents.

Ryan said soon-to-be-published research will document a reduction in hospitalization among Green House residents when compared with those in traditional nursing homes. Based on this finding, she said, it would be smart government policy to provide financial incentives for more people to receive Green House care. If this model can save Medicaid money, she argued, it would make fiscal sense to reward it with a higher rate of payment or a pool of special funding to subsidize new projects.

Although the number of Green House projects has grown in recent years, Ryan said the model “hasn’t scaled up as quickly as I had hoped.”

Farnan suggested that a major obstacle to adoption of the Green House model is its upfront cost. Most nursing-home operators are strapped for cash, he said, and few have their own foundations to help pay for the transition.

But Ryan said money isn’t the only issue.
“Gaining access to capital is always a challenge,” she said. “If you were going to rebuild a traditional nursing home, you’d have to get capital too.”

Inspired by the Green House example, “small house” nursing homes are growing rapidly. These small facilities implement only some of the features of the Green House model. They also avoid the costs associated with the Green House trademark.

“We think of them as Green House lite or Green House wannabes,” Farnan said.
Ryan conceded that simply adopting the decentralized physical layout of the Green House movement would be an improvement over the traditional nursing-home structure. But she cautioned that facilities that adopt only a portion of the Green House model won’t yield the same benefits for their residents and staff.

Lately, she added, her organization has been hearing from some operators who built nursing homes along the small-house model but now are looking for help “because it has not worked as they had hoped.”

Her organization, the national Green House Project, is based in Virginia and provides a range of services for projects that are planned or already operating. It creates the training curriculum for staff and an architectural design manual, among many other products.


Family-friendly setting
Lloyd, the Eddy Village Green’s nursing director, has so much faith in Eddy Village Green that two of her aunts, an uncle and her father live there. Her mother also was there for about two months but was able to return home; now she comes in every day to visit her husband.
As at any nursing home, the transition from living independently can be a challenge.
“My dad will say, ‘I don’t want to be here. I want to be home,’” she said.

But the other day, she saw him in the dining room at his new home. He was laughing, chatting with the shahbaz and enjoying the company of the other elders, she said.
That the staff has time to form relationships makes all the difference.

“In this model, I’ve had so many more visitors, because it’s more welcoming,” Farnan said. “Family members are invited to stay for dinner. People become very close. A lot of family members even come back after their parent passes on.”

At funeral services, he added, a lot of staff members turn out. And when a shahbaz went on to become a registered nurse, his co-workers and residents with walkers and wheelchairs boarded a bus to see him graduate.

Green Houses honor each person’s wishes for the end of life.
“Family members often are there,” Ryan said. “It’s so much like a home.”

In comparison with a traditional nursing home, Farnan said, “It may sound strange, but death is a better experience in a Green House.” The model allows the staff to deal with a resident’s death in a more respectful way and to give those affected a sense of closure, he explained.

At the Green House where Thomas works in New Jersey, only two of the original residents are still alive after four and a half years.

“I take it hard when I lose any of my elders,” she said. “I feel like the way the care is given in the houses helps extend people’s lives, but we can’t prevent the inevitable.”

Yet occasionally people make surprising recoveries in Green House homes. Lloyd said she brought a sister-in-law up from Florida to live at Eddy Village Green; the woman had become severely disoriented after surgery. Within six months, she had improved enough to go home.