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Description |
The Green House project creates small, intentional communities for eight to ten elders who need assistance with their daily activities and the staff who assist them. Green Houses are intended to de-institutionalize long-term care by eliminating large nursing facilities and creating habilitative, social settings that provide elders with support in activities of daily living and clinical care that meets skilled nursing requirements without allowing that assistance and care to become the focus of their existence. Because the model recognizes how essential the relationship between direct-care workers and the elders they support is to achieving that goal, considerable attention is given in all aspects of the program's design to the training and support of direct-care workers. |
Sponsoring Organization |
The Green House project is sponsored by the Center for Growing and Becoming, a non- profit organization in New York that grew out of the Eden Alternative. |
Setting |
The first four Green Houses were implemented at Methodist Senior Services in Tupelo, Mississippi. As of late 2005, additional replications were underway in Arizona, Michigan, North Carolina, Ohio, Pennsylvania, New York, Kansas, and Nebraska. |
Target Group |
Elderly, frail, and disabled people with a high level of need, and the certified direct-care staff, known as Shahbazim (the plural of Shahbaz), who support them. |
Start Date |
The Methodist Senior Services Green Houses in Tupelo opened in 2003. |
Objectives |
The goal of the Green House project is to create living environments for the elderly, frail, and disabled that are rich in meaning, vitality, and joy. The focus is on autonomy, dignity, choice, and keeping the locus of decision making as close to the elder as possible. In order to keep the decision-making close to residents, the project includes a strong emphasis on direct-care worker supports, training, and empowerment. |
Key Components |
Overview of the Program
Each Green House is designed to be a home for eight to ten elders who require a skilled nursing level of care. Each elder has a private living space with a private bathroom. There is a central hearth or living room with an adjacent open kitchen and dining area. All meals are cooked by the Shahbazim in the Green House and are eaten at one long dining table that acts as a focal point for a 'convivium', or communal meal.
The Center for Knowing and Becoming requires each Green House to adhere to a set of standards. In addition, a sponsoring health care organization must supply administrative, fiscal and 'back office' services, and each Green House must maintain specified clinical and team staffing requirements.
One licensed nurse is available to provide skilled nursing care for two to three houses, depending on the clinical needs of the elders. Clinical staff specializing in speech therapy, recreation, diet, occupational, and physical therapy also visit as required by the care plan. There is no nursing station. Nurses visit the houses frequently throughout each day taking notes via a wireless handheld device or laptop computer.
The Role of Direct-Care Workers
The majority of the care is provided by two Shahbazim on the day and evening shifts and one assigned to night duty. Only the Shahbazim and the elders have direct entry access to the house. All others must ring the bell to request entry.
Shahbazim receive 120 hours of training. The first 40 are administered by Green House staff and include information about the Green House philosophy and the role of the Shahbaz, empowerment, teamwork, Green House policies and procedures, and dementia care techniques. The other 80 are administered by contracted facilitators who teach classes on first aid, CPR, culinary skills, food safety, and home repairs.
Shabahzim who are not certified nursing assistants (CNAs) upon hire must undergo training and become state certified. Program administrators are developing a continuing education module for Shahbazim, which is expected to be available online in the spring of 2006.
Although they are CNAs, Shahbazim do more than traditional CNA duties. In addition to clinical tasks and assisting residents with activities of daily living, they are responsible for cooking, recreational activities, laundry, and light housekeeping.
Each replication site sets its own pay scale. When the Tupelo site opened, the Shahbazim earned a starting salary of $11 an hour, $4 more than CNAs who continued to work in Methodist Senior Services' traditional nursing home units.
Shahbazim do not report to nursing staff. Instead, they form self-managed work teams to operate each house. Each team has five rotating coordinator positions that are held by a Shahbaz: team coordinator, housekeeping coordinator, scheduling coordinator, food coordinator, and care coordinator.
Shahbazim are supervised by a guide who works as a liaison between Shahbaz and other staff. In addition a house sage, who is an individual from the community, volunteers to visit the house regularly to provide guidance and support to elders and staff.
In case of an emergency, all Shahbazim are equipped with two-way radios, with which they can contact the nurse on duty and other emergency medical response professionals.
The Green House Project does not have defined protocols on how to recruit and retain workers. They allow each facility to determine their own criteria. It does, however, suggest that when converting an existing facility, administrators should allow CNAs to decide whether the new role would be right for them and apply for the job on a voluntary basis.
The Shahbazim who work in Tupelo, Mississippi wrote a code of ethics, which Shahbazim at other replication sites are encouraged to rewrite.
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Results, Outcomes, Evaluation |
A formal evaluation of the Green House project in Mississippi was conducted by Dr. Rosalie Kane of the University of Minnesota. A series of studies of residents, primary family caregivers, and Shahbazim as well as two control groups showed that Green House elders reported a better quality of life and greater satisfaction, and their family members were more satisfied with their relatives' care and with how they themselves were treated. There was less of a decline in the ability to do activities of daily living, a lower prevalence of depression, less incontinence without a toileting plan, and less use of anti-psychotic drugs without a diagnosis among residents of the Green House homes.
Green House staff reported that they felt more empowered to assist residents, they knew residents better, and they experienced greater intrinsic and extrinsic job satisfaction. They were also more likely to say they planned to remain in their jobs.
To view the complete results of the Tupelo, Mississippi Green House evaluation, click here. |
Lessons Learned |
Green House project designers have had to revise the training curriculum and staffing patterns to better fit the facilities that used the original model and critiqued it.
In addition, they report that some experienced CNAs find it difficult to switch to the Shahbaz model, since the daily responsibilities of a Shahbaz are, at times, significantly different than those of a traditional CNA.
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Costs and Funding |
Project administrators have found that the general costs associated with running a Green House are similar to the costs incurred by a traditional nursing home facility. For example, in Tupelo, the Green House was able to operate at the Medicaid daily rate of $117 a day when it opened in 2003.
While certain economies of scale are lost when operating a small residence, the Green House model is designed to shift resources away from institutional overhead towards
supporting the direct care needs of residents. For example, many of the costs of conducting regular house maintenance and cooking are transferred to the daily operations of the direct-care worker.
Funding for evaluation, replication costs and general administrative support have been provided by the Robert Wood Johnson Foundation, the Samuels Foundation, and the Commonwealth Fund.
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Contact Information |
Jude Rabig
Project Director
1128 East 37th Street
New York, NY 10016
t: 212-685-3144
e: jrabig@rcn.com
Website: www.thegreenhouseproject.com/index.html
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