By Beth Baker
In October, 150 people stood in the rain to celebrate the groundbreaking of an innovative elder housing project on rural Key Peninsula in western Washington state. For the first time, older people who are no longer able to live at home there can still remain in their community. The nonprofit Mustard Seed Project is building three Green House homes, two for assisted living and one for memory care. Almost one-third of the studio apartments will be for low-income people who are on Medicaid.
Founded in 2006, the Mustard Seed Project helps people age in place, with transportation, home repairs, friendly visits, yard cleanup and information and referrals. “The missing piece was supportive housing,” says Executive Director Eric Blegen.
This rural community may be on the cutting edge of the future of elder care: creating supportive services to help older people remain independent; nurturing close-knit communities and developing small long-term care homes, rather than large hospital-like institutions, with well-trained staff, all offered in a way that won’t break the bank.
The beauty of small nursing homes
For more than 20 years, nursing home reform advocates have called for new models to replace the traditional, dreaded institutions. This demand was amplified when the pandemic ripped through nursing homes. As of October 10, 2021, more than 138,000 nursing home residents and more than 2,100 staff members had died from COVID-19 , a number widely believed to be an undercount.
Some smaller nursing homes, notably the Green House model, did much better than others at protecting their residents. One 2020 (pre-vaccine) study in the Journal of the American Medical Directors Association concluded: “Nontraditional Green House/small NHs [nursing homes] have better outcomes than traditional NHs in numerous areas; evidence now demonstrates they have lower rates of COVID-19 and COVID-19 mortality than other NHs as well. As such, they are an especially promising model as NHs are reinvented post-COVID.”
Susan Ryan, senior director of The Green House Project, says, “Interest in the model is at an all-time high. Media has been through the roof. Green Houses offered such a bright counternarrative to what we were seeing in nursing homes.”
She ticks off the model’s advantages: Every resident has a private bedroom and bathroom. Smaller autonomously functioning homes greatly reduce the number of employees coming into contact with residents. Green Houses use “universal workers” (called “Shahbaz”) who provide direct care, meals and household management, rather than having dining, laundry and housekeeping staff cycle through. Nursing staff is consistent throughout the week.
“So many things about the model afforded the good COVID data,” says Ryan. “And you can’t underestimate the physical environment and getting outside.”
Green Houses, which usually serve 10 to 12 residents, typically are single-story, with yards and patios its residents may freely access.
“We’ve shown that we have a model that performs really well in the worst of times,” Ryan says.
The first Green Houses went up in Tupelo, Miss., in 2003. Today there are 360 in 32 states, a tiny number compared with the 15,000 nursing homes nationwide. Despite considerable evidence that Green House and other small-home models have better clinical outcomes and higher resident, family and staff satisfaction, change has been sluggish.
One reason, says John Ponthie, managing member of the management consultant Southern Administrative Services who serves on the Green House Project board, is that 90% of Green Houses are operated by nonprofits, while almost two-thirds of nursing homes are for-profit.
For-profit owners have assumed that only nonprofits, which can raise construction capital through philanthropies, can afford to build Green Houses, he says.
While Ponthie had taken pride in running good-quality traditional nursing homes, from the first moment he set foot in the Green House in Tupelo, he knew that this was the future he wanted for long-term care. “I was stunned,” he says. “It’s too good to be true.”
He describes how everyday life is different in a small-home model. “At a Green House you’re part of the life of your loved one,” he says. “It doesn’t smell like it’s not supposed to smell — it smells like cornbread. Christmas is Christmas. You can get outside or go in the kitchen and have a Popsicle.”
Perhaps most important is the relationships.
“When you strip everything else, it’s all about this model’s ability to facilitate relationships between the elders and the caregivers,” says Ponthie. “You’ve got a commitment that goes well beyond your job tasks. There’s a relationship there, when it’s real and meaningful and rewarding. That is the difference, that is the magic.”
Ponthie’s company went on to develop and provide administrative services to 30 Green Houses on five campuses in Arkansas, with 23 more homes opening by April. Sixty percent of residents are on Medicaid.