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Cover Story: Nursing Home Revolution

A retired school librarian joins the movement for a paradigm shift in care for disabled elders

By Thomas Grillo

cover2.jpgAs her mother’s physical problems mounted and she started forgetting things more often, Ruth McKee realized that the moment she dreaded had arrived: She must put her mother in a nursing home. The level of care at her assisted-living residence was no longer enough.

cover1.jpg“It was hard. I was in tears several times trying to decide if this was the right thing,” says McKee, a 59-year-old retired school librarian.

It’s a predicament faced sooner or later by many families, although in one way, McKee’s burden was heavier than most. “I’m an only child, so I had no siblings to do this with me,” she says. “But I’m blessed with a husband willing to help as if she were his own mother.”

McKee vowed not to put her 95-year-old mom in a warehouse-style nursing home with long hallways, medicinal smells, and lack of privacy. “I wanted my mother’s next home to be a place where the residents were happy, with lots of activities, delicious meals, and staff who knew and cared about them,” she says. “I was looking for a place where there’s a sense of, ‘My life isn’t over, I can do things.’”

But could she find a nursing home like that?

As it turned out, she did find a good home for her mother not far away.

And she discovered—and joined—a nation-wide movement aimed at nothing less than overturning the traditional nursing home model. In the past, nursing homes have generally been organized to deliver services efficiently, says McKee. The new thinking is that even elders with serious disabilities live better if their nursing facilities are run like real homes.

McKee got involved with the Colorado Culture Change Coalition, whose mission is to transform long-term care institutional settings from places where elders are told when to wake up, bathe, and eat to settings where they are in charge of these basic decisions and many more besides.

“It requires a paradigm shift on the part of the staff as to how they view themselves working with residents,” says McKee. “I think I got interested in this partly because, when I was a school librarian, I worked on making the library part of an integrated language arts program, which was a paradigm shift from when the teachers used to just drop their kids off with you for a period in the library.”

Dinnertime at the Nursing Home

One good way to see where a nursing home stands on the road to this culture change, says McKee, is to visit during meals. In the new kind of nursing home, she says, “There’s a restaurant atmosphere. There’s a lot of interaction and the staff seems to know the residents well. Some of the food is cooked to order right there. And for each meal, there’s a window of time when people can come—they’re not all lined up to eat at 6:45.”

One radical new model is known as the “Eden Alterna-tive,” developed by Dr. William Thomas in the early 1990s. Thomas conceived the idea after working in a nursing home in upstate New York.

“I saw that nursing homes concentrate all their efforts on making sure people get their pills and meals on time, but not on matters of the heart,” Thomas said. “The people living there were lonely, helpless, and bored, the three plagues of long-term care. So we brought life to the facility with pets, plants, kids, and planted gardens. The impact on elders was amazing. Frowns turned to smiles, and residents did better.”

Now Thomas has gone further in the Green House Project, with facilities that are tiny compared to traditional nursing homes. Green House nursing homes are self-contained dwellings for seven to 10 elders designed to look like a private home. Residents have their own bedroom and bathroom. The rooms open onto a central hearth with an adjacent kitchen and dining area where residents can share meals together around a common table.

The first Green Houses were built in Tupelo, Mississippi, in 2003. The 10 ranch-style homes were quickly filled and now there’s a waiting list with another 80 elders hoping to gain entry.

Unlike in traditional nursing facilities, visitors, while welcome, don't just walk in—they ring the doorbell, as they would at any other home. All the food is prepared from scratch and each house decides on its eating time.

There’s a clinical support team for all 10 homes that includes nurses, social workers, therapists, medical directors, nutritionists, and pharmacists. A nurse from the clinical team serves the residents of each home, and the other clinical professionals visit the houses regularly and as individual residents require. There are also two full-time staff members in each home during waking hours and one at night.

The people who work in a Green House and the people who live there collaborate to create a daily routine that meets individual needs, much as they did in their own homes. If they wish, the residents can cook meals, prepare snacks, and help with light housekeeping and laundry. There is no institutional routine in terms of medical care.

“There are only two groups that are still institutionalized in our country: prisoners and elders,” says Alan Brown, chief operating officer of the Mississippi Methodist Senior Services, the non-profit that runs the nation’s first Green House. “It’s time to do something different for the future of elder care.”

Mississippi Methodist Senior Services built the 10 wood-frame homes with 6,000 square feet of living space for $850,000 per home.

Best of all, says Brown, Green Houses are not just for the wealthy. In Tupelo, his agency charges $160 per day, roughly what traditional nursing homes charge. The facility meets Medicaid and Medicare licensing requirements for a skilled nursing home. About 85 percent of the residents are on Medicaid.

Brown says each resident can have a private room and bath because Green Houses save money by not building standard institutional departments such as dietary and nursing stations. The cost per square foot is the same as for a traditional nursing home, he said.

For McKee, a Green House is exactly the kind of place she would love for her mother—or for herself some day.

“This will make long-term care facilities a lot better places for elders because it values their lives,” she says. “The elders make decisions about what they want in their lives rather than being at the convenience of the staff.”

A Green House could be opening in a city near you. At least 20 communities in 18 states are planning them. Last fall, the Robert Wood Johnson Foundation awarded a $10 million grant to help spur the widespread adoption of the Green House model for skilled nursing care. The goal is to establish at least one in every state over the next five years, so developers interested in adopting the model all across the country will have a Green House nearby to visit and study.

Why has it taken so long to develop a better way to care for our elders? Carmen Bowman of the Colorado Culture Change Coalition says the answer is that “nursing homes were modeled after hospitals, not thinking that people would end up living in these homes for the rest of their lives. They thought it would be temporary, but it’s not.

“No one wants to live in a nursing home, so we better change what we’re doing.”

The Green House project in Tupelo is the subject of a 30-month study conducted by a team from the University of Minnesota. The study is not finished, but so far, the results look very good:

  • high satisfaction levels from residents, family and staff; fewer complaints at the state level;
  • no unexplained weight loss and almost no nutritional supplement use;
  • less decline in residents’ ability to do routine daily activities;
  • staff turnover of less than 10 percent;
  • no transfer-related back injuries in elders or staff;
  • less prevalence of depression;
  • less incontinence without a toileting plan;
  • and less use of anti-psychotics without a relevant diagnosis.

“We are really asking long-standing institutions to change. That’s why we need your readers—educators—the movers and shakers—to hold nursing home administrators’ feet to the fire,” Green House founder William Thomas told This Active Life.

Just a little help

The Green House is for people who need the high level of assistance that nursing homes provide. Many other people have much milder disabilities, and change is afoot for them, too.

One new approach is called “elder co-housing,” in which older adults live interdependently within a close-knit group of neighbors. This approach also appeals to people who don’t need any special help at all, but like the sense of community.

Earlier this year, a dozen seniors in Davis, California, moved into their own dream retirement community at Glacier Circle Senior Community, the first elder co-housing neighborhood to open its doors in the United States. 

The idea is borrowed from the co-housing movement that has more than 80 intergenerational communities nationwide, with another 80 in the planning or construction stages. Sparked by Denmark's bofoellesskabers, or “living communities,” launched in the 1960s, co-housing is characterized by a diverse group of mixed-income families, couples, and singles who purchase land and design a cluster of private homes around shared living space.

Like a condominium community where each resident owns a private dwelling, co-housing features a “common house,” where meals are shared. Residents volunteer for child care and serve on teams to accomplish a variety of tasks. The cost tends to be at or slightly above the market rate for housing.

Elder co-housing communities have the same concepts and elements, except they’re only for those 55 and older. They have special design features in the homes and common facilities that make life easier and safer for their elderly residents, such as single-story houses, step-free entrances, wider doorways for wheel chair access, lever handles that are easier to grip, grab bars, low-glare lighting, and extra housing for caregivers to live in when the need arises.

Glacier Circle has eight new homes clustered together and specially built to the specifications of their owners. The homes range in size from 1,000 to 1,400 square feet. The commons house will have a large dining room, an exercise room, a large kitchen with a pantry, and a big television and music system. The development includes a one-bedroom apartment that can be leased to a health care provider, a nurse, or home health aide, depending upon the needs of the house. If no such care is needed, the apartment can be used as a guest room.

In Boston, there’s another model for elders who need extra help and don’t want to move to a retirement community to get it. Founded about five years ago, it’s a virtual retirement community called Beacon Hill Village, designed to make it possible for elders to stay in their own homes in safety and comfort.

By partnering with service providers, the non-profit Beacon Hill Village offers its members access to social and cultural activities, household and home maintenance services, as well as medical care and assisted living at home. There’s an annual fee of $780, and members also pay for an array of a la carte services such as a personal trainer for $60 an hour. Some services are included in the annual membership fee, with others provided at reduced rates.

Former Boston City Councilor John Sears, 75, was one of the first elders to join. “I live alone in a house with five rooms on five floors, and I get daily reminders of growing older such as arthritis,” says Sears. “I feel well supported and I believe this idea can be replicated in many neighborhoods, although it may need some public support.”

McKee believes the future will see more retirement alternatives like these, giving elderly who need help much more control over their lives than in the past. That’s because the new elderly are Baby Boomers.

“My mother graduated from high school in 1928 and remembers what it was like to go without during tough times,” McKee says. “The Depression generation accepted what was handed to them: It was better than nothing. But Baby Boomers demand more, and they—we—will figure out a way to get it.”

On the Web

Colorado Culture Change Coalition

The Eden Alternative

The Green House

Elder Co-Housing

Beacon Hill Village

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