July 30, 2020

Reimagining Elder Care: The Green House Project

The coronavirus pandemic illuminated the systemic deficiencies in long-term care facilities in the United  States, resulting in the deaths of tens of thousands of residents. Advocates, civic leaders and others are debating whether the catastrophic events created by COVID-19 will drive reforms, and alternatives, to long-term care facilities. We know these settings increase the spread of infection. Will shared bedrooms and bathrooms, large wards, common dining facilities and large buildings eventually be relegated to the past?

In the early 2000s, Bill Thomas, M.D., a geriatrician, sought to transform elder care with an alternative to the sterile, hospital-like nursing home settings i n which thousands resided. He founded the Green House model, and the resulting nonprofit Green House Project, which was responsible for replicating the model across the country. The project began as a collection of one-story homes with gardens and porches, situated in campus-like communities around the nation. Each house accommodates up to 10-12 residents with private bedrooms and bathrooms.

Residents in Green House properties apparently fared much better during the pandemic than those in traditional long-term care facilities. An analysis in USA Today suggested that up to 40 percent of deaths from COVID-19 took place in nursing homes or long-term care facilities, totaling about 40,600 residents and workers. The analysis, published on June 2, examined the death toll over the prior three months. By contrast, data collected from 256 of 268 Green House properties showed 47 cases and four deaths from COVID-19 between Feb. 1 to May 31. (These figures included skilled nursing and assisted living facilities). Green House officials said they were working to collect data from the remaining properties.  

BIFOCAL talked with Susan Ryan, senior director of the Green House Project, about the future of long-term care in the wake of the coronavirus, and the growing prospect that Americans reaching older ages will demand sound alternatives.   

BIFOCAL: The coronavirus outbreak was catastrophic for residents and workers in long-term care settings around the nation. The spread of the virus underscored the infection prevention and control deficiencies that have plagued many facilities for years. Do you believe the heartbreak from the pandemic will lead to positive change in the industry?  

SR: My hope would be that this is a profound wake-up call and an opportunity for policy makers, regulators and society at large to take a look and see that we’ve been warehousing [the elderly] for a long time. This pandemic has shone a light that we never had before. We need to establish a coalition of stakeholders – policy makers, regulators, providers -- and tap into their expertise for what could work. We need to ensure we are looking at this systemically and that we don’t endeavor to apply quick fixes to make it better. We need to think about how did we get here and why did we think warehousing was OK?

   The Centers for Medicare & Medicaid Services this week said they’re going to impose more fines to nursing homes for violations of infection control. It’s the blame game. You’re not going to punish your way to change and improvement from a quality perspective. We need to look at what worked in the pandemic, what have we learned, to drill down and take those lessons learned and have a broader application to policy and regulation and the like.

BIFOCAL: What will it take to reimagine elder care?

SR: We are getting ready to launch a podcast and we’re interviewing people about what their vision is and a call to action to elevate elder care. I like the idea of a task force. I’d caution we avoid quick-fix things. Self-awareness as individuals, and for those of us who are Boomers, we see ourselves as change agents and are willing to take a stand. If there’s hope for a generation to bring meaningful change to an industry, I think Boomers are well suited to do it. We’ve got to have a reformation in long-term care. We can’t go back to normal because you’re only as good until the next pandemic or whatever else comes along.

BIFOCAL: If the Green House Project is a model for the future of long-term care, or one example of how elder care can be reimagined, why hasn’t your model caught on more? Is affordability for residents a factor? What about incentives for developers and providers?

SR: There’s a misperception that the model is not cost-effective. Providers say, I can’t spend capital for 10 to 12 people in this model; there is no cost efficiency. And I can tell you that you can. You actually can gain efficiency by having greater occupancy. The occupancy rates are far higher than in traditional homes. And this is where you want your loved one to be in a COVID-19 environment. Three- to four-person rooms should never be an option. They should be forbidden. Private rooms with your own bathroom give you dignity and the infection control gives you a leg up.

   It’s important to me we don’t create a model for those who have the wherewithal to pay privately. We want it to be affordable and fit in Medicaid structure – 42 percent of elders living in Green House homes were supported by Medicaid. In some states Medicaid reimbursement is higher. What can we do to incentivize this? The ability to attract private pay in your payer mix – Medicaid, Medicare, private pay; getting the mix right is important to viability. Creating special financing opportunities to incentivize providers to do this affordably is important.

BIFOCAL: You talk about person-centered care in long-term care settings. Tell us more.

SR: You gain so much efficiency when you see people as individuals and you understand what they need. It sounds over-simplified but person-centered care in the Green House model is about creating deep, knowing relationships that see each person as an individual with unique needs -- and that translates into better quality of life experiences and good outcomes clinically and financially. The Green House has two consistent caregivers working with the same 10-12 people every day. When I get to know what Mary likes, and what she wants to eat, her care and living is optimized. If she’s not looking as well today, I can ask a nurse to take a look at her. We can intervene and address something earlier than when it’s so full blown that she has to go to a hospital.

   This is home. A person can decide what he wants to eat, when he wants to eat; he has control over his environment. We destigmatized it and humanized it and that feels really good to me.