What Makes a Green House Home? How You Decide Matters

Honor residents’ preferences in their care. Provide a home-like environment. Encourage collaboration among staff. Build close relationships between residents and staff. Support direct care workers’ professional and personal development.

Who could argue with the basic tenets of the nursing home culture change movement? Stated in the abstract, they seem eminently reasonable and undeniably beneficial. But putting these tenets into practice despite real pressures—from time constraints, physical and emotional needs, finances, regulations and human nature—can be another matter altogether.

Under what conditions can nursing home culture change thrive?

When geriatrician Dr. Bill Thomas asked himself that question, his answer was the Green House model (mentioned in our winter 2015 issue).

Green House Homes combine small, communal living spaces for up to 12 residents (called Elders) with greater interactions between Elders and staff, and emphasize staff empowerment and collaboration.

The first Green House Homes opened in 2003. There were more than 170 Green House Homes in 27 U.S. states in April 2015. In November 2019, there are more than 280 Green House Homes in 32 states.

That’s enough lived experience to begin evaluating whether Green House Homes are succeeding and what nursing homes could learn from their example. As part of The Research Initiative Valuing Eldercare (THRIVE), a national interprofessional collaborative, University of Wisconsin–Madison School of Nursing Associate Dean Barb Bowers, PhD, RN, FAAN and research manager Kim Nolet, MS are helping lead that effort.

Bowers and Nolet previously studied how the Green House model’s unique staff structure affects nursing practice and Elders’ care. More recently, they and other UW–Madison colleagues looked at how Green House Homes maintain culture change practices over time. They also asked how different care practices affect Elders’ clinical outcomes.

Sustainability isn’t a given when you’re making as many changes to generally accepted practices as Green House Homes do.

The role of the certified nursing assistant alone is so different that the Green House model renames them “Shahbazim.” Teams of Shahbazim manage daily operations, doing the cooking, cleaning, scheduling and personal care, and working with a clinical support team to provide resident care. Nurses and administrators (called Guides) coach the Shahbazim, helping them develop their skills.

By interviewing 166 staff members at 11 Green House Homes, Bowers and Nolet identified patterns of problem solving as important to the erosion or reinforcement of the Green House model over time.

When Shahbazim are consistently able to discuss problems and implement solutions, and are supported in doing so, it strengthens the commitment to the Green House culture change model. That commitment is also reinforced when Guides actively coach Shahbazim to solve problems and when nursing home regulators are supportive of collaborative decision making and more homelike settings.

Maintaining the Green House ideal is more difficult when budgetary pressures are significant or critical issues arise. Both conditions tend to trigger top-down decision making, which reassures management and regulators, but weakens the organizational commitment to the new ways of thinking and working inherent in culture change.

These findings suggest that Green House Homes can increase the likelihood that they will weather challenges without straying from their model. By prioritizing collaborative decision making across organizational policies and practices—for example, by emphasizing collaborative experience and decision making skills in staff recruitment, training and evaluation—Green House Homes can strengthen their commitment to culture change. Understanding when their organizational model might be vulnerable can also help Green House adopters devise strategies to resist reverting to institutional norms under pressure.

Collaboration has additional benefits, according to Bowers’ and Nolet’s research. A more collaborative relationship between nurses and Shahbazim can lead to earlier detection of changes in Elders’ health. In Green House Homes where Elders have very low rates of hospitalization, physicians and nurse practitioners say that Shahbazim’s deep knowledge of the Elders is vital to their care.

The Green House staffing model pairs the same Shahbazim with the same Elders daily, for personal cares, activities, meals and other interactions.

One Shahbaz illustrated how this fosters a greater sensitivity to potential health issues, saying of their Home’s Elders, “You know their rhythm. You know their routine. … We notice the small changes in them. … So we’re able to communicate with the nurses. Hey, red flag. Here’s something that’s not right.”

Even the architecture supports collaboration in Green House Homes. With their small size, single front door and common dining room, the Homes encourage interactions among residents, between residents and staff, and among staff.

As a physician for a Green House Home with very low hospitalization rates describes it, “There’s no … you know, sneaking in and out or missing someone going down the hall. When you have an open area like in the cottages, people are bumping into each other constantly. So if the OT [occupational therapist] is there, they [the physicians] bump into them. … You see people, and they mention things to you.”

While the Green House model encourages culture change practices that support Elders’ quality of care, ultimately each Home must work daily to realize the benefits. The THRIVE research collaborative is finding that those benefits are real and significant.

–Diane Farsetta
Photo from The Green House Project