How Family-Style Nursing Homes Are Better Weathering the Pandemic

LaVrene Norton, Action Pact's founder and managing director, said that she does not have official tallies of COVID-19 cases in Household Model homes. Action Pact worked with the developers of those homes to help design and build them some 20 years ago, and does not maintain contact with all of them.

"We've kept touch with a number of organizations. I hear that they're all COVID-free” Norton said. “We do know that compared to a more traditional nursing home, there's less opportunity for exposure."

"It really has to do with culture,” Norton added, “like a dedicated staff that absolutely does not want to bring this to the residents of the house."

The Household Model is physically self-contained, with consistent, versatile staff members, she added.

Common features of Green House Project and Household Model homes include:

• Private bedrooms, each with bathroom and shower
• Shared living rooms
• Large tables for dining
• Open kitchen areas
• Easy access to the outdoors

Residents dine together at St. Martins in the Pines in Birmingham, Alabama.

Courtesy St. Martins in the Pines

Dining in these homes differs from most traditional nursing homes, which typically have large dining rooms and centralized kitchen areas. In both models, food is prepared in open kitchens in the homes.

The staff at Green House Project homes is typically paid 3 percent to 30 percent more than at other nursing homes, according to a wage survey it conducted several years ago, said Green House spokesperson LaPorte. Its turnover is less, and research has found that the staff has higher job satisfaction, she said.

One expert suggested that more could be learned if the Green House Project crunched its coronavirus numbers differently to better understand how the Green House model affects the COVID-19 rate.

"My main concern is that the Green House homes need to be compared to organizations similar to them,” wrote Robyn Stone, senior vice president for research at LeadingAge, which represents nonprofit care providers, in an email.

"Are the populations served the same? Are they in high-risk areas?” Stone asked. “How does this model compare with other neighborhood, person-centered homes?"

Most Green House Project homes are not-for-profit, and 42 percent of residents receive Medicaid funds, LaPorte said. Most Household Model homes are also not-for-profit, with many residents on Medicaid. In traditional nursing homes, Medicaid residents make up 62 percent of the population.

A new approach

The Green House Project was founded by Bill Thomas, M.D., a Harvard-educated physician. He earlier founded the Eden Alternative, an approach emphasizing older adult care that's focused on people rather than institutions.

The first Green House home opened in Tupelo, Mississippi, in 2003. Thomas had persuaded a top administrator to choose this model rather than replace an old-style nursing home, said Renee Reid, spokesperson for Tupelo-based Methodist Senior Services, which runs Traceway Retirement Communities.

Today, Traceway has 19 Green Houses in Mississippi, with open kitchen and dining areas. “The smell of good food pulls you right out of your room,” Reid said.

Household Model homes also feature open kitchens, where residents can ask staff for food during much of the day, rather than having to eat on a rigid schedule, Norton said.

One Green House feature that stirred attention early on is the use of certified nursing assistants (CNAs), or shahbazim, as home managers, rather than being overseen by registered nurses, the typical system in most nursing homes.

Exterior of The Green House Homes in Rhode Island.

Courtesy Green House Homes

But those concerns have waned over time, with evidence that shahbazim work closely with nurses, said Barbara Bowers, a professor and associate dean for research at the University of Wisconsin-Madison School of Nursing and a Green House expert.

"There is a strong effort [for nurses and CNAs] to work as a team,” Bowers wrote in an email.

Today, a number of Green House homes are built as their own neighborhoods, and others are on larger continuing care campuses, LaPorte said. Such campuses typically include assisted living and independent living homes.

And the model continues to evolve.

A Rochester, New York, nursing home built the first two Green Houses in 2011, embedded in a residential neighborhood in nearby Penfield. There, they blend into the suburban setting, said Tom Harner, spokesperson for St. John's Senior Services.

Inspired by the concept, St. John's is now renovating its traditional six-floor, 455-bed building to follow some Green House tenets.

The onset of COVID-19 has altered the normal rhythms in many homes. Seating 12 people at the traditional large Green House hearth table, for instance, can be a challenge.

"They've had to get creative,” said Ryan, the project's senior director. She has heard of one home that instructed residents to eat in their rooms, and another that staggered six residents at a time around the large table so that they had more distance between them.