Green House homes, an alternative to traditional nursing homes, are best known for being smaller structures with just 10 to 12 residents that have the look and feel of a “real home.” But they also fundamentally differ in their workforce model, which is designed to improve the quality of work life for all staff, but particularly for the Shahbazim—the Green House home’s direct care team of certified nursing assistants.
The staffing model is unique and fundamental to Green House’s philosophy and results in positive outcomes for residents and workers alike. A national evaluation of the Green House model demonstrated that Green House homes consistently perform in the top tier of nursing homes on clinical/health outcomes of residents. (They have also fared much better than traditional nursing homes during the pandemic, with fewer COVID-19 cases and deaths.)
This report highlights those unique features, particularly the extra training and responsibilities that the direct care workers/Shahbazim receive. The coaching, supervision, and collaborative roles among the Shahbazim, Green House Guides, and nurses are starkly different from those found in traditional nursing homes and result in, among other benefits, significantly lower staff turnover rates.
Empowered Direct Care Staff: Shahbazim
The Green House model empowers the Shahbazim (singular Shahbaz, which also means “universal worker”) by focusing on key staff development areas such as enhanced training, consistent staffing, engagement and collaboration, and shared decision making.
- Enhanced training. Unlike traditional direct care workers, Shahbazim have an additional 128 hours of specialized training in such areas as emergency preparedness, dementia care, and culinary skills including food safety and handling as well as “soft skills” such as communication.
- Universal workers. Shahbazim work as a self-managed team of universal workers to respond to residents’ needs. They are trained to provide a full range of services and supports, including personal care, laundry, housekeeping, and meal preparation (which allows residents to enjoy favorite foods, rather than just what’s on the menu.).
- Consistent staffing. The Green House staffing structure is designed to operate like a family, where workers are consistent and are intimately involved in residents’ lives. This leads to strong bonds between Shahbazim and both residents and their families and is fundamental to achieving a better quality of life for residents and staff.
- The Guide. As the formal supervisor of the Shahbazim, the Guide is responsible for ensuring Shahbazim meet federal requirements for nursing homes, adhere to the organization’s values and procedures, and honor the Green House model. The Guide ensures high-level collaboration between Shahbazim, nurses, and other clinical support team members.
- Engagement and collaboration between Shahbazim and nurses. The Green House staffing model operates through an ongoing collaborative/team relationship between Shahbazim and nurses, with the role of the Green House Guide serving to supervise the self-managed work team of Shahbazim. This frees nurses to be mentors and teachers, and to focus on clinical care.
- Shared decision making. Shahbazim are equipped with problem-solving and decision-making skills and tools as part of their training. Leadership staff work with them to ensure decisions are value based, align with current regulations, reinforce quality care standards, and honor the resident voice.
- A unique model of leadership. Green House Guides, nurses, other department managers, and additional leaders practice a coaching approach to supporting the Shahbazim with five elements: creates a valued relationship; presents an issue (for the Shahbazim to work through); gathers information to understand the nature of the issue; engages in problem solving with the Shahbazim; develops a plan of action and evaluation measures with the Shahbazim.
- Shahbazim feedback in assessing the organizational practices. Each year, Shahbazim and other team members participate in an online assessment to evaluate the application of the Green House model in day-to-day practices.
It is also important to note that fairly compensating front-line caregivers is vital— regardless of whether they work in a Green House community. Historically low wages and thin benefits have forced many CNAs and other nursing home staff members to accept multiple jobs to make ends meet.
Finally, even if nursing home operators do not intend to alter their housing structures, they must examine their staffing model. Given the current workforce crisis, it is time to rethink traditional staffing models. Lessons learned from the Green House model can guide new thinking. Nursing homes can avail themselves of support from the Green House Project in order to apply the Green House principles.
Appendix A: Shahbazim Training: An additional 128 hours of specialized training
Appendix B: Green House Reporting Structures and Collaboration Processes
Appendix C: Green House Problem-Solving Framework for Team Decision Making
Appendix D: MERIT: Model Enrichment Resource and Integrity Tool
Appendix E: Green House Staff Testimonials
This report is part of the AARP Public Policy Institute’s LTSS Choices initiative. Learn more: www.aarp.org/ltsschoices.
Reinhard, Susan C., Edem Hado, Barbara Bowers, Susan Ryan, and Marla DeVries. Empowered Direct Care Worker: Lessons from the Green House Staffing Model. Washington, DC: AARP Public Policy Institute. January 19, 2022. https://doi.org/10.26419/ppi.00159.001
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