Green House Grows New Model of Care

by Stephanie Stephens, California Healthline Regional Correspondent

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When California's first Green House Project opens this summer at the senior community of Mt. San Antonio Gardens, it will represent four years of effort in search of a better way to age. The facility -- dubbed Evergreen Villas -- is on the border of the college towns Pomona and Claremont.

Green House Project founder Bill Thomas, a physician and eldercare expert, said Green House is an "intentional community" -- a "culture change" that reconfigures operations and environments, offering person-centered care that focuses on relationships and people. Thomas also founded the Eden Alternative, another de-institutionalized care model and predecessor to the Green House Project.

Green House facilities are self-contained residential environments designed around what proponents call "warm, smart and green" elements. Residents' bedrooms flow into open living and dining areas with communal dining and fireplaces, a departure from traditional models. Medical supplies are subtly hidden and "demedicalized."

Mt. San Antonio Gardens management hopes Evergreen Villas will open by the end of July.

Stakeholders and advocates have long championed a long-term care model that strives to replace feelings of loneliness and boredom, loss of control and dignity with autonomy, companionship and what proponents believe can be more meaningful lives. 

Advocates say it's about time for elder care innovations, considering that California's 65-and-older population is projected to nearly double by 2025. The state has the largest senior population in the country.

'Shahbazim' Key Members of Care Teams

Green House Project facilities are staffed by a medical support team reporting to a "guide." Certified nurse assistants called "shahbazim" receive an additional 120 hours of training aimed at boosting confidence and competence.  The plural word is from a Persian legend about a royal falcon who watched over the kingdom. Thomas describes the job as "the honor" of caring for elders, and in a video, encourages staff to "be as wonderful, and smart, and articulate, and funny and caring as you are -- in full -- because you're a shahbaz."

"This universal worker model is also more efficient than the traditional hierarchy of a departmentalized model," said David Farrell, Green House Project director. 

The Green House uses "an evidence-based model designed to fit within current regulatory and reimbursement structures, and to nurture people of all abilities, disabilities and financial circumstances," according to the Green House website.  

Evaluations conducted by the Green House Project comparing the new model to nursing homes found improved quality of life and resident engagement, care outcomes and family and staff satisfaction. The report said the Green House model produces cost-neutral operations, lower capital costs, more direct care time between staff and residents, and less stress for staff.

Green House conducted a 2012 pilot study that found the model can realize Medicare and Medicaid savings of between $1,300 and $2,300 per resident, per year, when compared to traditional nursing homes.

Long Road To California

Thomas developed the Green House Project in 2003. California's addition now brings the national total to 148 homes operating in 26 states. The first opened a decade ago in Tupelo, Miss.  

Evergreen Villas is "a milestone" for California, according to supporters and management at Mt. San Antonio Gardens. Regulation and approval processes in California had to be revamped for the new, non-traditional model. The state's health and safety codes, considered among the most stringent in the nation, posed hurdles not present in most other states. Legislators, agencies and stakeholders had to convene, re-think long-term care strategies.

"We haven't really changed the way we deliver nursing home care for 30 years," said Robert Jenkens, who until March directed the Green House Project at NCB Capital Impact –– the not-for-profit arm of National Cooperative Bank. NCB Capital Impact replicates the Green House Project nationally, aided by funding from the Robert Wood Johnson Foundation.

Evergreen Villas' unique design -- featuring an open kitchen, without a floor drain -- required new code language from the California Office of Statewide Health Planning and Development.

The state Department of Public Health had to approve kitchen construction and design. And because Evergreen Villas spans two local fire jurisdictions, it required a nod from the state fire marshal.

"The approvals process has required applications for alternate means of compliance in 16 areas," Jenkens told the state's Senate Subcommittee on Aging and Long-Term Care in April 2012. Pointing to four years of planning, regulatory compliance and costs that exceeded $1 million, Jenkens said that Mt. San Antonio Gardens officials "made a real commitment to serve the public purpose well beyond the immediate benefits provided to their campus."

"This effort was an innovation and radical departure from how nursing homes were structured, governed and regulated, and we didn't want to cut corners," said Green House's Farrell, who started his career as a nurses' aide.

"So many of us worked under traditional standards for many years, like Title 22 [in the California Code of Regulations], written to govern nursing homes and keep elders safe. The intentions back then were good, but now we're better informed. With everyone, there was a general spirit of, 'We can make this happen,' and we did."  

Behind the Care Curve

Jenkens said the U.S. culture's approach to aging is changing and so is the approach to the facilities where people grow old.

"The old model was designed when we thought old age was an illness," he said. "Regulations were developed to run nursing homes for efficiency around operations and good clinical outcomes -- to take care of the body and not the whole person."

Tracey Stoll, marketing and community relations vice president at Mt. San Antonio Gardens, lauded the commitment to new approaches that Green House made at Evergreen Villas. 

"We spent so many hours with them in person and on phone meetings, and they came to California to help with regulatory and legislative issues," she said. "Lots of things that were traditionally required didn't make sense for us, and it wasn't easy to figure out how we'd get beyond that. Ours was the most time-consuming and longest process of any state. We all had to go through this gestation period -- from birth to awesome." 

Sen. Elaine Alquist (D-Santa Clara) played a significant role in pushing the project across the finish line before she termed out last year, said William Dean, former consultant to the subcommittee. Alquist predicted other nursing home operators wouldn't have the patience or the resources to plow through miles of regulatory red tape, and she wanted to streamline the process.

Alquist, Dean and Jenkens teamed up with nursing home stakeholders and senior advocates to develop legislation (SB 1228) called the Small House Skilled Nursing Facilities Pilot Program, introduced in January 2012 and signed into law by Gov. Jerry Brown (D) in September. The law authorizes a pilot of 10 new, small house nursing homes -- a subtype of skilled nursing facility -- that don't have to be Green Houses per se.

"None of these will be 100% private pay," said Kate O'Malley, senior program officer of the California HealthCare Foundation. "In order for this to work, there must be a payor mix of Medicare and Medi-Cal patients. Homes that want to do this need to include a feasibility assessment." CHCF publishes California Healthline.

The legislation was amended a few times and language modified, Dean recalled. "We had to meet the Department of Public Health halfway. We wanted to create a much smaller, easier procedural process for them to initiate and implement a small house nursing home pilot program. When it happened, we were very proud and all embraced a tremendous feeling of success."

"The Green House model changed what people believed was possible, what was important, how good it can be, and unlocked creativity and energy. It was totally unique for a grant project," said Jenkens.

"I hope for California that Green House helps encourage more beacons of change and more inspiration about how things can be different," said O'Malley.

DPH is nearing the completion of drafting the standards for the Small House Skilled Nursing Facilities Pilot Program and anticipates releasing a draft to stakeholders for review during the first week of July.


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