Go Small and Go Home — Ingrid Weaver and the Porter Hills Green House Project

By / Posted on August 16th, 2013

Ingrid Weaver, CEO, Porter Hills

Buy in bulk, most people say. That’s how you save. So they flock to big box stores and buy big boxes of things to get them on the cheap. Likewise, the companies that serve people buy in bulk—like fast food chains—and the ingredients are cheap and there’s not a lot of variation on the menu but it’s affordable to the people they serve. The companies make money and we save money. And this is how it goes.

And so went elder care. Large institutional facilities housing and caring for large groups of elders was seemingly the only way to make the field of elder care financially feasible—both for the entities offering it and for the seniors needing it.

Ingrid Weaver worked in a large institutional nursing home when she started as a CNA while in college.

“Hurry up, go in, take care of everyone, and get done. It was very task oriented. It was almost like every senior you cared for was a task as opposed to a person. I was taught that way…and it was discouraging,” she said. “For me and for the elders, I’m sure.”

Twenty-five years ago Ingrid took a job at Porter Hills working with elders with irreversible dementia. She discovered that Porter Hills’ care was much more progressive than her previous employer’s. Instead of focusing on what elders couldn’t do, the Porter Hills staff was encouraged to focus on what they could do.

“It was a social model instead of a medical model,” she said. “If someone couldn’t tie their shoes, we got them a pair of shoes they could put on by themselves, with Velcro.”

Still, older buildings provided challenges to making alterations that would have been able to help improve ease of care.

“We had one main kitchen and three dining rooms that had to serve 600 residents. So if we were going to say that everyone could eat whatever they wanted whenever they wanted…it posed a challenge to existing systems,” said Ingrid. “It was all centered efficiencies and what worked well for staff.”

These challenges, combined with the progressive philosophy at Porter Hills, encouraged a dialogue to begin. This dialogue helped develop a foundation for a new type of care community that would cater to smaller groups of people based on their wants and needs. The staff at Porter Hills recognized that culture change was not a one-time event; it’s a process that requires continual transformation and growth.

And that’s when The Green House Project came into view. It not only offered a way forward for the design of the physical buildings and philosophical framework of care. It also challenged the big box, large institutional financial model for care.

In the smaller Green House homes, there was no longer a need for the legacy model of staffing that was necessary in the institutional care facilities. Instead, universal caregivers are responsible for a continuum of care within the home. They do everything from cooking individual meals to housekeeping to activities support and nursing care. As a result, Porter Hills didn’t require as many administrative and managerial staff because the empowered self-managed team worked collaboratively to support the elders and problem-solve issues.

Having fewer administrative staff saved money—as much as $124,000 per year, according to Weaver. It also meant that caregivers would form tighter bonds with the elders. And that meant better care.

“We have one elder who loves being outside,” says Ingrid. “She goes out and tends to flowers in her wheelchair. Because of the design, staff can see her from the windows while still caring for others. Making sure elders are safe while still having autonomy—this is much more difficult to offer in a traditional nursing home. And just that freedom…it’s meaningful to her.”


Leaving to Go Back: Al Power and the St. John’s Home Green House Project

By / Posted on June 6th, 2013

When Al Power was in med school and specializing in geriatrics, he would visit his grandmother in a nursing home. During one these visits, he noticed the nameplate on her door; the last name, “Power” had an “s” at the end of it.

“It was a note to me,” he said. “Of how anonymous she was.”

To Al, such anonymity wasn’t an issue unique to that particular nursing home — it was in the corners of every traditional nursing home. It is evident whenever elders are pushed into an institutional setting and away from their families. Away from the libraries. Away from neighbors. Away from the coffee shops. And away from the streets they know.

In other words, away from the community.

Al Power and The Green House Project are bringing elders back to a space where they know the greater community and the community knows them. It is a space that allows for growth, both for the people who serve elders and the elders themselves.

Eventually, Al left geriatric medicine, but he didn’t leave behind his passion for serving elders — not by a long shot. Even before he had left his practice he had already started working with St. John’s Home in Rochester, New York, and had learned about a new movement to revolutionize elder care embodied and supported by The Green House Project.

The Green House vision was the perfect marriage of the physical and operational change along with the philosophical change we really needed to move elder care forward,” explained Al.

“We talk about trying to create independence,” he continued. “But so many of our systems create dependence, make people shut down and feel incapable. I realized how a normalized environment can really liberate those people.”

Now Al Power and the team at St. Johns are focused on normalization. His goal is to maintain the same kind of life for elders in nursing homes as the one they had before they arrived. To do that, St. John’s took the real home concept of the Green House model one step further.

While many Green House adopters had built smaller, person-centric homes to replace the larger institutional-type buildings on their campuses, Al and his team wanted to build their new homes in existing residential neighborhoods. They wanted to bring elders out of isolation, back into multi-generational communities, where they could go to the local gym and the library and walk down the same sidewalk as other people.

Many nursing home executives try to save costs by having a central campus as a base of operations. St. John’s, in effect, wanted the exact opposite; they wanted to decentralize.

Although individual licensing of resident Green House homes proved to be an obstacle with the Centers for Medicare and Medicaid Services, the Green House Project helped resolve conflicts, brought everyone together, and helped St. John’s succeed in desegregating elders from the rest of the community.

In 2012, St. John’s became the first Green House adopter in the nation to locate individual Green House homes in the community. They built two houses, eleven miles away from their campus, in multi-generational, diverse neighborhoods. And it worked.

“When we saw the results,” said Al. “We were even more convinced that it was the way forward.”

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Al Power and everyone on the planning team knew that the St. John’s Home Green House Project would have success stories; they just didn’t know the stories would already be written before the homes even opened.

In preparation for opening day, the St. John’s staff invited family members, elders, and

people from the community to come have lunch. At one table, there was an elder, who Al recognized, sitting with his family. Al also knew that the man needed help from people to lift him up from one chair to another at his traditional nursing home.

Al ended up joining the man for lunch. When they finished their meal, the staff brought over the elder’s wheelchair. But before they could assist him, the man got up and got into the chair — by himself.

When one of the staff asked him how he did it, he said. “I don’t know, I guess over there I’m supposed to be sick.”

Al and the entire team at St. John’s have learned to expect more of the elders they serve. And by raising the bar for long-term services and supports in the community, they are inspiring providers everywhere to expect more of themselves.


On the Frontline: Randy Stoll and Mt. San Antonio Gardens

By / Posted on May 21st, 2013

Randy Stoll once watched a woman on staff wash a wall in the skilled nursing facility where he’s the president and CEO. He noticed how she washed—from the bottom up. Smart, he thought, that way there are no drip marks. But what he really noticed was that she was wearing high heels. She wasn’t a housekeeper—she was a director—but she knew how to do every job.

Randy knows about this. Not the drip marks maybe, but the idea of a versatile worker—everybody being able to do everything, everyone being responsible. While he’s currently the president and CEO of Mt. San Antonio Gardens, a Life Care senior community in Southern California, he started off in a completely different place and got there via a different route. Some people come up through academic programs in administration, which Randy would eventually do, but first, he worked at a hospital.

“My dad was a stickler,” he said. “When I quit college he told me to go get a job, so I did—first as an orderly—and I loved it. I was serving the patients—they were my customers, not the hospital.” Eventually he became a housekeeper, a supervisor, and then a director. And after doing almost all the jobs that he could within the hospital, only then did he go back to school in administration—another versatile worker.

Today Randy oversees an entire team of versatile workers at Mt. San Antonio Gardens, a senior community in Pomona, CA. This summer, the Gardens will open the Evergreen Villas—the first Green House retirement homes ever built in California.

“The Gardens has always been a ‘resident-driven’ community,” he said. “I inherited that when I came on board in 1995. There have been six residents on the board for years.”

And over time, the Gardens did everything they could to keep up with that ethos—remodeling social spaces and common areas, putting in flat screen TV, hiring skilled nurses and training the staff thoroughly and ethically—but the traditional medical-model skilled nursing facility just doesn’t lend itself to providing person-centered care that would be attractive to elders. Randy knew there had to be a better way.

Having tried all they knew, some key stakeholders visited the first-ever Green House home in Tupelo, MS. Intrigued by the model’s promise, they then sent five residents with a board member to visit The Green House homes in Lincoln, NE to gather information and stories about the concept. Everyone came back wanting to bring this model home to California.

“Green House homes gave us the best chance of surviving without creeping back to the old way of doing things,” Randy said. “The Green House Project provided the philosophical framework and the extensive training and support we needed.”

Green House consultants also shepherded Mt. San Antonio Gardens through regulatory and legislative processes by calling state senators and seeing it through to approval.

Randy knew that The Green House model would help the Gardens improve upon the delivery of their core set of values which are built on the principles of person-driven care. He knew it could be a complete culture change. They all knew. But Randy also understood that while the residents would approve it, and that eventually he would get the state to approve it, he also wanted something else.

“The CNAs, the front-line caregivers,” said Randy. “They’re the ones who are really there at the end of life. They’re the ones who should be enabled to be advocates for the residents.”

It took over two years to get it pushed through the state, and during that time, five housekeepers went back to school to become CNAs at the new Green House home. Instead of the director of housekeeping being upset that 25% of his housekeeping workforce were transitioning to the new homes, he knew that if the employees wanted to be there, that it would make a difference to the residents. In fact, he threw a party for them and invited the residents.

“ Isn’t it nice that my favorite friend will be there to care for me?” Randy heard one resident say.

Continuity of care is part of the culture. Everyone on staff at the Evergreen Villas were employees at Mt. San Antonio Gardens. And that’s just one of the reasons Randy says that from an operational standpoint, The Green House approach costs the same to operate as the model it is replacing, not including depreciation. “But we didn’t do it for the money,” he emphasizes. “We did it for the residents and staff.”

It goes both ways, as the residents have pitched in, privately donating over $1.3 million to the Gardens—not a couple lump sums, but a bit from each of the 400 residents currently living there. They knew they were all working towards something good. Something that should be universal: Real care.


Going Home: Ron Yoder, VMRC, and THE GREEN HOUSE® Project

By / Posted on March 21st, 2013

Ron Yoder has a deep memory of being a young child and, every weekend accompanying his parents to visit his grandfather, who had suffered a debilitating stroke. Ron remembers him in a bed in the living room, being cared for by the family. He remembers him in his home…and dying in his home.

Years later when Ron’s father got older and sick, the family got to a point where they couldn’t care for him anymore and eventually his father was transported to a nursing home. Ron was four hours away by car. His father died there. It felt different.

Maybe Ron knew it then or maybe he knew it later, but eventually he admitted to himself, “I’m the generation that’s not caring for their parents.” And he knew he needed to do something about it.

This is what Ron Yoder carried into his office when he became president of Virginia Mennonite Retirement Community (VMRC) and Woodland Park, a long-term care facility in Virginia, in early 1999. He also carried with him not a health-care background, but a business background, and a track record of making places better. And he carried his ability to listen.

So when he first came to work, he didn’t go forward. Instead, he went back—all the way back to the founding, planning, and vision documents that VMRC’s advisory board had crafted in the 1970s. What he found were articles about “normalization”—a desire to carry forward the residents’ patterns and conditions of everyday life. That stuck.

What also stuck was VMRC’s track record of following that path and implementing some radical change every decade. He wondered what he would do. He thought of normalization and how its intellectual and philosophical framework could help shape the design of new programs and upgrading of existing programs and facilities. That’s when he found The Green House Project and saw how perfectly the two aligned.

By the time he started, VMRC already had made innovations such as creating “neighborhoods” instead of corridors—an innovation that took place before Ron got there, but residents still needed more private space and still had to share rooms divided only by curtains. Ron knew that wasn’t home. It became a moral imperative to keep moving toward normalization. In The Green House model, Ron and VMRC found what they were looking for.

They found the blueprint for a system that could offer to someone who needs complete living care an environment that is home.
“There were other models out there, but most still used a lot of the same central services,” he said. “None went as far as The Green House Project does in creating a home environment. None rose to our levels of value—our philosophy.”

So VMRC signed on with The Green House Project, who provided a practical model and a plan for success. The Green House Project also gave VMRC a network and an association of project adopters so that it would continue to be a member of and contributor to a learning community.

The Green House Project had data showing increased satisfaction of residents, employees, and families, and it also shared the research it had conducted on other projects showing an increase in positive clinical outcomes. It was that last result, combined with the alignment in philosophy, in caring, and in dignity that solidified VMRC’s decision to work with The Green House Project.

VMRC opened three Green House homes this January in their Woodland Park neighborhood, with plans to build 10 in the future to replace the entire institutional environment. They’re all full. Actually, they were full before they opened. They had chosen one existing “neighborhood” of VMRC with around 30 residents, plus staff, and offered the new model to them as an option. Most residents and staff said yes.

And although the data is just coming in, the stories are already here. Ron was in the wellness center doing his strength training the other day and saw one of the new residents.
“Morris, what’s the news from Woodland Park?” he said. “You still happy?”

“Yes, yes, still happy,” Morris replied. “Actually, I heard one of the other residents say, ‘I never thought I’d live long enough to go home.’”