By Claire Lucas / Posted on October 17th, 2017
Many traditional nursing homes are scrambling to meet the new person-centered regulatory standards; however, it is business as usual for Green House homes. What set’s Green House homes apart is the comprehensive transformation of the homes… physical design, organizational structure and philosophy of care are all changed to reflect elder-directed care. The three Core Values: Real Home, Empowered Staff & Meaningful life provide a guidepost for establishing operational practices.
CMS is placing a larger focus on use of non-pharmalogical interventions and staff having appropriate competencies and skills. Appropriate treatment and services for Elders living with dementia is also emphasized in the new regulations.
A key element of The Green House model is the use of specially trained versatile workers, whose responsibilities include food preparation and service, activities, light housekeeping, and laundry. The versatile workers are called Shahbaz, and are Certified Nursing Assistants who receive an additional 128 hours of education which encompasses all elements of their work including infection control procedures, culinary skills, dementia, communication skills and activities. Not only are staffed provided the training they need, but consistent staffing allows for Shahbazim to get to know their Elders, establish strong bonds of friendship. Being well-known supports allows for non-pharmalogical interventions to be effective.
Residents Rights has become the largest section in the new CMS regulations.
Shahbazim understand that one of their fundamental roles is to nurture, sustain and protect the Elders in their care. Elders are in control, driving decisions in the home from menu choices to daily activities. Staff learn about how to provide Meaningful Life to elders in their care, including honoring their natural rhythms. Elders can sleep in and go to bed when they wish.
New regulations set new standards for care planning.
Elders can decide who attends and now must participate in setting goals. A nurse aide and a member of food services staff are required to attend care plan meetings. Again, this has always been part of the Green House model. Shahbazim lead the care plan meetings. Because they are consistently assigned to work in one home, they know their Elders well. Staff are coached on how to respect Elder’s wishes, while informing them of risks and benefits of proposed care. Ultimately, the Elder decides.
Grievances must be acted on quickly by staff and recommendations from Elders must now be considered. In a Green House home staff are talking to Elders daily, hearing their concerns and following up on their issues in “real time.”
Shahbazim are empowered and therefore can often make immediate changes to address Elder’s concerns, eliminating the need to go through a long chain of command to have issues heard and changes made.
CMS has put more emphasis on creating a “homelike” environment.
Green House takes it to another level providing “real home.” Every elder has a private bathroom and their own bathroom/shower. Elders can personalize their bedrooms, bringing in many items from home.
Meaningful Engagement is now a greater focus of new regulations.
Elders must be provided with a choice of activities that encourage both independence and interaction with the community. Activities in a Green House home include a combination of planned and spontaneous events, with a majority of activity occurring naturally and recorded as appropriate. Although the full-time activities director will act in a facilitative role, providing assessment and evaluation of activity preferences and individual engagement, assistance with activity programming, coaching and teaching; versatile workers within each home will have primary responsibility for leading meaningful and engaging activities on a daily basis. While anticipated activities can be scheduled, the spontaneity fostered in a Green House home means not all activities can be planned. Some programs will occur naturally, such as folding laundry, a family visit, or assisting with the day’s meal.
The Green House team is proud of the work of our adopters and the strides we have made to lead the field, creating better lives and better jobs.
By Rachel Scher McLean / Posted on April 7th, 2017
As thought leaders Green House adopters lead the way by supporting, and deeply knowing each individual living in their homes. With the introduction of new CMS regulations comes the opportunity for Green House homes to demonstrate how the model is designed to ensure each elder is able to live on his/her own terms. “Language and being focused on the elder vs. the disease, makes a difference. At The Green House Cottages of Carmel, we developed our policies and procedures prior to these new regulations, and it felt great to see that what we knew in our hearts to be right, was reflected in government mandates.” said Melody DeCollo, Guide of The Green House homes of Carmel, in Indiana.
The Green House Project invited, Carmen Bowman, a nationally recognized expert in all things regulatory and culture change to facilitate two webinars exclusively for The Green House Peer Network about the new CMS regulations. In these webinars, Carmen highlighted where, specifically, the new regulations support The Green House Core Values, and how Green House adopters can leverage them to even more fully realize the benefits of the model. Says Carmen, “There is power in the institution to shut people down, and there is power in the home to bring people back to life.”
There were many areas to highlight, but here are a few of the hot topics:
Language – Words Matter! Where are the opportunities for Green House adopters to utilize language that is more person-centered and less institutional?
- Community (or home) vs Facility
- Individual vs Resident/Patient
- Real Home vs Homelike
- Meaningful Engagement vs Activities
- Approaches vs Interventions
Proactive Approach- How can we learn to be ‘preventionists’ and align with an elder’s natural rhythms, patterns and preferences to meet their needs before an issue escalates?
Daily Community Meetings – How does The Green House model support teams to approach issues in real time to emulate the concept of daily community meetings? Where are the opportunities to involve/engage elders in decision making
Care Planning – What are Green House adopters doing to ensure Shahbazim (direct care staff), elder, and family voices are heard in care plan meetings? How can we intentionally gain the rich information that yields deep, knowing relationships?
Highest practicable level of well-being – By intentionally focusing on the physical, social and mental wellness of the person, it expands and elevates the experience. What do individuals need to thrive?
Creating Real Home and Personal Belongings – “We really want to know who you are, so please bring in things that are special to you to decorate our home”. WHO is doing WHAT to ensure elder’s personal belongings are brought into the home/their room?
Meaningful Engagements – Take a moment and consider, is it real life, or fake life? Break apart the word to understand… What is meaningful? What is engaging? People want to make a difference, how can we support people to live lives of purpose?
Food and Nutrition – What are Green House homes doing that showcase the power of deep knowing that supports individual preferences? What can we do to expand ‘choice’ and offer it around the clock.
These new regulations were created in response to person-directed care, that means that our work to change the culture of aging is making a difference! We need to keep telling our stories, and letting the world know that aging and long term care can be different. We want to hear from you! If these new regulations are supporting you to shine—email us at firstname.lastname@example.org.
By Rachel Scher McLean / Posted on October 8th, 2015
The Green House Project works with organizations in over 30 states to innovate long term care in a way that meets or exceeds the highest level of the regulations. Collaboration with state regulators is pivotal to the success of the movement and well being of elders. To build and deepen relationships with regulators, Senior Director of The Green House Project, Susan Frazier Ryan, recently attended the Association of Health Facilitator State Agencies (AHFSA) conference in Charleston, South Carolina. This conference is an important opportunity to engage in dialogue with state regulators of skilled nursing homes and ensure that there is a clear understanding of The Green House model.
“We believe that providers and regulators share the goal of creating the highest quality environments and experiences to serve people who require long term care, and help them ‘attain or maintain their highest practicable level of well being.’ In order to achieve the goal and move the field forward, it is imperative that providers and regulators do not work in silos, but rather build mutual respect for each other’s vital role,” Ms. Ryan states. The Green House Project supports organizations to partner with regulators and create real homes where people live meaningful lives.
By Tara Cugelman-McMahon / Posted on November 15th, 2013
On December 5th, Carmen Bowman will be presenting a webinar on Tools to Operationalize the New Dining Practice Standards. The New Dining Practice Standards were released in August 2011 and thanks to the generous support from the Hilda B. and Maurice L. Rothschild Foundation, Pioneer Network convened a Task Force to develop the Dining Standards Toolkit. To register for this webinar, click here.
This webinar will: 1) summarize the new dining practice standards and how they support residents to eat the food they want to eat, 2) explain how the standards are backed by research, and 3) describe the tools that will be available to help operationalize the new standards.
Carmen Bowmen is the owner of Edu-Catering: Catering Education for Compliance and Culture Change. For 9 years, Carmen was a Colorado surveyor and a policy analyst with CMS Central Office where she taught the national Basic Surveyor Course. Carmen also co-developed the Artifacts of Culture Change tool and facilitated both CMS/Pioneer Network Creating Home national symposium, Culture Change and the Physical Environment Requirements and Culture Change and the Food and Dining Requirements, among many other accomplishments.
By Anna Ortigara / Posted on January 21st, 2013
Eighty percent of Green House homes serve Elders with skilled care needs. The model strongly supports Elder choice and relationships but Quality of Care is also important to support meaningful lives in real homes. The case needs to be made for quality clinical outcomes from deeply transformative models like The Green House Project.
EQUIP for Quality* is the quality tool used for clinical benchmarking by The Green House Project and all skilled Green House Projects are encouraged to participate in data collection.
This report represents the MDS 3.0 data from 10 skilled Green House Project organizations from third quarter 2012. This is a snapshot in time, but very important in understanding quality of care in Green House homes. Below are Quality Measures where these homes performed significantly better than national benchmarks:
• Percent of Residents Who Self-Report Moderate to Severe Pain (Long Stay)
• Percent of Residents Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine (Long Stay)
• Percent of Residents Assessed and Appropriately Given the Pneumococcal Vaccine (Long Stay)
• Percent of Residents Who Have/Had a Catheter Inserted and Left in Their Bladder (Long Stay)
• Percent of Residents Who Have Depressive Symptoms (Long Stay)
• Percent of Residents Who Received an Antipsychotic Medication (Long Stay)
• Percent of residents who have behavior symptoms affecting others (Long Stay)
• Percent of Residents Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine (Short Stay)
• Percent of Residents Who were Hospitalized in the last 100 days (Long Stay).
Other Quality Measures were similar to national nursing home benchmarks.
Two measures that are particularly targeted in long term care today are re-hospitalizations in the previous 100 days and the use of antipsychotic drugs. These show significantly better performance during this period of time and are considered areas of both high cost and clinical significance in understanding and managing care transitions. All indicators are important to guide the understanding quality of care in Green House homes. Having regular data provides deeper understanding of the model and sharper targeting for education and process redesign within the model. For more information contact Aortigara@ncbcapitalimpact.org
*EQUIP for Quality, Leading Age New York www.equipforquality.com
By Carmen Bowman / Posted on October 15th, 2012
Drs. Judah Ronch, Dean of the Erickson School of Aging, and Dr. William Thomas, founder of the Eden Alternative and Green House Project, have coined a new term and developed a new concept called surplus safety. Instead of risk meaning the possibility that only something bad might happen, they teach that the real definition of risk is the possibility of an unanticipated outcome. They further explain that there are two kinds of risk, upside and downside. Downside risk is an outcome that is worse than expected and upside risk is an outcome that is better than expected. They point out that our obsession with downside risk unfortunately leads to the taking away of any chance of upside risk for those living in long term care environments and that we prevent outcomes better than expected (upside risk) because we our obsessed with minimizing the risk of a worse outcome. Dr. Thomas as a physician and Dr. Ronch as a psychologist point out that no other part of the human life cycle allows this removal of upside risk. For instance, we do not restrain toddlers as they try to learn to walk because they might fall. Not too many people talk about our development and growth at an older age but thankfully they do. Each advocate that our human development includes a balance of both upside risk and down side risk.
The current landscape of safety where the current conception of risk includes only downside risk – in which harm may come to elders if they attempt certain activities such as getting out of bed – has resulted in very restrictive policies and practices, such as bed and chair alarms. Many safety measures, such as alarms, are designed with only downside risk management in mind i.e. preventing falls. However, the upside risk of preserving one’s ability to continue walking and to keep their balance and strength are not evaluated. Nor is the other downside risk of losing these abilities talked about. Nor is the quality of life considered according to the person of being immobilized by an alarm or agitated or isolated. Therefore, there is a strong need to look at upside risk management in addition to the traditional focus of managing downside risk.
Thus the first-ever Surplus Safety Symposium was held on September 12 – 13, 2012 in Baltimore, MD. Many thanks to the Hulda B. and Maurice L. Rothschild Foundation for funding and to the Erickson School for hosting this event.
Approximately 50 stakeholders from a diverse group of constituencies discussed the current state of the safety landscape. Experts addressed the areas of: Policy as Written and Interpreted; Risk Assessment Methodologies; Case Law; Management and Workforce Conditions; and Resident Perspective presenting key issues and identifying levers of change. Workgroups then recommended ways to implement a strategy to change how risk is perceived, understood, managed and regulated.
The goals for the two-day symposium were to:
1. Identify strategies to promote a full evaluation of risk vs. potential outcomes in long term care.
2. Reframe the current concept of safety to better balance both upside and downside risk potential.
3. Identify codes and standards which should be addressed in order to better balance upside and downside risk.
4. Identify stakeholder groups to enlist in seeking necessary code and standard changes.
Some ideas collected (not consensus) were the following:
• Consider using probability instead of potential for harm in the CMS scope and severity grid; gather the research to back the use of probability of harm instead of potential which can be anything.
• Consider adding to every regulation “if the resident desires” or “according to the resident;” for example, Tag F363 Menus be followed if the resident desires.
• Discontinue making policies for the 1%, make the policies for the 99%. Broad global policies limit life for the 99%, individualize polices by stating that individual care plans will be adapted for each person in relationship to risk, safety, etc.
• Copy the CMS survey process for homecare where whatever provider has done is recognized and considered into survey findings.
• Incentivize like Colorado P4P bonus reimbursement and Ohio Medicaid Reimbursement where homes must implement a subset of person-directed practices in order to receive full reimbursement.
• Include each person’s goals for themselves and their perspective on risk. This should be individualized based on how much risk they want/can tolerate. Kind of like investing in 401K plans, some of us prefer low risk, others moderate or high risk. Risk needs to be determined by the Elder primarily, and not by surveyors, corporate leaders or other professionals who assign this determination based upon what they think is best for all parties involved.
• Concept of safety is one dimensional regarding the body. Need to add mind/spirit, psychosocial.
• Immediate Jeopardy includes potential for harm which is so very easy to cite, easier to cite IJ than a G. This needs to change because it has the greatest sanction associated with it – possibly move potential for harm somewhere lower down on the grid.
• Equitable attention to all relevant regulations; treat all requirements the same. Preventing accidents is just as important as resident has the right to refuse medical treatment or right to choice.
• Eliminate FOSS/federal surveys as they are over burdensome and do not result in better care for residents; redirect those resources to training of how culture change practices embody intent of OBRA ’87 Nursing Home Reform Law and current regulations.
• Explore legal strategies to promote resident choice and consistent enforcement of all regulations.
• Recognition that accidents happen – differentiate between accident and neglect/systems failure.
• Reconsider the current metrics for success and incentives: do we incentivize surplus safety or highest practicable physical, mental and psychosocial well-being?
• Research the benefits to upside risk.
As you can see, many good ideas on how to eliminate surplus safety were collected. According to Rob Mayer of the Hulda B. and Maurice L. Rothschild Foundation, this is just the start. Be on the alert for more to come. In the meanwhile, do whatever you can to promote the balance in every person’s life of both upside and downside risk. Better yet, do all you can to promote that the person continues to be the boss of their life. Promote this daily with persons you serve. Call for meetings with your survey agency that is to serve the persons living in nursing homes and assisted livings in your state. Lean on your state culture change coalition to bring up these issues in already-established stakeholder meetings. Don’t wait for someone else to do something. See what you can make happen. Go get famous. Eden has a great motto: “It’s Time.” Actually, it’s past time. We all want better.
Carmen Bowman, Regulator turned Educator, owner Edu-Catering: Catering Education for Compliance and Culture Change and Facilitator of the 2012 Surplus Safety Symposium
By mhonig / Posted on August 10th, 2012
The Pioneer Network’s National Conference in Jacksonville, FL, challenged participants to build a bridge to a new culture of aging. Skip Gregory, retired Bureau Chief at the Agency for Health Care Administration (AHCA) in Florida, is building that bridge with patience and regulatory resourcefulness.
Nearly every new neighborhood, small house and Green House home is impacted by codes. Building codes, fire codes, and design codes alike, “exist to provide minimum protection,” said Gregory. The August 6th all-day intensive Defining the future of long term care included a discussion on how regulations are “transforming to better support person-centered care.”
The 2012 NFPA Fire Code now allows for furniture in a nursing home’s eight foot corridor. And, gas fireplaces are OK in sleeping areas (though not in bedrooms). Alternate Methods Section 104.11 of the International Building Code (IBC) supports creative approaches to design and equipment. ADA code section 2.2 affords “wiggle room” that includes smarter bathroom design for Elders and their care-partners.
Green House adopters should connect with their Project Guide and architect to learn more about how new codes support their vision for real home. For more information on The Green House Project and its regulatory successes, please visit www.thegreenhouseproject.org.
By mhonig / Posted on February 24th, 2012
Is there a time where you found institutional rules and practices getting in the way of an Elder’s quality of life? Have you ever wished you could ask CMS a question to gain clarity on how to best serve an Elder while meeting the regulations? If so, stop rubbing that genie bottle because your wish has been granted!
Earlier this morning, deputy division director for the Nursing Homes Division at the Centers for Medicare & Medicaid Services (CMS), Karen Schoeneman ,challenged us all to brainstorm questions we have around culture change. In her role with CMS, Karen and her team administer the long-term care survey process, the interpretive guidelines and the Quality Indicators Survey process. In addition, Karen and her colleagues commit to publishing a Q&A letter that tackles hot topics in culture change.
As champions of The Green House model and the appreciative inquiry approach, what would you like to see addressed in their next publication? (Don’t worry about Life Safety Code, as that issue is being addressed in a separate response.) We’ll collect all of your thoughts and send them to Karen ASAP!