THRIVE research: Examining deep culture change adoption in the Green House model

By / Posted on June 26th, 2012

The Green House Project has partnered with the Robert Wood Johnson Foundation’s THRIVE (The Research Initiative Valuing Eldercare) collaborative to learn more about the Green House model as well as other models of care. Supported by the Robert Wood Johnson Foundation, the THRIVE team is conducting a series of interrelated research projects that together will comprise the largest research effort undertaken to date in Green House homes. Each month, a member of the THRIVE team will contribute a blog post to the Green House Project website.

There’s an old saying, “you can’t know where you’re going until you know where you’ve been.” The culture change movement is a shift in philosophy towards a more person-centered model of nursing home care. Green House specifically, and the nursing home culture change movement more generally, has grown tremendously over the past two decades. If policymakers are to further encourage adoption of this model, they need to better understand the factors that promote adoption of the model. To help, the THRIVE research team examined nursing home adoption and non-adoption of “deep” culture change as well as of the Green House model specifically. 

Where has Green House Been? The results suggest culture change adopters are more likely to be nonprofit, faith-based, independently-owned, located in urban areas, and larger in size. Settings that eventually adopted culture change or the Green House model initially had fewer minority residents, lower Medicaid census, and lower resident acuity.

Those that didn’t adopt had more survey deficiencies, lower registered nurse staffing, and a greater debt relative to assets. Greater culture change adoption occurred when states rewarded adoption in t their pay-for-performance (P4P) system, had a culture change coalition, and paid a higher Medicaid per diem.

The bottom line finding is that, to date, nursing home culture change models such as Green House have been adopted differentially by higher resource organizations, and that nursing homes are responsive to state policy factors when adopting culture change. 

Where is Green House Going? Deep culture change such as the Green House model requires significant investment, vision, and leadership on the part of nursing homes. Not surprisingly, our findings suggest resource-challenged organizations have lagged behind in the adoption of culture change and the Green House model.

Medicaid nursing home payment policies such as P4P can be used as an important first step towards expanding the number of settings adopting Green House. Other policy and related efforts to promote Green House might include regulatory changes, quality reporting, lowering the costs of capital, and workforce enhancements. However, states will need to develop additional policies and incentives to target resource-poor settings that have higher numbers of Medicaid enrollees and minorities.