Green House Blog

Visiting Mt. San Antonio Gardens, A Reflection on The First Green House Project in California

Visionary leader Randy Stoll, CEO of Mt. San Antonio Gardens, and his dedicated team have been toiling away for years to navigate California’s complex regulations in order to introduce the very first Green Houses to the state. As we toured the construction site, you could see the home taking shape – the fireplace, the kitchen, plenty of windows and the 10 bright, private bedrooms with private baths and showers. At the end of the tour I thought – the day the elders move in, these two homes will immediately become the top two places to receive skilled care in the state.

I felt a great sense of relief to see Green House homes under construction on the campus of Mt. San Antonio Gardens. After all, I have been a licensed Administrator in the state of California since 1989. We have over 1,150 licensed Skilled Nursing Facilities here – more than any other state. In California, many well-intentioned providers are struggling to deliver high quality care and service to over 100,000 people each day. The typical setting is an old institution with 2, 3 or 4 beds per room with an adjoining single bathroom (one sink and one toilet for 4 – 8 people to share). Speaking from experience – we paint the walls, we buy new beds, we add flat screen TVs, but…at the end of the day, it’s still not the place we would want for our loved ones or ourselves.


I am grateful for the leadership team at Mt. San Antonio for making this happen. California needs to see this. When The Green House homes open this spring, California’s providers, regulators and policy makers will see the future of skilled nursing care. It represents a radical change from what we are all used to, because, these Green House homes are the places that we would want for our loved ones or ourselves.

Environments for Aging, Impact of Community based Green House homes

Green House Chief Operating Officer, Susan Frazier, joins SWBR architect, Rob Simonetti, to present, “A Community-based Green House Approach—Development Goals, Opportunities, and Outcomes” at the upcoming Environments for Aging conference in New Orleans on Monday, April 8 | 9:15 a.m. – 10:15 a.m (we are exhibiting: BOOTH 103)

This seminar will explore the unique development opportunities available to providers and developers collaborating to provide healthcare via a decentralized community based approach. Presenters will explore the objectives of (re)integrating elders into their hometown communities in lieu of a centralized healthcare campus.

Participants will consider opportunities to leverage the strength and skills of local developers in this effort. Using the nations’ first Community-based Green House project as a case study, attendees will examine common goals of the provider and developer and will learn the potential marketing, cost, and approval benefits associated with pairing a healthcare occupancy with a small scale residential development.

Notes from The Green House Director: Achieving the Triple Aim of Long Term Care: Quality, Health, Affordability

Recently, I was honored to speak at the Michigan LANE (Local Area Network for Excellence) conference in East Lansing that was attended by close to 300 dedicated leaders of skilled nursing facilities.  It was there that I was reminded of the Centers for Medicare and Medicaid Services (CMS) Triple Aim –

1.) Improve the persons’ experience of care – both quality and satisfaction

2.) Improve the health of people and the community’s health

3.) Reduce the cost and wasteful spending

I feel confident that The Green House Model addresses all three of these goals.  And we have a significant amount of independent research to support this feeling.   Thanks to the support of The Robert Wood Johnson Foundation, The Weinberg Foundation and AARP, model is spreading and Green Houses nationwide have the outcomes that hit these marks and outpace traditional SNF’s.

After the LANE event, I stayed in Michigan and I saw an excellent example of how visionary leaders in Michigan collaborated in order to hit the CMS Triple Aim while helping to revitalize downtown Detroit.  I had the opportunity to tour the new Rivertown Neighborhood, an affordable senior community that will provide over 770 seniors access to desperately needed housing and supportive services.   The grand opening is April 12th.

Presbyterian Villages of Michigan (PVM), in collaboration with Henry Ford Health System and United Methodist Retirement Communities, have creatively adapted an old dilapidated pharmacy plant and expanded The Center for Senior Independence (CSI) program (nationally recognized as PACE).  Two Green Houses serving 20 – 24 elders will be an integral part of the Rivertown Neighborhood.

At the end of the tour, Roger Myers, the President and CEO of PVM, and his incredible team of partners, brought us into bottom floor of a cold, open space of a four-story brick building attached to the beautifully renovated building.   None of the floors were in the building so that you could look up to the ceiling that was 4 stories up.  This is where a huge vat of cough syrup used to brew and this is where the two Green Houses will sit on two floors above a café.

The Rivertown Neighborhood demonstrates how we can tackle complex social factors that effect elders’ heath and their well-being.   Over 200 employees (and Shahbazim) at Rivertown will address the social determinants of health, and the healthcare, of hundreds of the community’s seniors every day.  In so doing, they will give peace-of-mind to thousands of the elders’ family and friends.   Its’ an exciting project and am thrilled the Green House Project is a part of it.



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

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.’”

Quilt Sections Made by Elders for Green House Project

Residents of the Green Hill Green House® Homes created four custom quilt pieces in celebration of the 10th Anniversary of The Green House Homes project. Each open and operating Green House Home in the country are contributing to the Green House Homes quilt which will be on display at The 6th Annual Green House Meeting and Celebration in Boston Mass in November 2013.

Stories of Love and Family from Boersma Cottage

While attending a Green House Conference, one of the main things that was discussed was “The Story”. The Story as they say has a beginning, middle, and an end, it can be a sad story, a happy story one with lots of twists and turns or it can be a very simple story. My story, or rather, our story, is all of the above and more.

At Boersma Cottage, The Green House home at Resthaven Care Community in Holland, MI, there is an Elder who lives with Muscular Dystrophy. Through his illness, he is confined to a scooter and he finds it hard to lift his head. It is a struggle every day for him to perform everyday tasks, yet it rarely slows him down. He has a son that struggles in his day to day life as well and is in need of a liver transplant. On a cold night in November, our Elder received a phone call that struck terror into His heart, as it would any parent. The call was to say that the Elder’s son was enroute to the hospital, and they didn’t know if he would pull through. Our Elder was upset, to say the least. The Nurse and the Shahbaz on duty instantly knew something terrible had happened and stepped up the plate to help. While trying to find out answers, we focused on the needs of the Elder, since he was worried sick, not just for his son, but also, his wife.

So we did what needed to be done even if it meant we were going to have to load him and his scooter up in the back of our Nurse’s pickup truck to get him to the hospital. We called to our legacy home and found our ever-willing Floor Man and asked him for a huge favor. We asked if he could please drive our Elder to the hospital so that he could be with His son and Wife? We had no sooner asked than he called his supervisor who said he could use the van to drive our Elder to the hospital. In less than 15 min our Elder was loaded up and on his way to the hospital. His wife was surprised as all get out when her husband came rolling into the hospital. She needed the support and our Elder got to be what he is, “the Man of the House”. Our Elder got to see his son whom he hadn’t been able to see in 4 months due to his son’s illness. He was able to reassure His wife and son and be with them in a great time of need. When our Elder arrived back home he was relieved and very happy. It was one of the very few times that we got to see our Elder smile.

I am proud to say that I am part of an amazing team that will do whatever it takes to be there for our Elders. Everyone was so willing to pitch in, everything worked smoothly, as if every move was pre-planned. Our Elder thanked us repeatedly for helping him, and each one of us told him the same thing, “We are a family and that’s what families do. God blessed us to be together and together we all are family. “

Our story is ongoing and I am sure there will be many more twists and turns, but to end this tale on a wonderful note , our Elder’s son did get his liver and is doing well. Thank you God.

Empowerment is Foundational to Success: Herzberg and The Green House Model

One of the subjects that have befuddled Long Term Care leaders over the years is worker motivation. One of the foremost researchers in this field is Frederick Herzberg, an industrial psychologist. It is Herzberg’s work on motivation and job enrichment that strikes at the heart of the success of self-direction concepts that are so foundational to The Green House model.

In the 1960’s, Herzberg proposed that a person’s needs break down into two categories: hygiene factors and motivational factors.
Hygiene factors relate to what makes us work and our biological needs, such as providing food, clothing, and shelter. Herzberg says we have a build-in drive to avoid pain relative to these needs, so we do what is necessary, such as work, to provide what we need.

Motivator factors, however, are very different. These factors include those specific items related to what makes us work well such as achievement, and through achievement, the ability to experience psychological growth.
Herzberg used the term job enrichment to describe how the motivator factors can be used to achieve higher levels of satisfaction with a job. The following list was taken from his Harvard Business Review article of 1968 (reprinted in 1987) entitled, One More Time…How Do You Motivate Employees? Take particular note of how closely these factors align with concepts embodied in radical workforce redesign with The Green House model.

Herzberg said that meaningful job enrichment involves the following:
1. Removing controls while retaining accountability.
2. Increasing the accountability of individuals for their work.
3. Giving a person a complete natural unit of work.
4. Granting additional authority to employees in their activity such as job freedom.
5. Making data and reports directly available to the workers themselves rather than just to supervisors.
6. Introducing education programs designed to enrich critical thinking skills.
7. Assigning individuals specific assignments or specialized tasks, enabling them to become experts.

It is surprising to think that Herzberg first discussed these concepts in the 1960’s, but that we are now just beginning to incorporate them through innovative models. In the elder care field, we have a mountain of research that supports the link between frontline caregivers involvement and improved clinical outcomes of care and quality of life. Organizational changes that support self-direction will continue to grow because it makes sense to leaders desperately searching for ways to increase responsibilities of frontline staff as well as the elders’ perception of feeling valued and respected. The Green House model’s systematic approach to workforce redesign and the creation of the Shahbazim, combined with radical environmental redesign, help ensure that the institutional, hierarchical model can’t slip back in.

The empowered Shahbazim that you find within the Green House homes nationwide helps to explain why 83% of Green House projects are ranked as either 4 or 5 Star homes on the CMS Nursing Home Compare website. The Green House model supports the relational coordination among the Shahbaz and the nurses and other staff. The theory of relational coordination states that the effectiveness of care and service is determined by the quality of communication among staff. The quality of staff’s communication depends on their relationships with each other. This theory is highly applicable in healthcare settings where tasks employees perform are closely interrelated. Their interdependence forces the staff to work with one another. But if their relationships and communication are weak, and institutional hierarchies minimize the voice of the elders and their caregivers, then elders’ needs tend to fall through the cracks.

The Green House model develops people’s communication and critical thinking skills so they know what to share and why it’s important. And the redesigned work environment supports good communication creating both a culture of safety and a meaningful life for the elders. Systems and redesigned roles that support relational coordination among staff are the key to the successful outcomes achieved by Green House projects.

Forty-five years ago, Herzberg was spot on. And he still is.

Maria Shriver's Blog Depicts a Sense of Peace for One Family

Maria Shriver is a national voice for Alzheimer’s Disease.  Through her blog, she is able to reach people around the world to give this disease a human face.  Recently a blog about The Green House model, shared how the small environment and deep-knowing relationships, helped to create a meaningful life for one family:

For the last six months, from the day [Joan] moved in [to White Oaks Cottages] on July 4th, Joan has gotten a letter from her kids. Each letter starts out, “Please print and three whole punch for Joan Hogan” followed by “Today is…”

The letters were signed at the end but Joan kept asking, “but who is writing these?” so a third line was added, “This letter is from your daughter, Kathleen.”

Then, in three to four paragraphs, Kathy and her siblings would write what was going on with the family. “We realized we could have sent her the same letter every day, but because we shared it with our extended family, we enjoyed keeping it up to date.”

Joan holds each day’s letter in her hand all day; the news fresh every time she reads it. She shares it with her friends and even reads the letter to Kathy when she calls. It gives them something to talk about.

“What she’s saying is accurate and interesting, it removes some of the frustration.” Kathy jokes, “I wouldn’t need to speak to siblings for a week because she would fill me in on everything!”

For five to six months, Joan was able to put the letters in order in the binder. She can no longer do that, so a bit of organization and assistance is required when they visit.

Kathy says having her mother at a Green House home has been a great change and a big relief.

Green House homes around the country provide a sense of peace to family members, that their loved ones are being treated with value and as an individual regardless of their cognitive or physical abilities.  To read the entire blog and more on Maria Shriver’s site, click here

The Great Personal Alarm Toss…Minnesota Nursing Home has a goal to eliminate all personal alarms creating a better home for Elders

We’re all looking for better ways to impact the quality of life for our Elders and one home in Minnesota has decided to do something about environmental noise—more specifically personal alarms.

About 20% of Episcopal Church Home’s Elders in St. Paul, Minnesota have a personal alarm.  Like many of us, those alarms are usually in place because the Elder is a “high fall risk”.  However, when the staff began to do some research on alarms they learned that by having them it really doesn’t mean that there will be a decrease in the number of falls.  In fact, the alarms at their home increased the amount of noise, fear and confusion for the Elder and those around them. 

So, the team at Episcopal Church Homes has taken the bold innovative step to eliminate all personal alarms!  Read more about their research, decision and steps moving forward…then tell us what you think!

Highlighting THE GREEN HOUSE® Project Team: Marla DeVries

Being an advocate for others is what Marla truly enjoys.  In fact, most of her professional career has been in roles where it has been her responsibility to make sure the voices of others are being heard.  Elders have been her focus for the last 20 years.

Marla began her journey in Michigan as a Long Term Care Ombudsman for a nonprofit group called Citizens for Better Care.  In her position she would visit with Elders to make sure they understood their rights, conducted education sessions for Skilled Nursing Home staff and participated in family and Elder councils.  It was during this time that Marla heard a lecture by Eden Alternative and Green House founder, Dr. Bill Thomas, and within months the Ombudsman program partnered with the Eden Alternative.  Marla became an Eden Specialist instructing her colleagues on the principles of the Eden Alternative.  She implemented a Western Michigan Eden Support group for long term care communities. 

Training and educating others about Elders became a passion for Marla.  In Michigan over 2,500 participants learned about the Eden Alternative through her training programs.  She developed educational materials and learning sessions for Area Agencies on Aging staff in Michigan and became a sought after speaker for long term care conferences.

For the past 5 years, Marla has focused all of her attention on culture change. Most recently she led the management of culture change work teams across five care communities in Utah employing 400 staff positions.

Marla is now sharing her skills and knowledge about Elders and culture change in THE GREEN HOUSE ® Project as a Project Guide.

  • 20 years of experience in aging services—with a passion for culture change  
  • Recipient of the Eden Alternative 2010 Leadership Award
  • Initiated curricula development for state-wide adult abuse and neglect prevention training and train the trainer sessions reaching over 7000 direct care staff in Michigan
  • Eden Educator authorized to conduct Certified Eden Associate training, Eden leadership training, Eden at Home trainer certification, and Eden Alternative Neighborhood Guide workshops.
  • Speaker/Presenter for numerous Utah Healthcare conferences

 Marla thoroughly enjoys the outdoors, especially hiking on a good trail…whether in the sun or snow!  Marla and her husband live in Utah and have 3 children.

Real Home and Real Relationships are Positive for People Living with Dementia (and all people)

At a recent Leading Age Luncheon, CEO of Virginia Mennonite Retirement Community (VMRC), Ron Yoder, shared a story that illustrated the power of home over institution to support those living with dementia

In 2000, VMRC had a secured Alzheimer’s neighborhood in its nursing center. The layout is semi-private rooms on both sides of a middle corridor and a sitting area at the entrance to the neighborhood. When the carpet needed to be replaced, the residents were moved to an assisted living neighborhood during the day while the workers were laying the carpet.

The assisted living neighborhood is “homelike” — private rooms and private baths surrounding common/shared spaces consisting of a dining room, living/sitting room, and residential kitchen.

The first day the residents were in the assisted living neighborhood their caregivers reported that the residents were more alert and active. At the end of the day residents asked, “can we stay here?” and not return to the Alzheimer’s neighborhood.

I remember reflecting that if a “homelike physical environment” has that profound of a life giving impact on residents with Alzheimer’s disease compared to an “institutional environment,” it creates a moral imperative to change.

Several years ago the Alzheimer’s neighborhood in the nursing center was closed. We now have three memory care neighborhoods in the assisted living community for residents with various types of dementia. Residents with dementia who require 24-hour complete living care (need assistance with all ADLs) live throughout the nursing center rather than in a dedicated neighborhood.

The Green House Model takes this concept to the next level through a real home environment, person-centered focus, and deeply knowing relationships that create an ideal space for a person with dementia to thrive.   As a thought leader in the field of aging, The Green House Project recently participated in a TEDMED Great Challenges Series on the growing challenge of dementia. Through this online panel and twitter (#GreatChallenges) conversation, many innovative ideas were shared, with a focus on person-centered care, increased training for staff, and support for caregivers.

Intergenerational Engagement at White Oaks Cottages

Charlene, a nurse at White Oaks Cottages, brings her daughter in to spend time with the elders.  In this video, Charlene shares two endearing stories about the joy that comes from real relationships between elders and children.  You are not going to want to miss these stories, they are guaranteed to bring smiles to your day.