Green House Blog

Who Will Be the Next Champion of Eldercare Reform? Celebrating the Legacy of Claude J. Pepper

In the latest episode of The Green House Project’s “Elevate Eldercare” podcast, Senior Director Susan Ryan sat down with Director of Communications and Marketing Alex Spanko to discuss the life and legacy of perhaps one of the most impactful public servants America has ever had – Sen. Claude J. Pepper, whose journey from an impoverished town in Alabama to Harvard Law School to Congress culminated with the reception of a National Medal of Freedom from President Bush prior to his retirement and passing.

Pepper’s life and career throughout the twentieth century sought to empower not just elders but everyone to live a life of dignity. He championed a staggering number of impactful reforms and regulations, from introducing equal-pay legislation for women to fighting to protect Social Security benefits. Through research as well as clips from a previous interview with Dr. Larry Polivka, who was the director of the Claude Pepper Center in Florida until his recent retirement, this episode aimed to examine one main question: first Claude Pepper – now who? I took away three lessons in leadership from this discussion.

  • The courage to be provocative

Claude Pepper was born prior to World War I and, as such, saw a government capable of complete transformation through the passage of the New Deal and Great Society programs. Today, it’s hard for any of us to fathom lawmakers working across the political aisle to push for radical structural change – in fact, it’s not bold to assume that in today’s climate, something like the New Deal would not pass, although many of us can’t imagine a country that doesn’t support Social Security, Medicare, Medicaid, or food stamps.

While Pepper might have had it easy, therefore, to push for the passage of an enormous number of social programs, it’s also hard to see how any change can be enacted today without a similar push. In today’s political world, it will take guts, decisiveness, and a stubborn streak to push past the status quo.

  • The gift of pragmatic idealism

Some of the greatest leaders in history – Mahatma Gandhi, Nelson Mandela, Martin Luther King Jr. – are now remembered for their relentlessly inspiring idealism. But if idealism is the fire, then pragmatism is the heat that emanates from it. Without a dose of practicality, ideas remain ideas. As mentioned in the podcast, pragmatism in the modern eldercare reform movement might even be a gift.

For example, the Boomer generation stopped a war in the 20th century, and routinely turn out to vote. To generate action, they can be, and are, a huge source of support for the eldercare reform movement. Similarly, there are fiscal reasons to reform eldercare that should be emphasized – chiefly, that we spend millions of dollars on a system that no one likes or wants to find themselves in. There must be a better way to not only be more cost-efficient, but also do better for each other. 

  • The vision to see what could be

As the podcast highlighted, we have a tendency to stop at “good enough.” When so many cogs in the machine of government are seemingly working against social movements, it’s hard to summon the willpower to push for more. Yet everyone in eldercare, and for that matter, healthcare, agrees that the system is broken. When will we do something about it? In my mind, the purpose of an ideal is like a compass, and it’s something that Pepper likely held on to for his life. Without direction, we could be going fast, but we’re also going nowhere.

The last point from the podcast I want to highlight is that of a coalition for change. Although history likes to celebrate its figures as heroes – and there is no doubt that Claude Pepper is one – the fact is that no one can go at it alone. To ask one person to carry the torch ignores the communities that changemakers continually rely on for support – and often, stand because of.

But I think this is a good thing – all over the country, little pockets of people and organizations have been gathering momentum by pushing for reforms in eldercare. When someone, or a group of people, takes it upon themselves to unite everyone, the movement for eldercare reform will quite literally be unstoppable.

Three takeaways from the 99th and 100th episodes of ‘Elevate Eldercare’

This week, colleagues at The Green House Project highlighted some of the most profound insights from the variety of incredible guests that the Elevate Eldercare podcast has hosted. I’d highly recommend giving both a listen – they weave together an inspiring and optimistic narrative of where eldercare has been and where it’s going.

There’s lots more to unpack, but these are my top three takeaways

Eldercare is not one-size fits all

I’ve always thought it was ludicrous that medicine and society push and push for optimal care from the time we’re conceived in the womb – and then suddenly grow complacent when we hit old age. While all the guests on Elevate Eldercare are leaders pushing back on this “default” podcast guest David Grabowski of Harvard summed it up well when he said that we need to reimagine nursing homes while investing in home health care models – it’s not a dichotomous pairing but a complementary one. The needs of a complex and diverse society do not become any less complex when that society ages, and to truly place people at the center of the care they receive, we need to do a better job of getting creative, being flexible, and designing solutions that can fit all kinds of people.

Take more risks

Podcast guest Anne Montgomery of Altarum called it “negotiated risk” – perhaps no other branch of care is as risk-averse as eldercare, but the field is past due for a dose of boldness. If the goal is safety, then maybe perpetually cautious decisions are fair. But if the goal is the holistic wellbeing of elders, then it’s not safety we need to prioritize but social connection, autonomy, joy, purpose, and a connection to the outside world. As Alex Spanko, GHP director of communications and marketing, pointed out in conversation with senior director Susan Ryan, the federal government stalled the streamlining of visitation procedures in nursing homes for almost a full year in the name of “playing it safe.” That means that for one year, nursing home residents lived in isolation, and that should not be normal, even in abnormal circumstances.

Impactful leaders are humble leaders

I was so awed by podcast guest Deke Cateau’s approach in controlling the spread of the pandemic at the organization he leads, A.G Rhodes. During the height of the pandemic, rather than getting defensive at criticisms launched at the nursing home industry, he was humbled by it. One death for them was one death too many, which was a response in stark contrast to homes that defended their policies by saying that at least their death count was low.

The message of Elevate Eldercare has been consistent throughout its 100 episodes – that elders are people, not patients, and that eldercare needs to address the needs of elders, not its own agenda. Here’s to the next 100 episodes being just as radical, visionary, and inspiring as the past ones.

Pat Sprigg of Carol Woods leads through person-centered care

I loved listening to this week’s podcast, featuring senior director Susan Ryan in conversation with Pat Sprigg, the CEO of Carol Woods, a retirement community in North Carolina.

Referencing Maya Angelou

In 1975, Sprigg began her first job working with elders but entered the job with apprehension – she never saw herself working with elders and wasn’t sure whether she would like it. She was quickly struck by how harsh society’s views were on aging, and this one experience formed the philosophy that has shaped her entire career.

Sprigg referenced a famous Maya Angelou quote when she described the environment at Carol Woods: “I’ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.”

Sprigg has worked hard to design a community in line with this sentiment. At Carol Woods, there is no segregation of elders with dementia – everyone lives together. If an elder seems to be having problems, the staff at Carol Woods is trained not to default to a textbook response but to sit with the elder and understand what might be triggering their discomfort.

An example that I absolutely loved was the approach that Carol Woods has taken in caring for elders with dementia that forget how to get back home if they’ve traveled out. Rather than control where elders can go on the Carol Woods campus, staff simply jump on the bus with them and make sure they can get back home. As Sprigg says, “person-centered means person-centered.”

Intentional design

Carol Woods is uniquely innovative in a space like eldercare, which has a long history of doing the same thing over and over, regardless of the negative consequences.

For example, none of the residential buildings are multi-storied – they’re all spread out, like a park, situated in acres of lush green grass, so that elders can get around without the hassle of an elevator or stairs. The health center, rather than being at the fringe of the community, is at the very center, so that the most frail and vulnerable elders are not relegated to being outsiders.

I took two things from this podcast: the first is that people who truly move the needle, in any field, are the people that are uncomfortable with stagnancy and comfortable asking “what if?”

The second thing I took away is that a strong moral compass as acting director can almost replace the need for a physical CEO or ED. In fact, as Sprigg reflected on her nearing retirement, she expressed that Carol Woods has never been dependent on her. That, to me, is the mark of a timeless organization – one that is not profit-directed, but mission-directed.

A flexible, diverse vision for eldercare with Jennie Chin Hansen

This week’s podcast episode with Senior Director Susan Ryan featured Jennie Chin Hansen, who has served as the CEO of On Lok, president of AARP, and a stakeholder in California’s Master Plan on Aging.

A happy, peaceful abode

Much of the podcast focused on Chin Hansen’s time as director of On Lok.

On Lok, which loosely translates to “happy, peaceful abode” in English, started out as a community center providing social services to elders in San Francisco’s Chinatown in the 1970s. When Chin Hansen joined in 1980, the organization merged social services with medical services.

In 1984, On Lok received funding from the Robert Wood Johnson Foundation to see if this model – which had nailed the concept of serving the needs of elders without infringing on their autonomy or desire to live in their own homes – could be replicated elsewhere. As Chin Hansen admitted, at the time, the stereotype of On Lok was that it worked only because it served a largely Chinese, tight-knit population. They aimed to upend this conception, and they certainly did: There are currently 250 PACE models based on the On Lok blueprint in 31 states, serving incredibly diverse populations.

An ecosystem, not a transaction

Chin Hansen talks a little about the role of serendipity in paving her path throughout her career. I thought the process of On Lok’s development was a perfect example of what can happen when you choose to seek out opportunity in the face of uncertainty and chance. For example, the eventual merging of social with medical services happened because On Lok took a look around and realized that the needs of elders were not being met with the single-pronged approach that they had started with. Rather than throw in the towel, they chose to rebrand, resulting in an organic merge that has made On Lok the holistic, reliable care model it is today.

Another story Chin Hansen shared was when On Lok ran into a lack of funding when they wanted to build a nursing home. They were forced to build a community without walls, but this flexibility ended up being its strength, especially during COVID-19, when elders that were ill could still be in their homes, surrounded by loved ones.

Having leadership that embodies adaptability, resilience, and flexibility is perhaps what leads On Lok to be what Chin Hansen calls “an ecosystem, not a transaction.”

Chin Hansen’s vision for eldercare

Chin Hansen ends the podcast suggesting that medicine, for all the good it has done, may not be the ultimate solution to our health and wellbeing. We see this in eldercare all the time –when we prescribe anti-psychotics, limit favorite foods if they’re deemed “unhealthy”, time bathroom breaks, and resign elders to tiny clinical rooms in the name of health and safety.

Though this care is often well-intentioned, I resonated with Chin Hansen’s sentiment that it’s the most inexpensive expenditures that lead to wellbeing. In fact, as she further mentions, studies have suggested that clinical medicine accounts for only 15% of our health outcomes. While we still have a while to go in ensuring that all people have access to this 15%, On Lok and the leadership of Jennie Chin Hansen makes me optimistic that around the country, eldercare will start to look less like a pill and more like family, friendship and feelings of home.

An age-friendly vision for America’s capital city: in conversation with Gail Kohn

Gail Kohn was the latest guest on the “Elevate Eldercare” podcast, in conversation with Senior Director Susan Ryan. A powerhouse leader, particularly in pushing for diversity and community, she is the former executive director of Capitol Hill Village and Collington. Now, she leads the Age-Friendly DC initiative, as part of a World Health Organization project to establish a network of cities dedicated to better aging all over the world.

Simple fixes for a more inclusive city

As Kohn describes, the story behind age-friendly cities is an interesting one, involving the popularity of Rio de Janeiro’s Ipanema neighborhood skyrocketing as a residential area for elders after the real-life “Girl from Ipanema” relocated to a high rise there. Dr. Alexandre Kalache noticed that Ipanema was creating a lot of difficulties, particularly for its aging population, and identified several small but impactful fixes the city could make. For one, he noticed that buses would often pass by stops when elders were waiting there, knowing that it would take a while for them to get on the bus. The bus system at the time was touted for being incredibly punctual, leaving bus drivers no leeway to wait for slower customers. So he pushed for a restructuring of the system that put an emphasis on the number of customers a bus could attract – not the exactness of the time in which it arrived and departed. This quick fix made the city far more accessible to elders.

I was struck by the simplicity of this solution, because it raises the question of what other quick, easy, and effective solutions to people’s problems we’re missing simply because we take our circumstances for granted. As someone who is perpetually running late, I would depend heavily on the punctuality of the Ipanema bus system. I’d likely never consider that the very same system may be rendering the city inaccessible to people who can’t get on the bus fast enough. There is incredible power in empathetic leadership – and significant results that can be obtained just by working to better understand the concerns of others.

Age-friendly DC

Kohn then transitioned to talking about her experience leading the Age-Friendly DC initiative, which comes up on its 10-year mark in 2023. As she describes, the initiative is positioned on top of three main pillars – the built environment, changing attitudes about growing older, and lifelong health and security. It was remarkable to hear about how the built environment was approached. One example that Kohn gave was of a block-by-block walk taken by politicians, students, and community members alike. The walk allowed them to identify possible hazards – such as unclear intersections, potholes, and cracks in the sidewalk – that were promptly fixed.

As Kohn mentioned, 95% of surveyed elders want to live and grow old at home, but for many people, that is not a reality. Considering the rapid demographic shift that not only the U.S but the world is going to experience in the next few decades, rethinking how our cities cater to the elderly is not just a unique, interesting pursuit but incredibly crucial to the quality of life for everyone, young and old.

On discrimination and diversity

There was comment of Kohn’s, attributed to Susan Donnelly of LeadingAge, that particularly stuck with me:We’re discriminating against our older selves when we dislike older people.

This is why I think Age-Friendly DC, and the network of cities under the WHO, is so powerful. Fixing cracks or potholes in a sidewalk helps those of us that are already nearing older age, but those changes will still be around as the rest of us grow older and require more thoughtful design of our communities. Moreover, potholes and cracks don’t just pose a problem to elders – fixing them would help young parents pushing strollers, or people riding a skateboard.

One of my favorite quotes, from Paul Hunt in A Critical Condition, says “The quality of the relationship the community has with its least fortunate members is a measure of its own health.” As a leader, I think Kohn embodies this sentiment remarkably. Whether it was pushing for diversity and neighbor-to-neighbor relationships with Capitol Hill Village, Collington or now Age-Friendly DC, Kohn proves that as a society, we can be committed to lifting everyone up – we just need leaders courageous enough to push for it.

Green House in Wyoming: A Story of Firsts

In 2007, Doug Osborn and Charles Scott of the Wyoming legislature brought a bill up for consideration. The bill would authorize three pilot projects, in three different communities in Wyoming, to study alternative elderly care homes. 

The passage of the bill was a catalyst for radical change in eldercare in Wyoming. Prior to this bill, Osborn and others had traveled to Tupelo MS to study the Green House model of care. They decided to bring it back to the community of Sheridan. 

Two cottages finished construction at the end of 2011, while two more finished in early 2012. The four cottages at Green House Living for Sheridan opened to residents on January 31 of 2012.

But what is truly remarkable about Green House Living for Sheridan is that it was built not by an established religious organization or nursing home company. Instead, it was conceptualized, funded, and constructed from the ground up by the individuals living in Sheridan. 

When it was built, Sheridan held the audacious title of being the only grassroots Green House community in the nation. 

The Wyoming Life Resource Center 

For a state that set one record with the conception of its first Green House home, it’s no surprise that they’re on track to set another. 

The Wyoming Life Resource Center (WLRC) in Lander, Wyo., is a state-owned Green House community that has long served the needs of the Wyoming population and is being rebuilt as the first Green House home to be established as an Intermediate Care Facility (ICF) for people with intellectual disabilities, in addition to housing cottages established as a traditional skilled nursing facility (SNF). In accordance with federal Medicare and Medicaid regulations, this means that WLRC will serve people who have organic brain syndrome, high medical needs, and those who are “hard to place.”

Construction began in 2018 will host a total of 100 beds in 10 cottages, all built using the Green House model. There are four types of cottages in terms of licensure—ICF Medical Cottages, ICF Behavioral Cottages, SNF Medical Cottages, and SNF Behavioral Cottages. The campus also includes a recreation center with a pool, therapies and gym, an outpatient clinic with a pharmacy and lab, and a kitchen (existing) with a pharmacy and lab. 

Doug Osborn has since passed away, but his legacy lives on in the Green House community he helped to create.

The WLRC is an example of how best to meet the needs of diverse people with diverse needs, all under the Green House core values of Real Home, Meaningful Life, and Empowered Staff. The model of WLRC is innovation at its core. It sets an example that many residential care facilities across the U.S, Green House or not, are looking to replicate and learn from. 

What Is it About Wyoming? 

What is it about Wyoming that makes it such a hotspot for the sort of tenacious idealism demonstrated by Sheridan and WLRC? Former director of WLRC, Virginia Wright, describes it well: “Because we are a small state, we have a different mindset than some of the larger states. We still look at people as people and not just as numbers. I’ve worked in many states, and I have never seen as high of standards as I have seen here.” 

With Wyoming proving what’s possible in terms of diverse eldercare, it’ll be exciting to see how the eldercare landscape across the country shifts in response. 

Biophilia, Salutogenesis & the Roots of Humanity

In this week’s podcast, GHP Senior Director Susan Ryan sits down with Tammy Marshall, founder and CEO of Biophilia Pharma, for a second time, to delve deeper into biophilia, salutogenic approaches to healing, and imagining a future of eldercare that prioritizes a holistic relationship to nature. I ended this podcast completely in awe of the enormous power of nature as a healing force that seems to be completely untapped in our modern, busy lives. Further imagining the power of biophilia in eldercare could result in a radical, refreshing, and humane way to age.

Designing a Better Life with Biophilia 

The textbook definition of biophilia is the innate desire of humans to be in or around nature. Marshall further breaks down biophilia into its two components—bio, or life, and philia, or to love something. I think this is a beautiful way to frame our relationship to the natural world around us. To love nature is really just to love ourselves. 

A salutogenic approach to healing is a mode of “causing” health, instead of attacking a disease, and biophilia fits well into this model. Proximity to the outdoors, sunlight streaming in through windows, even something as analog as a floral motif on a curtain—these biophilic aspects of environmental design have all been proven by research to positively impact our wellbeing and can be seamlessly integrated into our lifestyles.

On Recognizing Our Roots 

For me, a big takeaway from this podcast is that biophilia isn’t for “fringe, sustainable, eco folks,” as Tammy expressed. Instead, biophilia is deeply rooted in what makes us human. And whether or not we recognize it, we know it on an intuitive level. I’ve always felt more relaxed and at peace when I dig my toes into the grass or look up at a massive blue sky. But only now have these benefits been translated to clinical language. 

Marshall brought up a study at Mount Sinai that re-engineered rooms for a stressed-out workforce to recharge and take a break before returning to work. These rooms were designed in a biophilic manner, with sounds of nature in the background, natural materials, and sunlight. A measure of biometrics before and after showed a marked decline in stress-related measures. What’s so profound to me about this study is how easy it is to engineer our own lives for similar results. Simply a walk in a garden, a run in the morning, or a taking a Zoom break by looking out a window can recenter and recharge us. This isn’t hard to do. After all, nature has always been free.

Taking Action

In the last podcast episode with Marshall, there was mention of Florence Nightingale, the founder of modern nursing in the 1800s. She was an early example of taking a salutogenic approach to caring for patients. We saw a shift to pathogenic approaches to illness with the onset of the Industrial Revolution. Speaking to that point, Susan related the back-and-forth of health approaches in history as a pendulum swinging. She posited that maybe, the pendulum is finally swinging back to what feels right. That thought is chilling to me, but in a thrilling way.

To see healthcare shift before our eyes is truly to witness history, and after the destruction of COVID-19, I hope that we take lessons from the pandemic to heart and aim to “cause” our health proactively.

Meghna Datta is a GHP intern and a pre-med student at Duke University.

Medical & Policy Perspectives on Eldercare with Michael Wasserman, MD

Meghna Datta
Meghna Datta, GHP Summer Intern 2021

Hello! My name is Meghna Datta and I’m an undergraduate intern with The Green House Project (GHP) this summer. I’m a student at Duke, originally from the Midwest, and working here has been a dream of mine for such a long time that being here feels surreal. 

I will be blogging about podcast episodes, webinars, and other GHP content for the duration of the summer and am excited to do a deep dive on developments in the world of eldercare. 

I’ve been following GHP since I read Being Mortal by Atul Gawande, MD, in high school. That book—combined with a rather serendipitous series of events in college—pointed me down the pre-medical path. Specifically, I’m drawn to eldercare and mitigating the impacts of neurodegenerative diseases. So, I am doubly excited to be sharing some reflections on the latest Elevate Eldercare podcast episode.

On His “Why” 

In this episode, Susan Ryan sat down with Mike Wasserman, MD, a geriatrician and tour de force in the world of eldercare and geriatric medicine. When answering the question of why he wanted to be a geriatric doctor, Dr. Wasserman made a joking admission that he was “born an old man”—which he later remarked is a common thread among many people that end up working with older adults. I really resonated with this. It seems like many of us who enjoy working with older adults have had multiple positive experiences with them in our own lives. He later spoke to the dangerous impacts of ageism, which brought me back to the idea of why certain people decide to go into geriatric medicine.

If there’s one thing I think could really bolster the national policy response to eldercare, it would be combating ageism. In other words, instilling in our youth-obsessed society that older adults are holders of a lot of generational wisdom and history, and that their wellbeing matters. Policy reflects priorities, and until the crippling problems with eldercare in the U.S are brought to the front, effective policy is unlikely to emerge.

Dr. Wasserman decided in his third year of medical school that he wanted to go into geriatrics but ended up diversifying later in his career with a gig as CMO and then CEO of Rockport Healthcare Industries—the largest nursing home chain in California.

Effective Nursing Home Reform 

This experience gave him the kind of unique perspective that few doctors are able to receive. Dr. Wasserman was able to speak to what he believes is the real obstacle to nursing home quality improvement, which is not poor administration but the larger hand at play. Criticism of the nursing home industry should really be criticism of the money in the industry, and not nursing staff or administration, who work tirelessly, generously, and with very little pay. So when talking about ways in which to elevate care in the nursing home industry, he pointed out that the profit in the nursing home industry exists in private equity and real estate, not in operations. In other words, when nursing home operators say that they need money, it’s wise to believe them. 

Dr. Wasserman also spoke of the impact of COVID-19 on nursing homes and elders. In his eyes, the key to managing a crisis of this type lies with the nursing home infection preventionist, which every nursing home has. But when talking about the crisis response on a national level, he minced no words, positing that the U.S. response to COVID-19 will likely be regarded as the worst crisis management example in the history of the country. It’s devastating to me that it took the loss of hundreds of thousands of lives, disproportionately from the most vulnerable populations in America, to bring the many problems in medical care access to light. On the other hand, I can’t help but think that sometimes, the largest transformations require the most massive catalysts. 

The Future of Eldercare 

In response to poor healthcare policy, grassroots activism has been especially effective—geriatricians and eldercare experts have been featured in news publications large and small, voicing opinions that have been needed to be heard for a while. But as Dr. Wasserman pointed out, the real impact is at a policy-making level, and few of these types of positions in government are held by geriatricians or eldercare experts. Until that happens, the fight for improved policies and funding to elevate nursing homes and eldercare is stacked, but certainly not insurmountable. 

If there’s one thing I took from this podcast, it’s that there’s no reason to be pessimistic about the future of eldercare. If anything, after COVID-19, there’s a momentum driving the need for change that many experts in the field are riding on.