Green House Blog

Research Update and Map of Green House Projects

Download this one page overview of the latest research findings of The Green House Project, as well as an up to date map of where there are projects open or in development. 

Improved quality of life: Green House elders reported improvement in
seven domains of quality of life (privacy, dignity, meaningful activity,
relationship, autonomy, food enjoyment and individuality) and
emotional well-being.
Improved quality of care: Green House elders maintained self-care
abilities longer with fewer experiencing decline in late-loss Activities
of Daily Living. Fewer Green House elders experienced depression,
being bedfast and having little or no activity.
Improved family satisfaction: Green House families were more
satisfied with general amenities, meals, housekeeping, physical
environment, privacy, autonomy and health care.
Improved staff satisfaction: Green House staff reported higher job
satisfaction and increased likelihood of remaining in their jobs.
Green House homes relative to nursing home comparison sites3
Higher direct care time: 23–31 minutes more per resident per day
in staff time spent on direct care activities in Green House homes
without increasing overall staff time.
Increased engagement with elders: More than a four-fold increase in
staff time spent engaging with elders (outside of direct care activities)
in Green House settings.
Less stress: Direct care staff in Green House homes reported less jobrelated
Improved care outcome: Fewer in-house acquired pressure ulcers in
Green House homes.
Green House homes versus traditional and other culture change
nursing home costs4
Cost neutral operations: Green House homes operate at the same
median cost as the national nursing home median cost.
Lower capital costs: Green House homes provide private bedrooms
and baths and enhanced common space while building the same or
fewer square feet than other current culture change nursing home
models. Lower square foot costs lead to lower capital costs.
Role of direct-care workers5
Comparable quality: Removal of formal nurse supervision of direct
care workers did not compromise care quality.
Timely intervention: High level of direct care worker familiarity
with elders led to very early identification of changes in condition,
facilitating timely intervention.
1 Kane R, Cutler L, et al. “Resident Outcomes in Small-House Nursing Homes: A Longitudinal Evaluation of the Initial Green House Program,” Journal of the American Geriatric Society

Evaluating The Green House Model

The Research Initiative Valuing Eldercare, Launched

The Green House Project has partnered with THRIVE (The Research Initiative Valuing Eldercare) to learn more about the Green House model as well as other models of care. The THRIVE team is launching a series of interrelated research projects that together will comprise the largest research effort undertaken to date in Green House homes. This effort is funded by the Robert Wood Johnson Foundation.
The THRIVE researchers represent leading research institutions and long-term care organizations around the country, including Harvard University, the University of Wisconsin-Madison, Health Management Strategies, Institute for Clinical Outcomes Research, Pioneer Network, and the University of North Carolina at Chapel Hill. Many of the THRIVE team members have previously researched the Green House model, and in part, these previous studies – and the questions left unanswered – provided impetus for the current project.
For example, in a comprehensive review of the research literature, THRIVE team members Sheryl Zimmerman and Lauren Cohen found strong support for certain components of the Green House home model, such as that private rooms and bathrooms and communal dining are related to positive outcomes. However, these researchers also found that very little research has been done around the concept of normalized engagement, and therefore there is no evidence to show that this type of engagement relates to better care or outcomes.
Other THRIVE team members, including Siobhan Sharkey, Sandy Hudak, and Susan Horn, found in their earlier studies of work flow that Green House elders receive more direct care time per day than do similar residents in traditional nursing homes. They also found that Shahbaz spend about 20 minutes more per day with elders than do CNAs in traditional homes. In their work on elder outcomes, they also found that elders living in Green House homes maintained their ability to perform activities of daily living such as dressing and eating, to a greater extent than residents living in traditional nursing homes. These findings suggest further exploration into what structures and processes are associated with better outcomes, such as less decline in activities of daily living or fewer falls.
Earlier work by Barbara Bowers and Kimberly Nolet provided important insights into the role of the nurse and how it differs across Green House homes; they found, for example, that there are differences across homes in how the Green House model is implemented. In particular, there are important differences in how Shahbazim and nurses relate to one another and the degree to which they collaborate or work separately. Although this study demonstrated that the choice of model had meaningful consequences for both staff and elders, it did not determine what had led some homes to use one model over another.
It is these unanswered questions – plus many more related to staffing, care provision, clinical outcomes, and costs – that the THRIVE collaborative intends to address. The THRIVE project will be taking place through 2013, and during that time, members of the team will be contacting Green House homes to complete interviews, request records, and schedule visits. In addition to providing homes the opportunity to inform these matters and influence the direction of nursing home care, participating homes will also receive confidential feedback about their organization.
We are excited to be able to learn more about the Green House model, and look forward to working together.

(Questions about THRIVE can be directed to Lauren Cohen,, (919) 843-8874).

GE Healthcare Finance Award for The Green House Project

Today, The Green House Project had the honor of accepting the GE Healthcare Award for Best Paper. Over 1,800 leaders, including top lenders in health care finance, assembled at the National Investment Center (NIC) conference in Washington, DC. The National Investment Center for the Seniors Housing & Care Industry (NIC) is committed to advancing the quality of seniors housing and care by facilitating informed investment decisions for investors, lenders, owners, operators and developers through groundbreaking research, actionable data and dealmaking events. NIC is driven to empower the industry with the insight needed to accurately measure performance, drive business decisions and communicate performance to key stakeholders.

Important findings from The Green House journal article were summarized by NIC’s president:

• Significantly more direct-care and nursing time is delivered in The Green House home
• Overall staffing needs and costs do not increase compared to traditional settings due to a shift from supervisory and department hours to direct care hours.
• The Green House model uses time more effectively, delivering significantly more direct care and nursing hours within lower total direct service hours.
• Average operating costs for Green House homes are between the 50th to 60th percentile of nursing homes nationally.
• Consistent and financially important differences were found in Green House providers’ overall occupancy (7% higher) and private-pay occupancy (a 24% increase) compared to nursing home averages.
• No hidden or unexpected costs were associated with The Green House model.
• Green House homes’ capital costs, including all private rooms and bathrooms, were found to be at the low end of culture change models.

The full journal article, Financial Implications of The Green House (r) Model, can be found in the 2011, Volume 19, Number 1 edition of Senior Housing and Care Journal

Nursing Home Workflow Study: Analysis of Staff Workflow in Traditional Nursing Homes and THE GREEN HOUSE® Project Sites

A new study funded by the Robert Wood Johnson Foundation found that The Green House model’s organizational and staffing redesign delivers more direct care time, a key component of improved quality, without increasing staff hours and maintaining expenses at levels similar to traditional nursing homes.  Continue reading “Nursing Home Workflow Study: Analysis of Staff Workflow in Traditional Nursing Homes and THE GREEN HOUSE® Project Sites”

Making The GREEN HOUSE® Model Work in Your Community

At the 2007 annual meeting of the American Association of Homes and Services for the Aging, representatives from three operating Green House projects discussed the impact that the development of Green House homes is having on communities and how flexibly the core principles can be applied to meet local needs (e.g., design adaptations, project diversity, financial structuring, operational differences, strategic planning).  Continue reading “Making The GREEN HOUSE® Model Work in Your Community”

Outcomes in Small-House Nursing Homes: A Longitudinal Evaluation of the Initial GREEN HOUSE® Program

In 2003, Dr. Rosalie Kane and a team of researchers from the University of Minnesota began a two-year study of the first Green House homes in Tupelo, Mississippi, collecting information from residents, primary family caregivers, and staff.  Continue reading “Outcomes in Small-House Nursing Homes: A Longitudinal Evaluation of the Initial GREEN HOUSE® Program”