Green House Blog

Relational Coordination-A Practice with Big Benefits

Via Provider Magazine

As we all know advances in medical equipment and technology play an important role in the care we provide Elders, but leaders must remember that staff and their relationships have the greatest influence on performance.   In the latest edition of Provider Magazine, relational coordination is explored as a critical element for high-performing nursing homes.  David Farrell, the new Director of THE GREEN HOUSE® Project, is one of three authors for the article.

Deep, knowing relationships are the foundation for Green House homes and support the core value of Meaningful Life.

Read more about the evidence that supports relational coordination and tell us what you think!

Thrive Research: Guidelines for Reducing Risk Levels

There are different types of research, and some are riskier than others.  Take the study of new medications, for example.  While a medication is tested for safety before people are asked to participate in a study to see how well it works, there might still be unknown risks to taking it and it’s not certain that the medication will be effective.  Some other types of research are very low risk, including studies that learn new things by watching people and asking them about care practices – both of which describe the THRIVE study that is learning about Green House homes and different models of nursing home care. 

To keep risks as small as possible, all research studies must follow guidelines.  Even low risk studies where researchers are simply watching people and asking questions must follow guidelines.  To make sure that researchers follow the guidelines, every study must first be reviewed and approved by an Institutional Review Board (or IRB), sometimes referred to as an ethics committee. 

A few of the rules that must be followed include:


  • Respect for people participating in studies.  This means that people must be volunteers and not feel coerced, and must consent (often in writing) to participating.  There are special rules to protect people who have trouble making their own decisions (such as children or people with advanced dementia).  Respect for people participating in studies also includes protecting confidentiality.  For example, researchers aren’t allowed to tell anyone the identity of who participated in a study. 
  • Beneficence.  This fancy word means that there must be a possibility that the research will benefit society, and that it will not harm society or the people participating.  When there are risks to taking part in research, the potential benefits must outweigh the risks.  A good example of beneficence is when a new drug might have some risks and side effects, but might also have the potential to cure cancer, so might be worth the risk.
  • Justice.  Research should benefit as many people as possible.  This means that unless there is a good reason why some people can’t or shouldn’t be in a research study (such as a study about pregnancy which might justifiably exclude men), everyone should have the right to participate in, and possibly benefit from, research.

All research conducted by the THRIVE collaborative has been reviewed and approved by an IRB.  Approval for THRIVE has been pretty easy, as THRIVE is a low risk study. THRIVE is collecting information to learn about existing components of care and resident status, to understand specifically which types of care are better care. We expect to learn ways to improve care, which will benefit all of us.

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

The THRIVE research studies are funded by the Robert Wood Johnson Foundation.

THRIVE Research – What does this mean for Green House Homes?

THRIVE Research – What does this mean for Green House Homes?


You’ve probably heard about the THRIVE  research studies aimed at learning more about how the Green House model works and how it differs from other models of care.   You might be curious what this means for the Green House projects over the next few years.


Many of the Green House projects will be getting calls over the next year to discuss participation. Research team members from Pioneer Network, University of Wisconsin-Madison, University of North Carolina, and Health Management Strategies will be contacting several projects to ask them to participate in one or more parts of the study.


Here are some terms you might hear or see:


Questionnaires: These are paper or electronic surveys staff complete on a topic.


Site Visit: Several Green House projects will be asked to host a visit by a small team of friendly researchers (usually 2-4 people).  The purpose of the visit is to collect information on what life is like in the Green House homes for shabhazim and elders and how care is provided.


Interviews: Interviews are one way researchers get to know details about how things work in the Green House homes. Interviewees will be asked questions that allow them to tell stories and share their experiences.


What is a site visit like? 

Enjoyable !  A site visit from the research team is not like a visit from state regulators, in that the intent is to learn and not to evaluate.  It’s a time for researchers to learn about what life and care is like in a Green House, and for Green House staff, shabhazim, and elders to have the opportunity to contribute to what is being learned.  


Lori Kinney, Green House Guide at Lebanon Valley Brethren Home, has experienced a few site visits from research teams. “The research team’s communication was great, whether it was through emails or phone conversations. The visits went well… Since we, staff and elders, were prepared for the visits from the research team, things moved along swiftly and elders always appreciate visits from ‘new’ people that enjoy listening and talking with them.”


The researchers understand that the Green Houses are the elders’ homes and intend to minimize disruption as much as possible. The researchers are flexible and know things can “pop up” that make it difficult for staff to attend to the research needs during the visit. Elder’s needs are always the top priority.


The research team looks forward to working with the Green House homes! Questions about THRIVE can be directed to Lauren Cohen ( or 919-843-8874).


 The THRIVE research studies are funded by the Robert Wood Johnson Foundation.

Building an Evidence Base for Enjoyable Dining

“All great change in America begins at the dinner table.” -Ronald Reagan

Eating at a dinner table with friends and family is not only the quintessential portrait of Thanksgiving, but also an activity that can promote significant positive change.

In this month’s LeadingAge Magazine, the article, Enjoyable Dining: Can We Build an Evidence Base? , speaks volumes about how creating a dining environment that looks and feels more like home can have a tremendously positive impact on elders- boosting overall morale, without significant cost increases.

“We have had better intake. We’ve reduced the use of supplements. They are eating real food. Our meals are part of a concerted period when the residents are up and active, which then has a positive effect…We have less weight loss, and residents have fewer complaints about food service. They are better nourished, and there’s an increase in family involvement. And it doesn’t add to the cost, because residents are getting what they like. There is less waste.”

The article also highlighted recent research conducted by The Pioneer Network to develop great evidence-based food and dining standards for long-term care facilities. These best-practices contain sections that concentrate on the liberalization and honoring of choice when it comes to diet as related to diabetic and calorie controlled, low sodium, cardiac and altered-consistency diets. The new dining standards of practice can be found here.

Click here to read the full article.

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