Green House model of nursing facility spreads nationwide; how will it be financed?

Smaller units, more personalized care planning, and greater autonomy for elders are three hallmarks of the Green House model of care, identified by the Robert Wood Johnson Foundation last year as a model worthy of support so that it may be propagated across all 50 states.  The RWJF awarded a $10 million grant to help make this vision a reality.  Today, three Green Houses are open — in Mississippi, Michigan and Nebraska — and a couple dozen more are on the drawing board nationwide. 

The Boston Globe recently ran an article describing the model, the original project in Tupelo, Mississippi, and a project underway in Massachusetts, composed of ten 10-unit Green Houses.  The article reads in part:

Each of the 10 Green Houses will be managed by the residents and two primary caretakers on each day shift, one of whom is "devoted to loving cooking," [Chelsea Jewish Nursing Home executive director Barry] Berman said. The caretakers will also do light housework and help residents with bathing, grooming, and dressing.

The residents in each Green House will determine their own daily routine, menu, and activities. Meals generally will be served family-style, around one long table, with staff and visitors joining in. Residents can volunteer to help keep the household running by doing chores like cooking, folding laundry, and accompanying the cook to the grocery store.

"That’s a more important activity for some residents than anything we could provide," Berman said.

One nurse will serve two 10-resident Green Houses, but medical trappings will be kept to a minimum.

The Green Houses typically cost no more to run than traditional homes, even though there are more caretakers per resident, because they have less waste and do not need such infrastructure as dietary departments. As at conventional homes, most of the bills will be paid by the Medicaid program for low-income seniors and the disabled .

State regulators support the Chelsea project, and have waived some regulations to allow innovation, Berman said.

A two-year study that compared the Tupelo Green Houses with two traditional nursing homes [see abstract here] found that quality of life was better in the Green Houses, with residents saying they had more dignity, privacy, meaningful activity, relationships, and autonomy, according to Rosalie A. Kane, a professor at the University of Minnesota School of Public Health.

Kane said the Green Houses provided small benefits in the quality of care — residents showed less depression, less incontinence, and less of a decline in the ability to feed themselves.

"It’s impressive and worthy of replication," said Kane. "It defies people’s idea of what a nursing home is."

Staff turnover, which averages 71 percent annually in nursing homes, fell to just 10 percent, according to the Green House national staff.

Sounds promising, and sounds consistent with the trends in government and industry trying to create more homelike models of long-term care.  The Globe article reports that one in six Massachusetts nursing facilities plan to implement programs incorporating some elements of the Green House approach.  The issue that may stop others from implementing these plans is lack of funding.  Since Massachusetts Medicaid payments to nursing facilities are no longer even designed to reimburse providers for their reasonable capital costs, the design and construction or renovation of facilities to accommodate new models of care has become cost-prohibitive.  Creative financing will be pursued by a few providers (the Chelsea facility’s approach mixes tax credits and philanthropy), but rolling out any improvements on a system-wide level — whether it’s the Green House model or simply renovation or replacement of the aging physical plants of many nursing facilities — requires either the continued large-scale commitment of public funds, or the maturation of alternative models of long-term care financing.  Unfortunately, neither seems to be on the horizon.

I invite your comments on whether or how the health savings accounts and consumer-directed health initiatives of the Bush administration may be translated to the long-term care arena, or on other means to the worthy end of further disseminating the Green House model.