The Green House-- Deinstitutionalizing Nursing Homes
The Green House-- Deinstitutionalizing Nursing Homes
Objectives: To determine the effects of a small-house nursing home model, THE GREEN HOUSE® (GH), on residents' reported outcomes and quality of care.
Design: Two-year longitudinal quasi-experimental study comparing GH residents with residents at two comparison sites using data collected at baseline and three follow-up intervals.
Setting: Four 10-person GHs, the sponsoring nursing home for those GHs, and a traditional nursing home with the same owner.
Participants: All residents in the GHs (40 at any time) at baseline and three 6-month follow-up intervals, and 40 randomly selected residents in each of the two comparison groups.
Intervention: The GH alters the physical scale environment (small-scale, private rooms and bathrooms, residential kitchen, dining room, and hearth), the staffing model for professional and certified nursing assistants, and the philosophy of care.
Measurements: Scales for 11 domains of resident quality of life, emotional well-being, satisfaction, self-reported health, and functional status were derived from interviews at four points in time. Quality of care was measured using indicators derived from Minimum Data Set assessments.
Results: Controlling for baseline characteristics (age, sex, activities of daily living, date of admission, and proxy interview status), statistically significant differences in self-reported dimensions of quality of life favored the GHs over one or both comparison groups. The quality of care in the GHs at least equaled, and for change in functional status exceeded, the comparison nursing homes.
Conclusion: The GH is a promising model to improve quality of life for nursing home residents, with implications for staff development and medical director roles.
After a critical 1986 Institute of Medicine report, regulatory reform in nursing homes was launched, aimed at improved quality assessment, monitoring, and enforcement. A 2001 Institute of Medicine report noted improvements in overall health care but little reduction of societal dread of nursing homes or improvement in quality of life. The problems of maintaining a sense of well-being in a nursing home are well documented in decades of anthropological, ethnographic, and ethics studies. Efforts to combat residents' learned helplessness with increased choices have resulted in measurable health benefits.
A movement for culture change in nursing homes has gathered force since 1995, embracing transformed physical environments (e.g., smaller-scale, more-private rooms and baths and household-type neighborhoods for dining and occasionally cooking), transformed staff roles with more empowerment of line staff, and a philosophy of individualized care. The "Eden Alternative," a set of principles overlaid on existing nursing homes to flatten hierarchies, invest decision-making in residents and frontline staff, and normalize nursing home life, addressed psychosocial problems of residents, such as loneliness, boredom, helplessness, and lack of meaning. Eden training has been widely sought, but the few formal evaluations had unimpressive results, suggesting that, without more-systemic changes in nursing homes, this model will have limited effects. In contrast, THE GREEN HOUSE® (GH) envisages a radically reconfigured nursing home. The current study determines the effect of the GH on the quality of care in nursing homes and compares the quality of life of GH residents with that of those in conventional nursing homes. It was hypothesized that resident quality of life and satisfaction would be greater in the GH than in the comparison settings and that functional status and quality-of-care indicators would be at least equal to those of the conventional nursing homes.
Objectives: To determine the effects of a small-house nursing home model, THE GREEN HOUSE® (GH), on residents' reported outcomes and quality of care.
Design: Two-year longitudinal quasi-experimental study comparing GH residents with residents at two comparison sites using data collected at baseline and three follow-up intervals.
Setting: Four 10-person GHs, the sponsoring nursing home for those GHs, and a traditional nursing home with the same owner.
Participants: All residents in the GHs (40 at any time) at baseline and three 6-month follow-up intervals, and 40 randomly selected residents in each of the two comparison groups.
Intervention: The GH alters the physical scale environment (small-scale, private rooms and bathrooms, residential kitchen, dining room, and hearth), the staffing model for professional and certified nursing assistants, and the philosophy of care.
Measurements: Scales for 11 domains of resident quality of life, emotional well-being, satisfaction, self-reported health, and functional status were derived from interviews at four points in time. Quality of care was measured using indicators derived from Minimum Data Set assessments.
Results: Controlling for baseline characteristics (age, sex, activities of daily living, date of admission, and proxy interview status), statistically significant differences in self-reported dimensions of quality of life favored the GHs over one or both comparison groups. The quality of care in the GHs at least equaled, and for change in functional status exceeded, the comparison nursing homes.
Conclusion: The GH is a promising model to improve quality of life for nursing home residents, with implications for staff development and medical director roles.
After a critical 1986 Institute of Medicine report, regulatory reform in nursing homes was launched, aimed at improved quality assessment, monitoring, and enforcement. A 2001 Institute of Medicine report noted improvements in overall health care but little reduction of societal dread of nursing homes or improvement in quality of life. The problems of maintaining a sense of well-being in a nursing home are well documented in decades of anthropological, ethnographic, and ethics studies. Efforts to combat residents' learned helplessness with increased choices have resulted in measurable health benefits.
A movement for culture change in nursing homes has gathered force since 1995, embracing transformed physical environments (e.g., smaller-scale, more-private rooms and baths and household-type neighborhoods for dining and occasionally cooking), transformed staff roles with more empowerment of line staff, and a philosophy of individualized care. The "Eden Alternative," a set of principles overlaid on existing nursing homes to flatten hierarchies, invest decision-making in residents and frontline staff, and normalize nursing home life, addressed psychosocial problems of residents, such as loneliness, boredom, helplessness, and lack of meaning. Eden training has been widely sought, but the few formal evaluations had unimpressive results, suggesting that, without more-systemic changes in nursing homes, this model will have limited effects. In contrast, THE GREEN HOUSE® (GH) envisages a radically reconfigured nursing home. The current study determines the effect of the GH on the quality of care in nursing homes and compares the quality of life of GH residents with that of those in conventional nursing homes. It was hypothesized that resident quality of life and satisfaction would be greater in the GH than in the comparison settings and that functional status and quality-of-care indicators would be at least equal to those of the conventional nursing homes.
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