Column: Nursing homes need new vision

Lisa Gonzalez
Lisa Gonzalez
Published May 27, 2016

As states realize that deteriorating nursing homes combined with an aging population mean that new nursing homes need to be constructed, they are faced with an option—build more of the same traditional, large nursing facilities or construct innovative homes that allow elders to live full and enriched lives.

Although Certificate of Need (CON) programs restrict the supply of new nursing home beds in 36 states, some states have lifted the moratorium on new construction as the demand has outgrown supply. For example, Florida's Agency for Health Care Administration is currently reviewing CON applications and has approved the construction of 23 new nursing homes, and the expansion of 23 current nursing facilities, totaling close to 3,000 beds. The agency can approve CONs for a maximum of 3,750 beds between July 1, 2014, and June 30, 2017. Nine of the new construction approvals are for large facilities that plan to have 120 beds or more, while one of the approvals is for a 180 bed facility. These "new" facilities will be similar to the traditional nursing homes that have prevailed over the past 50 years, with little design change despite the persistently negative views of nursing homes by the public and the people who are most likely to need to live in one.

There are alternatives to the traditional model. The Green House model, born out of the nursing home "culture change" movement in 2003, is one such alternative. Today, almost 200 Green Houses operate in 27 states across the country. Licensed as skilled nursing facilities, Assisted Living Facilities or adult group homes, Green Houses are groups of homes, each with 10-12 elders living in each one. They provide care within Medicaid reimbursement rates. Each Green House is designed to be just like a regular home. They provide elders with their own private bedroom and bathroom that they can decorate however they wish, a hearth area with a fireplace and a dining room table. There are unlocked doors with safe green outdoor spaces, which allows those who are living with Alzheimer's or dementia to safely wander.

The Green House staff know the residents well and behave as if they are visitors in the elders' home. The Green House model of care gets rid of the traditional staff hierarchy and allows staff to provide quality care while engaging in social interaction for a more meaningful life for residents. The staff cook with the elders, dine with them, play games, and watch movies together. Green Houses are places where people love to work, visit and where elders can truly live a meaningful life.

Studies have shown that Green House staff are able to provide more direct care time doing things like communicating with residents and families and helping with activities of daily living — all for a cost that is about the same as a traditional nursing home ($199.13 per resident day in Green Houses compared to $197.51 per resident day in traditional nursing home).

As the model continues to spread across the country, advocates, researchers, and policy makers will continue to monitor its development and highlight areas for improvement. Although Green Houses are clearly the most promising alternative to the traditional model, physical design changes will not occur unless preferences are included in the CON criteria. In Florida, we've entered a critical period where the window of opportunity to build small homes like Green Houses will close in the next few years. We must not lose the opportunity to give nursing home residents the quality of life they deserve.

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Lori Gonzalez is a research faculty member at the Claude Pepper Center at Florida State University.