Not Your Father's Nursing Home: A Visit to the Urban Green House
New model for long-term residential care offers dignity and comforts of home
My first indication that the Leonard Florence Center for Living in Chelsea, Mass., was truly a new breed of nursing home came when my guides and I stepped out of the elevator on the fifth floor, turned toward a closed door — and rang the bell.
"May we come in?" vice president of clinical operations Betsy Mullen asked the residents and staff gathered inside. They indicated that we could.
If you've spent any time visiting a nursing home, you know how radical that simple exchange was — resident privacy and autonomy are typically nonexistent.
The Florence Center is, as the expression goes, not my father's nursing home. The well-regarded Boston-area facility where both my father and mother spent their final years had a fairly standard layout: a nursing station and a hallway of double-occupancy patient rooms with doors that could close, but almost never did. When we visited my parents and brought lunch or wanted to play a game, we'd close the door ourselves. But if the nursing staff had any reason to enter, they just strolled in, never knocking. At first, this struck me as disrespectful. But I eventually got used to it and stopped questioning it.
Fortunately, others are challenging the model.
The Green House Project
Geriatrician William H. Thomas of the Erickson School at the University of Maryland, Baltimore County developed the Green House Project, a model for long-term residential care. The goal, as he put it in a recent column for Next Avenue, was to create "a real home that provides care, but also supports those seeking to redefine the worth and meaning of late life."
"Our archipelago of institutional long-term care facilities houses 1.6 million elders and adults living with disabilities," Thomas wrote. "Most of them are serving life sentences, stripped of privacy, independence and choice. The fact that so many people, whose only crime is frailty, are confined in this way is powerful evidence that we live in a deeply ageist society."
Our goal, he said, should be to "turn the challenge of caring for an aging population into an opportunity to abolish nursing homes as we know them."
There are now more than 100 Green House Project homes in operation or development across 32 states. Most sites are collections of ranch or town houses in suburban communities, where 10 residents — "elders," in the project's vernacular — live together in private rooms under the care of "shahbazim," as nursing staffers are known. (Shahbaz is from the Persian word for "royal falcon"; shahbazim is the plural form.) Shahbazim don't wear white uniforms. They are assigned full-time to a specific Green House home, instead of being shared by the entire facility.
The project's patient-centered approach has influenced the long-term care industry, which is rapidly adapting its traditional or "legacy" nursing homes to incorporate more of Thomas's ideas, with a greater emphasis on the daily preferences of residents, increased staff empowerment and a more homelike atmosphere. Shahbazim, for example, cook for the elders in each residence along with maintaining the house and providing nursing care; as in many private homes, the kitchen is the center of activity.
But for all its acclaim, there had never been a Green House Project in an urban setting until the Florence Center was opened in 2010 by the Chelsea Jewish Foundation, which already operated a large legacy nursing home as well as an assisted-living apartment complex on its campus just minutes from downtown Boston with a view of Boston Harbor. (A second high-rise Green House facility is about to be constructed in Manhattan.)
The first urban Green House is a gleaming facility with amenities like a lobby deli, a European day spa, a large common space ideal for musical performances and a fresh bakery. The aroma of homemade cookies greets every visitor. To be sure, generous private donations have enabled the foundation to build these extras, but it insists that, like other Green House Project sites, the core functions of the facility cost no more to operate than they do in legacy homes. More than half the residents are on Medicaid; about 75 percent have some level of dementia.
There are 10 Green House homes in the Florence Center, two on each of five upper floors, each with 10 residents. Five serve elders exclusively; three are for short-term rehabilitation care; and two are specialty homes for residents with multiple sclerosis, ALS or similar conditions, who may or may not be seniors.
"I love it here," one elder, Ruth Romanoff, told me. "This doesn’t feel like you’re in a nursing home. It feels like a house.”
Residents like Romanoff are welcome, in fact encouraged, to bring their own furniture, choose paint colors and decorate their rooms as they see fit. Elders in each house also hold regular meetings with staff to voice their concerns and desires. “Nursing homes are usually the most depressing places," Romanoff said, "but here, it’s so uplifting. I have more fun here than in my own house."
That's the point, says the Chelsea Jewish Foundation's chief executive, Barry Berman. The communal living and eating structure combats the isolation endemic to living alone or in legacy nursing homes, where residents tend to stay in their rooms. “If I had to live in some of these other places, I’d die,” Romanoff said.
Green House sites are fully licensed and must meet the same standards for care as any other nursing home, but each home's independence is staunchly maintained. In general, Berman says, the philosophy is that "nurses and doctors should be behind the scenes." (Emergency buttons are located throughout the facility, and staff members can rush to elders in seconds, if needed.)
Such a commitment to patient-centered care is almost disorienting for someone like me who'd become used to facilities where the architecture, schedule and attitude are so staff-focused. Here, the rhythms of the day are largely determined by the elders, not the administrators.
Each home has a central communal space near the kitchen and a dining table for 10. There's also an electrical hearth. With shahbazim preparing food much of the day, the common space often smells of home cooking. (The facility has no central kitchen.) Coffee, tea and snacks are provided at each resident’s preferred times throughout the day.
Having staffers who know their patients so well leads to increased job satisfaction as well, Green House Project studies have found. The Florence Center, for example, claims to have less than 10 percent staff turnover in its Green House homes, far less than industry standards, which by some estimates is nearly 70 percent.
“The focus is on the natural rhythm of the day,” Berman says, “and not the staff’s tasks.” That approach helps keep both shahbazim and elders in a positive mood, especially residents with dementia who crave daily rituals. Elders will not be awakened at 7:30 a.m. every day for breakfast because management has determined that's when the meal "must" be served. "If someone’s routine is to sleep later, they can have it when they’re awake and ready," Berman says. "The rhythm of each house is totally different.”
"No one wants to come" to a nursing home, Mullen told me. "But if you have to be somewhere, why not be here?" She pointed out that many elders like Romanoff who had felt isolated in their own homes appreciate the sense of community the Chelsea facility provides.
As impressive as the design, the food, and the technology at the Florence Center were, what stayed with me as I drove away from Chelsea was that simple doorbell and the dignity it represented. My parents, I'm certain, would have appreciated it.