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Could the Pandemic Transform Nursing Homes?

If COVID-19 taught us anything, it's that it's time to rethink (and redesign) America's long-term care facilities

By Beth Baker

In October, 150 people stood in the rain to celebrate the groundbreaking of an innovative elder housing project on rural Key Peninsula in western Washington State. For the first time, older people who are no longer able to live at home there can still remain in their community. The nonprofit Mustard Seed Project is building three Green House homes, two for assisted living and one for memory care. Almost one-third of the studio apartments will be for low-income people who are on Medicaid.

An older woman sitting in a chair holding an infant wrapped in blanket. Next Avenue, pandemic change nursing homes
Jan Parker, who recently passed away, was a resident of a Green House in Arkansas  |  Credit: The Mustard Seed Project

Founded in 2006, the Mustard Seed Project helps people age in place, with transportation, home repairs, friendly visits, yard cleanup and information and referrals. "The missing piece was supportive housing," says Executive Director Eric Blegen.  

This rural community may be on the cutting edge of the future of elder care: creating supportive services to help older people remain independent; nurturing close-knit communities and developing small long-term care homes, rather than large hospital-like institutions, with well-trained staff, all offered in a way that won't break the bank.

Small Nursing Homes Are Beautiful

For more than 20 years, nursing home reform advocates have called for new models to replace the traditional, dreaded institutions. This demand was amplified when the pandemic ripped through nursing homes. As of October 10, 2021, more than 138,000 nursing home residents and more than 2,100 staff members had died from COVID-19, a number widely believed to be an undercount.

Some smaller nursing homes, notably the Green House model, did much better than others at protecting their residents. One 2020 (pre-vaccine) study in the Journal of the American Medical Directors Association concluded: "Nontraditional Green House/small NHs [nursing homes] have better outcomes than traditional NHs in numerous areas; evidence now demonstrates they have lower rates of COVID-19 and COVID-19 mortality than other NHs as well. As such, they are an especially promising model as NHs are reinvented post-COVID."

People standing outside in the rain. Next Avenue, pandemic change nursing homes
150 people stood in the rain to celebrate the groundbreaking of The Mustard Seed Project’s Green Houses  |  Credit: The Mustard Seed Project

Susan Ryan, senior director of The Green House Project, says, "Interest in the model is at an all-time high. Media has been through the roof. Green Houses offered such a bright counter-narrative to what we were seeing in nursing homes."           

She ticks off the model's advantages: Every resident has a private bedroom and bathroom. Smaller autonomously functioning homes greatly reduce the number of employees coming into contact with residents. Green Houses use "universal workers" (called "Shahbaz") who provide direct care, meals and household management, rather than having dining, laundry and housekeeping staff cycle through. Nursing staff is consistent throughout the week. 

"So many things about the model afforded the good COVID data," says Ryan. "And you can't underestimate the physical environment and getting outside." 

Green Houses, which usually serve 10 to 12 residents, typically are single-story, with yards and patios its residents may freely access.

"We've shown that we have a model that performs really well in the worst of times," Ryan says.

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Incentivizing Change

The first Green Houses went up in Tupelo, Miss., in 2003. Today there are 360 in 32 states, a tiny number compared to the 15,000 nursing homes nationwide. Despite considerable evidence that Green House and other small-home models have better clinical outcomes and higher resident, family and staff satisfaction, change has been sluggish.

One reason, says John Ponthie, managing member of the management consultant Southern Administrative Services who serves on the Green House Project board, is that 90% of Green Houses are operated by nonprofits, while almost two-thirds of nursing homes are for-profit.

For-profit owners have assumed that only nonprofits, which can raise construction capital through philanthropies, can afford to build Green Houses, he says.

Two people sitting outside grilling on the barbeque. Next Avenue, pandemic change nursing homes
During the pandemic, at a Green House in Tupelo, Miss., the staff and residents enjoyed a “quarenque.” Shown here is nurse Barrie Hamilton and Essie Hubbard.  |  Credit: The Mustard Seed Project

While Ponthie had taken pride in running good-quality traditional nursing homes, from the first moment he set foot in the Green House in Tupelo, he knew that this was the future he wanted for long-term care. "I was stunned," he says. "It's too good to be true."

He describes how everyday life is different in a small-home model. "At a Green House you're part of the life of your loved one," he says. "It doesn't smell like it's not supposed to smell — it smells like cornbread. Christmas is Christmas. You can get outside or go in the kitchen and have a popsicle."

Perhaps most important is the relationships.

"When you strip everything else, it's all about this model's ability to facilitate relationships between the elders and the caregivers," says Ponthie. "You've got a commitment that goes well beyond your job tasks. There's a relationship there, when it's real and meaningful and rewarding. That is the difference, that is the magic."

Ponthie's company went on to develop and provide administrative services to 30 Green Houses on five campuses in Arkansas, with 23 more homes opening by April. Sixty percent of residents are on Medicaid. 

According to Ponthie, although the construction costs are higher than for a traditional model, once amortized over 30 years, the cost difference was "negligible."  Operating costs are also some 5% to 8% higher annually, "but given the staggering differential in quality of life and all the outcome differentials, it's a pittance," he says.

"We need to look towards creating tax advantages for those who are investing in good care, for investing in redesigning homes."

Because Medicaid covers the cost of most nursing home care, the federal government could better use its leverage to compel change, Ponthie and others argue. "I'd figure out the metrics and pay better providers with better outcomes and take [payments] away from those who aren't," he says. 

Those that build Green Houses or provide private rooms, for example, could get paid a higher rate from Medicaid, Ponthie adds.

The government could also offer more low-interest construction financing to build small homes, as the Mustard Seed Project did. It received a $7.8 million low-interest construction loan from a U.S. Department of Agriculture Rural Development program and raised $5.6 million through state and county government, foundations and the community for its Green Houses.

One obstacle to change is the entrance of bad-actor private equity firms that buy up nursing homes and wring profits from them, often with dire results. A study by researchers at University of Pennsylvania and University of Chicago found "a robust decline in nursing staff, leading to greater decline in per-patient nursing staff availability" after private-equity purchase, even in the midst of the pandemic.

Barry Barkan, co-founder of The Live Oak Project (part of the national nonprofit Pioneer Network working to improve long-term care), agrees that change needs to be incentivized.

"We need to look towards creating tax advantages for those who are investing in good care, for investing in redesigning homes," he says. "We need to have a system of regulation that is supporting positive innovation and coming down really, really hard on the bad actors."

A Future of Fewer, Better Nursing Homes?

The broader question, according to Robyn Stone, senior vice president of research at LeadingAge (a trade group representing nonprofit aging services providers and othes), is: "How does the nursing home in the twenty-first century fit into all of the other options out there? With the aid of technology and the expansion of home and community-based services, how many can remain in their own homes with some family support, some formal care and some technology?"

Creating high-quality elder care across the spectrum is enormously complex, she notes. It's all well and good to push for small homes, but "what do you do with all the existing stock? Are you going to knock down old buildings and build small houses on expensive land? You really don't have the space in urban areas to do that."

"If [the pandemic] doesn't turn the tide on nursing homes, then shame on us."

One option is to create "neighborhoods" with homelike environments within large buildings.

"The most important thing in a nursing home is trained staff who know what they're doing and know how to implement evidence-based practices around mobility, around preventing decubiti [pressure sores], around managing pain," Stone says. "That is the challenge."

With older people being able to extend the time they remain at home, adds Ponthie, moving towards fewer, better nursing homes may be the answer.

Getting From Here to There

The Live Oak Project, which has been in the trenches for decades, promotes systemic culture change in institutional elder care. When COVID-19 hit, the group quickly got to work, developing an action plan for moving forward and lobbying key members of Congress.

Simply demanding more regulation isn't the answer, Barkan says. Working at the grassroots and with government, he notes, the Live Oak Project seeks "to reimagine, redesign and transform the whole system of elder care from top to bottom and inside out."

It's first focusing on three main areas: growing and training the direct-care workforce, redesigning buildings from institution to home and creating an age-friendly culture

Among the Live Oak Project's initiatives: a $55 billion Medicaid investment in better wages and benefits for full-time nursing home staff; $1 billion to beef up recruiting and training of direct-care workers; incentives to move from large institutions to small homes and the creation of a digital network through the U.S. government's Administration for Community Living, aimed at sharing research and strategies for enhancing the well being of older adults.

Leaders of this effort are meeting with staff of key congressional committees to push for funding to be included in the Biden administration's Build Back Better package. Regardless, Barkan says. "We have to be dug in for the long haul."

Adds Ryan: "If [the pandemic] doesn't turn the tide on nursing homes, then shame on us."

Editor’s note: This story is part of The Future of Elder Care, a Next Avenue initiative with support from The John A. Hartford Foundation.

Beth Baker is a longtime journalist whose articles have appeared in the Washington Post, AARP Bulletin, and Ms. Magazine. She is the author of With a Little Help from Our Friends — Creating Community as We Grow Older and of Old Age in a New Age — The Promise of Transformative Nursing Homes. Read More
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