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Reimagining What a Nursing Home Can Be

A growing trend focuses on providing companionship and comfort

By Beth Baker and SCAN Foundation

Editor's Note: This article is part of a year-long project about aging well, planning for the changes that aging brings and shaping how society thinks about aging.

Can a nursing home ever be a genuine home, a comforting place where we live in contentment if we can no longer live on our own?

A “culture change” movement in long-term care is demonstrating that the hospital-like institutions that most of us dread can indeed be transformed, improving the quality of life for both residents and staff.

One leader of this growing movement is Dr. Bill Thomas, a geriatrician in Ithaca, N.Y., who proudly calls himself an “abolitionist” when it comes to traditional nursing homes. His vision: replace them with a model he dubbed the Green House, a home of 10 to 12 elders, assisted by specially trained staff, as shown in the new PBS documentary Homes on the Range.

(MORE: Transforming Life As We Age)

The Green House is a leading example of a growing trend in person-centered care that has been percolating for 15 years. Pioneers in the field of aging are seeking to transform not only nursing homes, but a societal culture that they say marginalizes and warehouses frail elders.

Elevating Caregivers      

The Green House is perhaps best known for its homey environment — all private bedrooms and baths, family-style dining room and open kitchen, large living room with hearth and comfy chairs. But even more important than the setting may be the reimagined role of the caregivers who work there.

For starters, their job title: nursing assistants are called shahbazim (plural for shahbaz, which according to Thomas, means “royal falcon” in Persian. When I asked him if there were any English words to describe what he envisioned, he said no). The name is meant to convey a person worthy of respect, someone who is valued.

The moniker seems to pay off. As I wrote in my book Old Age in a New Age, when Steve McAlilly, President and CEO of Mississippi Methodist Senior Services, was hiring staff for the nation’s first Green House, in Tupelo, he placed an ad for aides to work in an “innovative setting” and received two applicants. When he reran the ad, recruiting “shahbazim,” 70 people applied.

It’s not just the name that’s changed. In a traditional top-down nursing home setting, a charge nurse assigns aides tasks to perform — so many baths, so many meals, so many blood pressures. If an aide is caught sitting down and chatting with residents, she might well get into trouble for “goofing off.”

In contrast, shahbazim are given much more responsibility and respect. They combine many roles — personal caregiver, cook, housekeeper and companion — and are given 128 hours more training than aides. Two shahbazim per shift manage the household on behalf of the elders, as residents are called, supported by nurses, therapists and physicians, who essentially do “house calls” on a regular basis.

The shahbazim’s role is to make each elder’s day as pleasant and meaningful as possible, including not only physical care but friendship. If that means sharing a cup of coffee or playing a hand of poker, then they’re doing their job. They not only prepare meals, but may pull up a chair and eat with the elders. Family members, too, are encouraged to come for meals.

The idea is that together the shahbazim and elders form a tight-knit community that feels as much like home as possible. This conforms with the growing body of research on the ill effects of loneliness and isolation on our health, and the benefits of having a strong network of social support.

(MORE: How to End the Senior Loneliness Epidemic)


“One thing I love is the shahbazim,” McAlilly said. “They have become these amazing professional people. I think they were stuck in jobs that were too small for them.”

Rena Reid, a shahbaz in Tupelo, told me how much she loved her work and how much better it was than when she worked as an aide in the old nursing home on the same campus. “To be a good shahbaz,” she said, “you have to have it in your heart. This is a big responsibility. If you’re not here to protect the elders, you don’t need to be here.” She said that every day, she feels proud of what she’s doing.

Happy Workers, Happy Residents

This sense of pride and satisfaction extends to the residents. Cynthia Dunn, who lived in the Green House where Reid worked, said proudly, “This is my home.” She enjoyed helping out around the house by doing laundry and other chores (“but I don’t do windows”) and going on outings to yard sales and the mall with Reid.

That was a decade ago, when there was only one Green House. Today, with funding support from the Robert Wood Johnson Foundation and NCB Capital Impact, 170 Green Houses in 27 states are operating, with dozens more in development. That's progress, but still only a tiny fraction of the nation’s nearly 16,000 nursing homes.

Researchers are finding real promise in the model, however. A small 2012 study compared 97 Green House residents with 158 traditional nursing home residents who had similar medical conditions. The findings suggest that Green Houses not only provide a higher quality of care, but may actually be less expensive. Green House residents had fewer hospitalizations and were able to maintain higher functioning, leading to $1,300 to $2,300 annual savings to Medicare and Medicaid per resident. Other studies have found Green Houses have higher occupancy rates and higher levels of resident and family satisfaction than traditional nursing homes.

(MORE: Are You Set to Pay a $262,800 Nursing Home Bill?)

I was asked to speak at a November gathering of Green House leaders in Memphis, Tenn., where I encountered retirees Twylah and David Haun of Pompano Beach, Fla. They said they’d been skeptical about Green Houses being built at the retirement community they run, John Knox Village. Their nursing home was already highly rated, so why change, they wondered. David Haun said he couldn’t believe that the model would be affordable or that its staff would accept such a big change.

The Hauns set out to see for themselves, visiting seven Green Houses in the South.

“The more I’ve studied, the more I’m convinced that the Green Houses will work at Pompano and anywhere,” he said. “Our nursing home was already a Cadillac. Now we’ll have a Rolls Royce.”

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
By SCAN Foundation
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