The Green House Model and Outcomes Real Tales of Transformation

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1 The Green House Model and Outcomes Real Tales of Transformation

2 Nursing Home History Passage of Medicare/Medicaid Offered a Nursing Facility Benefit Began the rise of Convalescent Hospitals Convalescent Hospitals designed like hospitals Quality of Life concerns 1960 s - depersonalization of nursing home life 1970 s - custodial care 1980 s - psychic despair 1990 s - loneliness, helplessness and boredom Frank, B. 2004

3 What if? What comes next is a clear break with the past. A massive shift towards deinstitutionalization of older people is called for, and the foundation for such a shift is being laid right now. A Green House home is a sanctuary for a new kind of elderhood; it is an intentional community for people seeking the worth and meaning in late life. Dr. Bill Thomas, 2005

4 Green House Transformation Shift within current nursing home regulatory and organizational structures Transformation: Philosophy: Meaningful Life Organizational Redesign: Empowered Staff Physical Design: Real Home 4

5 The Story of Leonard Florence Center for Living Story and Vision Chelsea Jewish Foundation Founded in 1919 by Mrs. Goldberg. Mrs. Goldberg purchased a two-family house and created a haven for elderly Yiddish-speaking Jewish immigrants who needed homemaking and personal care. In 1950, CJF needed increased capacity and built a 60-bed institutional home on the same plot of land Late 1970s, new leadership came in and soon thereafter CJF started construction of a replacement facility, the 123-bed Chelsea Jewish Nursing Home; at the time, the newly constructed CJNH was a modern, innovative facility with programs which generated interest far and wide Come mid-2000s, CJF had grown beyond CJNH and in addition now had assisted living, home care, and other services. On one of its campuses, CJF owned land which leadership long thought of as a potential future home for a second nursing facility.

6 The Story of Leonard Florence Center for Living Story and Vision, continued Instead of embarking on a new project which offered more of the same, and reasoning that traditional nursing facilities were institutional environments that they themselves hoped never to reside in, leadership decided to explore options beyond the traditional nursing home setting. Soon thereafter, they found the Green House Project, which they found inspiring as a radical departure from the traditional model and much more than nursing homes with private rooms In terms of philosophy, the Green House was in some ways not particularly novel it was what Mrs. Goldberg originally created in 1919! We were coming full circle

7 Meaningful Life

8 Living, Growing, Thriving Structure decision-making with elders Facilitate deep knowing Support a life worth living: engagement, enjoyment, purpose All people are creative, resourceful and whole

9 Leonard Florence Center Meaningful Life Resident participation and input in all aspects of care No Schedules Breakfast cooked to order and served all morning (or evening!) Residents wake up as they please No classic across-the-board staffing pattern; in one house, 50% of the residents typically are up at 3am!

10 Leonard Florence Center Meaningful Life No resident council Instead, house meetings. Smaller groups leads to increased and much more meaningful participation No carts or other institutional trappings No medication cart; meds and treatments are stored in locked drawer in resident room (narcotics stored in locked room off of the kitchen) Staff responsible for cooking go shopping downstairs for food stuffs with full resident input in menu and snack design No steam tables, food carts, etc. everything cooked in the house

11 Leonard Florence Center Meaningful Life Beyond the homes Main Street on lobby level European Day Spa (aesthetician, nail technician and hairdresser services) Bakery and Café Kosher Deli Chapel

12 Real Home 12

13 Real Home Small homes: Elders Best at 7000 square feet or under - Normalized living: Living and dining room to accommodate residents and staff Full kitchen open to dining Private bedrooms, bathrooms, showers Single family style in rural and suburban areas, low-rise/garden apartment style in dense suburban, high-rise in urban areas 13

14 Urban Green House

15 Typical Residential Floor Plan

16 Living Room

17 I want to go home. Often when a resident says - I want to go home - they are not necessarily referring to the house they came from, but rather to a state of being that was comfortable, ordered, and fundamentally orienting. Caulkins, M. 2003

18 Leonard Florence Center for Living Activities both large and small Some of the most meaningful activities are not classic activities e.g. kibitzing with cook Larger-scale activities (concerts, large bingos) exist but are not the sole dayto-day activities, and overall are more appreciated than they would be in traditional environments The 10-person house creates a sense of family. Resident-to-Resident support is tremendous

19 Leonard Florence Center for Living People in Short-term rehab support each other in their recovery Encourage each other to participate and push each other along Minutes are up and there are less denials compared to traditional facility

20 Empowered Staff 20

21 Organizational Redesign Elder at the heart of the organizational chart Shahbazim versatile worker Prepare meals, housekeeping, laundry Additional education hours = 128 Redefines roles and responsibilities of the direct care worker, nurses and the clinical support team

22 The Hierarchy Structure Administrator Director of Nursing Dietary Supervisor Environmental Supervisor ADON Cooks Diet Techs Housekeeping Supervisor RN Supervisors Dishwasher Housekeepers LPN s C.N.A. s

23 Organizational Redesign 23

24 Nurses in The Green House Homes Care Role Model Gerontological Expert Care Partner Mentor and Teacher

25 Direct Care Staffing 12 Room Green House Shahbazim 3 Shahbazim am shift 2 Shahbazim pm shift 1 Shahbaz - night shift Total = 4.0 HPPD Universal worker role Nurses One Nurse per two houses am shift One Nurse per two - three houses pm shift and night shift Total: HPPD 25

26 Self-Managed Work Team Group of Shahbazim who are responsible and trusted to manage the Green House home Work collaboratively with leaders and members of the clinical support team

27 Leonard Florence Center for Living Typical Elder and STR Homes 1:5 Shabaz day/evening, 1:10 overnight 1:20 Nursing 24/7 Specialty Homes (ALS/MS) 1.5:5 Shabaz day/evening, 1.5:10 overnight 1:10 Nursing 24/7

28 Quality Care and Quality Life An institutional model that provides basic medical care but does not address the human needs of connectedness and relationships is one that shuts down human beings. The literature amply documents the indisputable link between psycho-social well being and clinical outcomes, between quality of care and quality of life. Barbara Frank Frank, B. 2004

29 Satisfaction & Clinical Research Kane: JAGS 2007 Satisfaction and Clinical Significant improvements in satisfaction Better clinical outcomes Sharkey: JAGS 2011 Staff Time and Clinical Acuity the same between settings Fewer total hours in GH homes Better clinical outcomes 4 times more engagement between staff and elders Bowers: Working Paper Nursing Quality Seamless communications and deep relationships Nursing care as good or better than traditional

30 Consumer Research Edge Research 2012 Caregivers 97% say GH model addresses their greatest concerns about NHs 90% think it is important or very important for providers to build more GHs in their community 68% of caregivers believed GH better for relative than being cared for at home 73% would drive miles to receive GH services 60% would pay 5% - 25%+ more

31 Consumer Research Components considered very desirable: Private rooms 80% Individualized schedules 75% Extra staff training 74% Shahbaz role 74% Home design 74% Increased direct care time 70% Family dining table 63% Home cooking 61% Small size 60%

32 Financial Research Green House Homes Jenkens et al: % more direct care time 5% less overall labor costs Median operating costs essentially equal to traditional nursing home (+$1.49/day) Capital cost at the low end of culture change model

33 Business Case Video Covers aggregate experience 3 adopters own experience Covers diverse scenarios - Rural, suburban, urban - Southeast, Mid Atlantic, Northeast - High income, low-income communities - LTC only, LTC + rehab - Not for profit, for-profit 33

34 Total Time Per Resident Day Traditional Nursing Home Green House Home 60 fewer minutes per day 6 Hours 58 Minutes 5 Hours 58 Minutes 34

35 NIC Article - Financial Benefits Occupancy increases: GH homes average 96% National average 86% and falling Private pay occupancy increases: GH homes increased private pay days by 24% Nationally, NHs lost 8% private pay days in same period Private pay rates increase with private rooms Short-term Medicare, HMO occupancy increases with all private rooms 35

36 Leonard Florence Center for Living Financial Outcomes NOI for 2012 $1.1 million Operating costs higher than traditional facility because of specialty populations served, but offset by solid quality mix (55-60% in an area without a large amount of private pay) Overall construction costs significantly higher, but if debt can be lowered enough through fundraising and/or governmentsponsored programs (eg New Market Tax Credits), the on-going operations are sustainable

37 Case Study Before LTC NH beds, 26 private rooms Existing building well maintained Average occupancy of 88.5%, 22% private pay Private pay: $219/day Medicaid : $167/day Operating costs: $200/day After - 3 Green House homes of 10 people Move 30 beds to Green Houses 86 private Rooms (26 existing +30 GH + 30 formerly doubles) Increases occupancy 6.5% Increases private pay days 24% 37

38 Short-Term Rehab in GH Homes A real home is the best place to recover and get back home: Home layout Medication management Private rooms with private bathrooms Home cooked meals Access to fresh air and sunlight Rehab in a real home Lower ratios and consistent assignment Leonard Florence Center for Living 38

39 Other Innovations Repositioning CCRC Assisted Living Dementia Care PACE 39

40 5-Star Nursing Home Rating System 83% of Green House Homes are 4 or 5 Stars compared to 42% of nursing homes nationwide!

41 Press Opinion A Real Home Rising Challenger Takes on Elder-Care System Culture Change Goes Mainstream - Green House Homes, Considered the Pinnacle of the Movement, Spread to 26 States Green House Homes: A Model for Aging That Promotes Growth Where We Live As We Age Reformers Seek To Reinvent Nursing Homes Rethinking Old Age Home Sweet (Rest) Home A Healthier Take on a Nursing Home A Nursing Home You Can Call Home

42 Spread Operating 146 homes On 35 campuses In 23 states In Development 120 homes On 19 campuses In 9 additional states 42

43 Green House Team Implementation Partnering Approach: Partner with organization Expertise in Model: Provide expertise in model components, implementation, training Risk Mitigation: Help to get it right and mitigate risks

44 The Green House Project Comprehensive Culture Change Model Strong consumer response Product differentiation in crowded markets Evidence-Based Model Known performance satisfaction, clinical, financial Revenue enhancement opportunities Tested implementation approach Sustainable Model On-going education and support Peer Network Slip-resistant Agile Model Small homes allow flexibility/specialization 44

45 Contact Information Anna Ortigara, RN, MS, FAAN Resource Development Director Maura Porcelli (703)

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