Imagine This





From a caregiver’s perspective, what would a long-term care system that’s not “broken” offer?

Imagine this…

Start with a 5-1 ratio. Yes, 5-1. Caregivers to residents.

Next, each resident has a private bedroom with a full bathroom. The bedroom opens to a central living area and a common dining area. There are no corridors, no nursing stations and no med carts.

There is a full kitchen with food available 24/7. The caregivers prepare the main meals – with assistance from residents who wish to help. Caregivers are encouraged eat with the residents in the common dining area. Family and friends are welcome to join.

There are no rigid routines or schedules. Residents get up when they want, eat when they want and go to bed when they want.

Caregivers serve in universal or “blended” roles. This means that along with the traditional direct care function, they are also responsible for things like housekeeping, minor maintenance and scheduling. And, of course, they will receive an additional 120 hours beyond their CNA training so that they have the necessary skills to accomplish these other duties. Residents who wish to do so will be able to assist caregivers in routine tasks such as daily housekeeping and laundry. While group activities will be available for those who care to participate, caregivers will also facilitate each resident’s pursuit of his or her individual interests.

All of this takes place in a small group home of 6-12 residents. The home can be a part of a cluster of homes offering all necessary skilled nursing and other clinical and support services. The majority of these services take place in the home, freeing both the caregivers and residents from the burden of transportation. While one RN is assigned to every two homes to meet the medical needs of residents, the RN’s job does not include supervising caregivers. Each home is run by self-managed teams. While caregivers will have the support and guidance of a manager, they make most of the day to day decisions themselves.

Most important of all, caregivers are encouraged – and are given the opportunity and support – to develop deep personal relationships with the residents. These relationships are at the heart of the entire process. Without them, the idea of “person centered care” cannot become a reality.

Of course, it’s not necessary to imagine this. For those who are familiar with the Green House Project, the description above should sound familiar. I’m sure I’ve left out some things, I’ve only recently began learning about the project. In fact, I’ve never actually visited one. However, the concept addresses so many of the problems that we have raised on CNA Edge that I think it is well worth exploring. And that’s exactly what I’ll be doing on this blog over the next several months. There is a Green House in my area and I plan on making a visit later this month and reporting what I find. I also intend on speaking with caregivers who have experience working in Green House Project homes.

From what I’ve learned thus far, my impression is that the Green House Project isn’t just about establishing an alternative to the typical skilled nursing institutional setting. It is a movement whose principles are centered on creating a genuine person centered environment and thus deinstitutionalize the institution and radically reinvent the long-term care system.

No doubt there are tremendous challenges involved in such an effort and not all of them are financial. Advocates of the project express concern over what they call “reverse creep” – a kind of backsliding into old institutional ways and habits. Ideals and principles are great things, but it’s how we put them into practice that really counts. We can work in the most perfect system, but at the end of the day it still boils down to us and how we respond on a daily basis.

For more information on the Green House Project, visit

3 thoughts on “Imagine This

  1. Anna Ortigara

    The Green House Model is a powerful new way to create person-centered skilled care. Just want to clarify that it is 1 caregiver (Shahbaz) for 5 elders in a 10 person home. I am honored to have work with the project for 6 years.

  2. Yang Post author

    Yes, I wondering about the math on that. I did have one caregiver tell me her ratio was 4-1 in a 12 person home.

  3. May

    5 residents to one aide sounds pretty good! I can usually handle up to 8 with grace…over 10 and I start to unravel!


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