Tag Archives: Green House Model

More on the Green House Model of Long Term Care

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Minstrel 

In a series of posts in 2015, CNA Edge offered a caregiver’s perspective of the Green House Project, an innovative alternative model for Long Term Care. In today’s post, caregiver and guest contributor Minstrel gives her take on the Green House Project after a visit to one of the homes.

Yang has written previously on the Green House Project.  Recently I also visited a Green House Project complex.  Today these embody the most promising ways of caring for those needing long-term skilled nursing care.  It’s a tremendous care model.  I do have several reservations.

First, this model depends on having a majority of residents with substantial nest eggs.  (At one home in New Jersey, I’m told this is about $350,000.)

Second, while Green House homes do pay their Shahbazim more than what they were previously earning, they are still not earning a living wage, and some work a second job to supplement income.  One of the Green House Project’s three philosophical underpinnings is staff empowerment.  Doesn’t staff empowerment need to include their economic empowerment?  I asked this question at a GHP seminar but didn’t get a satisfactory response.

Third, as aging impacts physical and mental health, some elders will develop dementia and some will need two-person assists for transfers. We may find that even a two-to ten ratio won’t sustain the quality of care as care needs increase.  The current staffing ratios, which seem ideal, may not be adequate.  Down the line there is likely to be a need for more staff at greater cost to the home; or, if staff isn’t increased to meet the greater needs, a diminution in care.

It’s hard to imagine how this model could be affordable on a large scale — and Dr. Bill’s vision is enormous — without a changed allocation of national resources.  In 2014 the US GDP was over $17 trillion. Green House nursing homes are an economic possibility, just not a political possibility yet.  Thus the current model of LTC homes seems likely to survive.  But the culture of care — for residents of LTC homes and also for their caregivers — must and can be improved radically.  This belief is at the heart of CNA Edge’s mission.

How the Green House Model Makes Staff Empowerment Possible

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Yang

In my last post, I began looking at the second core value of the Green House Project: empowered staff. This features an organizational structure that “flattens” the traditional hierarchy and leaves the responsibility for day to day decisions in the home to direct care staff (shahbazim). How and why the Green House model makes this organizational structure viable from a caregiver’s perspective will be the subject of my next two or three posts.

There are three tangible and interrelated ways in which the Green House model makes it possible for the Shahbazim to perform this expanded role. First, as previously noted, the shahbaz to elder ratio is 5-1. In most LTC settings that ratio is much higher, sometimes 10-1 or more on the day shift and higher on the evening and night shifts. The higher ratios guarantee that a caregiver in a traditional setting is going to be overwhelmed with basic daily care concerns and is not a position to take on the additional burden of assuming responsibility for matters not directly related to care. The 5-1 ratio allows a shahbaz the flexibility to effectively deal with these additional responsibilities.

Second, along with the CNA requirement, shahbazim receive an additional 128 hours of training specifically related to their expanded role. This includes instruction in safe food handling, culinary skills, first aid, basic home maintenance and management skills. Shahbazim also receive instruction in dementia care, critical thinking, communication, teamwork and policies and procedures. The shahbaz builds on this foundation of knowledge and develops professionally through a combination of practical experience, coaching and peer networking. There is an expectation that with proper support, caregivers can and will grow into the expanded role.

Third, Green House homes are limited to 10-12 elders. The small scale significantly changes the nature of the problems and decisions faced by the Shahbazim as opposed to what managers deal with in large institutions. For example, nutrition in a traditional institutional setting involves a whole range of problems such as large scale procurement, storage, inventory control and staff management, not to mention the difficulties involved in preparing and delivering large volumes of food. While preparing meals for a home of 10-12 people is not a small job, the problems revolve more around individual preferences and are thus more similar to what a shahbaz experiences in his or her own home.

While we can point to these more tangible factors that make staff empowerment possible, the dynamics that really make the whole thing work are a little harder to define. But I’ll give it a shot in my next post.

A Flattened Hierarchy

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Yang

Continuing my exploration of the Green House Project, I will now turn to the second core value of the model, “Empowered Staff.” Empowered staff refers primarily to the workers who provide direct care.

The Green House term for a caregiver is “Shahbaz” (plural: Shahbazim). Shahbaz means “royal falcon” in Persian and is meant to convey a person worthy of respect, someone who is valued. The title is representative of the Green House Model’s investment in and support of the workers closest to the Elders.

The Shahbazim perform the same basic personal care duties as CNAs in a traditional long-term care setting, but along with the new title they are given a significantly expanded role which makes them responsible for the day to day management of the home. They make decisions that would normally be made by supervisors or mid-level managers. These include decisions involving scheduling, food preparation, laundry, housekeeping and care planning. They rotate the leadership roles – typically each quarter – so that each shahbaz takes a turn coordinating each of these functions.

This organizational structure is often characterized as a “flattened hierarchy.”  However, while the homes are operated by self-managed work teams, the Shahbazim do not work unsupported. They report to a “Guide,” an experienced LTC professional with extensive training in coaching skills. The Guide is responsible for providing the team with support, accountability and the resources necessary for the Shahbazim to succeed.

While it would be easy for a caregiver to simply regard the Guide as just another kind of supervisor, the core value of Empowered Staff requires the Guide to leave the day to day problem solving in the hands of the Shahbazim. A Shahbaz must be willing to receive coaching and grow into these new roles. In this sense, empowerment is not simply a matter of delegating responsibility, but it is a process that depends on the personal and professional growth and development of individual caregivers.

How and why this organizational structure works from a caregiver’s perspective will be the subject of upcoming posts.