Tag Archives: Shahbaz

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.

One Reason Why the Green House Movement Can Grow

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Yang

Before moving on to the third core value of the Green House Project, meaningful life, I would like to address one key question regarding staff empowerment. Currently, only a tiny fraction of residents in Long Term Care in the United States live in Green House Homes. Something under 2000 nationwide, but it’s growing. If the Green House movement ever grew to the point where it became a major alternative to traditional institutional care, would there be enough direct care workers with the right blend of personal and professional qualities to meet the demand? Or is the potential shahbaz candidate a rare breed drawn from an elite group of exceptional caregivers, high in motivation and ability, but too small in numbers?

There is much about the feasibility of the Green House Model that I am not qualified to answer. I know very little about the financial aspects and I don’t have the administrative experience or education to speak to the problems involved in organizing and sustaining something like a Green House Home. But what I do know and what I am qualified to address is the caregiver issue. And my answer to the question of whether or not there would be enough direct care workers with what it takes to meet the demands of a large scale Green House movement is an emphatic “yes.”

Yes, they are out there. I’ve worked with them. I know them. I know that many strive to maintain high standards of care while practicing a deep and genuine brand of compassion that endures despite difficult circumstances. And while they are acutely aware that the system they work under is deeply flawed, they are no less motivated by a sense of pride in their work and by the strong personal connection they have with their residents. These are caregivers who refuse to define themselves by the environment in which they work.

This breed of caregiver is all over social media. There, as in the work place, they find like-minded caregivers and create bonds of mutual support and understanding. Whether onsite or online, good caregivers are drawn to one another. And as we witness this larger community of caregivers begin to take shape and develop a sense of itself, we can see an independent grassroots ethos form, expressed in a thousand different ways, but with a common theme: “As a CNA, I know I am underpaid, not appreciated like I should be and worn out. But I also know that under my care, I will do whatever it takes to make sure you will have the best life possible.” While the words are simple, the commitment behind them is profound. And it is the essence of what it means to be a shahbaz. 

Of course, there are administrators and LTC professionals who don’t see it that way. There are those who would look at the unique labor requirements of the Green House Model and tell you – at least in private – “It wouldn’t work here – we just don’t have that kind of people.”

I think this lack of faith in the average caregiver extends from the fact that the skeptics are judging caregivers from the outside and in an environment that limits them. Heavy workloads, rules and regulations that do not make sense at the caregiver level and a hierarchical system that stifles initiative masks a powerful underlying and largely untapped potential. Even well intentioned administrators often lack the awareness of what caregivers actually do and are capable of doing. You have to descend into the trenches and become a part of it to really see it and understand it.

I have little doubt that with proper support and training, most caregivers would thrive in an environment of staff empowerment. If the Green House Project fails to become a large scale movement, it won’t be because the right kind of people aren’t available.

Staff Empowerment and Caregiver Relationships in the Green House Model

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Yang

I think one of the things that make the Green House Model viable from a caregiver’s perspective is that it incorporates many of the positive things that direct care workers in traditional institutional settings already do – or would like to do – and then formalizes and enhances them in a supportive environment. For example, that “deep knowing” of elders so vital to the Green House Model also exists in traditional settings. However, in places where caregiver workloads are too heavy, that level of awareness can’t happen consistently – even with the best of efforts – and some residents are going to fall through the cracks.

This is also applies to how workers relate to one another. Anyone who has been in the business for any length of time will tell you that friction among direct care staff is a staple of the institutional work environment. At its worst, it is exhibited in things like petty rivalries, cliquish behavior and bullying. Some of this behavior borders on the juvenile and the atmosphere on a nursing home unit can sometimes feel more like a middle school cafeteria than a home for the elderly. A quick check of the CNA Facebook pages will confirm this. Frustrated managers will often respond by saying something along the lines of “Why can’t you just act like adults – aren’t we all here for the residents?” apparently oblivious to the fact that having to remind workers of something so patently obvious is an indication that the problems go deeper and require a better solution than simply telling people to “grow up.”

On the other hand, it’s not unusual for direct care workers to create strong and positive relationships with one another and cooperate in ways that benefit their residents. Even in the worst work environments, caregivers often form very close bonds that resemble family ties and can even last a lifetime. Sometimes these are bonds are formed because of poor work environments, as a matter of mutual self-preservation. These relationships develop spontaneously, more a result of the nature of the work and the individual personalities of caregivers than from any systematic institutional initiative. And the value of these relationships often go unrecognized. Indeed, according to the conventional wisdom of many managers and caregivers “We are here to take care of the residents, not to make friends.” As if creating heathy personal connections with your coworkers is somehow inconsistent with good care.

By empowering staff, the Green House Model depends upon self-managed teams of workers to deal with the day to day issues of the home. In this model, strong interpersonal relationships among caregivers is a critical element. As part of their extended training, shahbazim receive instruction in interpersonal skills. This provides them with the tools that enable them to defuse personality clashes and focus their energies on resolving common problems. In the process, the natural bond that forms between caregivers is nurtured and can grow into a strong and effective professional relationship.

Furthermore, prior to the opening of a Green House Home, direct care staff go through a team building process that enable workers to develop positive relationships. In this way, caregivers become familiar with one another, learn to trust each other and a cooperative foundation is established even before the real work begins. As new workers are hired, they are brought into an environment that is open and supportive. The self-managed team has the supportive aspects of a clique, but without the exclusion. In a Green House Home, everyone belongs to the clique.

The shahbazim I talked to characterized their work relationships as “like a family.” I have no doubt that this is precisely what the creators of the model intended.

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.

The Core Values of the Green House Project

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Yang

Last week, I promised an outline of the core values of the Green House Project. There are three of them. Straight from the brochure, they are:

Meaningful Life

“Individual needs are met because each person is deeply known and valued as creative, resourceful and whole. Everyday tasks, such as personal care, bathing and mealtime, are seen as opportunities to support elder autonomy, decision making and meaningful engagement.”

Empowered Staff

“Direct-care staff functions within self-managed work teams to provide day-to-day care and act as managers of the home. They partner with nurses and other clinical team members and report to a Guide, who is responsible for providing the team with the support, accountability and resources necessary for success in their role. This model returns power to elders and those who are close to them.”

Real Home

“The physical environment of each Green House home is designed to transform the institutional nursing facility into a small, residential environment that is home to 10 to 12 elders. Each person who lives in a Green House home has a private bedroom and full bathroom with a shower. Elders share meals prepared in the full kitchen in the home, at a common table. The homes fit in the surrounding community.”

And that’s it. While the language used in expressing these values is important, the real challenge is putting them into practice and sustaining them on a day to day basis. In my current exploration of the Green House Model, I have heard of instances of Green House Homes “not working.” While this depends on upon one’s definition of “not working,” my guess is that it has something to with practical problems causing administrators and staff to stray from these core values.

We’ve already shared a good example of the Real Home core value in practice (see At Home With the Green House Project) . The only thing I would like to add is that the purpose behind this physical environment can be defeated by staff reverting to institutional-like habits and patterns of behavior (see An Institutional Mindset). You can build the house exactly right, but to sustain the culture and avoid “reverse creep” requires administrators and staff who are totally committed to the core values and philosophy of the Green House Model.

In my next post, I would like to take a closer look at the Empowered Staff core value and the people who ultimately make the model become reality: the caregiver – or in the Green House vernacular, the Shahbaz.