Tag Archives: The Green House Project

More on the Green House Model of Long Term Care

FB_IMG_1453111718856

 

 

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.

It’s About Who They Are

DSC00999

 

 

Yang

The third and final Green House Project core value I’ll be dealing with is meaningful life.  I think this is really the essence of the Green House movement. It says that “good care” isn’t enough and that we can’t truly address the humanity and dignity of those who reside in LTC without awareness of what it is that makes their lives worth living – to them, as individuals. It’s not just about what they need, it’s about who they are.

The basic premise behind meaningful life is that in some respects the last stages of life are really no different than any other stage. We don’t stop growing and developing just because we hit a certain age or suffer from some debilitating physical or mental condition. Whatever our life circumstances, stagnation is unnatural and harmful to both body and spirit.  People in their 70’s, 80’s and 90’s can still have their dreams. Sometimes we just have to work harder to see it. And harder still to facilitate it.

But what does this mean from a caregiver’s perspective? I often hear caregivers say that the hardest part of the job is losing residents to whom they’ve become attached. While I’ve also experienced that kind of loss, the most difficult part for me had more to do with what was going on with certain residents while they were still very much with us. It’s not easy to describe the blend of emotions I felt after providing routine care to a favorite resident – hygiene, dressing, transferring, grooming and finally wheeling him down to the day room – and then having to turn and step away, leaving him there in front of the TV, waiting for his next meal as if getting a few spoonful’s of pureed meat and vegetables was the point of all of this and the pinnacle of his daily existence could be found in his dessert pudding. And I had no choice but to leave him there and move on because there were nine other people waiting for me. We did this day in and day out.

In those moments when I had to turn and walk away, I experienced more than just that sense of emptiness. I also felt guilty and angry and frustrated because I wanted to do more. I really believed we could do better than this. Yes, the facility provided activities and encouraged him to participate and this was better than nothing. But none of it was really about him. It was more about meeting some requirement imposed from the outside or impressing the never-ending train of oh-so important visitors. It was really about what the institution needed – and quite honestly, in this regard, he was just part of the window dressing.

What a person finds meaningful – what to him makes his life worth living – is intensely individual. It varies widely from person to person and can significantly change with time and circumstance. And it is not something we can choose for another person.

What we can do is know that person so well that we are able to engage him and help him experience what he does find meaningful. And no one has more opportunity to know a resident on this level than his caregiver. This is even more so when dealing with people who suffer from some degree of cognitive impairment or inability to express themselves in the usual ways. The caregiver-resident relationship provides a context that allows communication that might otherwise be overlooked.

The genius of the Green House Model is that it recognizes the potential of this deeper awareness and enables caregivers to act on their profound desire “to do more.” 

One Reason Why the Green House Movement Can Grow

DSC00999

 

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

DSC00999

 

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

DSC00999

 

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.

The Core Values of the Green House Project

DSC00999

 

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.

An Institutional Mindset

DSC00999

 

Yang

In my last post, I shared my initial impression of the physical aspects of the Green House Project based on a workshop group tour of a local Green House Home. While the design of the home is a key element in the Green House “revolution,” it is only one piece of the puzzle. There is also a set of core values and a philosophy behind the Green House approach. For a Green House Project home to succeed, staff and administrators must totally embrace these values. In future posts, I’ll outline what these values are, explore what they mean from the caregiver’s perspective and talk about the philosophy that makes the Green House model truly revolutionary. In this post, I would like to share a simple personal epiphany.

Embracing the Green House core values means shedding the institutional mindset that comes from working in a traditional long-term care setting for any length of time. During the workshop, I noted a kind of “born again” theme running through the presentations. One speaker actually used the phrase “in my former life in long-term care,” more than once. I got the sense that in order to accept the principles of the Green House model and practice them effectively, one must first go through a process of internal psychological change. My epiphany: as much as the Green House model appeals to me, I have not gone through that process and as a caregiver, I am still very much a product of my institutional work culture.

The institutional environment is task orientated. For a caregiver, this means going full steam through the shift, efficiently organizing your activity so that you can get as much done as possible in the time you’ve been given. That is how a good worker responds to heavy workloads. It is a necessary approach, because the alternative is allow the sheer volume of tasks to overwhelm you and ultimately you simply leave things undone. When it comes to residents, “things undone” is actually another way of saying “neglect.”

But residents aren’t “tasks” or “things to be done,” and to approach them this way is another form of neglect. So within this flurry of activity, a good caregiver will seek to engage residents on an emotional level. The posts on CNA Edge deal with this aspect of caregiving almost every single week. I’ve always thought of the Art of Caregiving involved the ability to go full tilt until the point of physical and emotional contact with the resident, then decelerate as if time was standing still. But the art is imperfect and we don’t always make that shift.

For a caregiver, shedding the institutional mindset means to liberate yourself from that anxious “gotta get it done” mentality with which we have been conditioned. There are tasks to perform in a Green House Home, but the work environment is such that they are performed within the context of the emotional and social relationship with the Elder and not the other way around. In other words, there is no reason to “decelerate,” because you don’t “accelerate” in the first place.

I think that with the proper support and appropriate training, most good caregivers would be both capable and highly motivated to make this psychological adjustment. But if the change is to be real and sustained, one must first be aware of his or her starting point.

For me, such a psychological shift would require me to reshape my definition of The Art of Caregiving. Perhaps the first step has been taken with my growing awareness of how much the institutional influence is still with me.

At Home with the Green House Project

DSC00999

 

Yang

Last month, I was treated to a tour of a Green House Project home at Porter Hills, a long-term care provider in Grand Rapids, Michigan.  In today’s post I would like to share with you what I saw from a caregiver’s perspective.

The house is meant to blend in with the surrounding neighborhood. I know nothing about architectural styles, but I can tell you that when I was looking for the house prior to the workshop, I drove past it not realizing what it was. This despite a sign – and my defense, a rather modest sign – with an arrow indicating “Green House this way.” Other than the extra parking spots, there was nothing on the outside to suggest it was anything other than just another house in the neighborhood.

As our group gathered around the front entrance of the house, our tour guide explained that everyone enters the house through the front door. This includes staff. They are required to ring the doorbell and wait for someone to answer it like any visitor. The tour guide pointed out that in our own homes people don’t walk in without ringing the doorbell, even if they’re expected. She added that studies have been done indicating that when the doorbell rings, care improves. I’m sure if Dr. Pavlov was alive today, he would be pleased to hear it. Whatever it takes, I say.

After we entered the house, the tour guide pointed to a restroom door near the entrance. The door had a sign next to it that read “Powder Room” with corresponding Braille dots. Regulations require such signs, one of several unhome-like but minor compromises Green House Project practitioners must make to get the proper certifications. They do their best to make the signs as unobtrusive as possible, such as labeling the restroom “Power Room” in subdued colors rather than the unmistakably clear, but crude “TOILET” that blasts at you as you walk down the corridors of more institutional-like facilities.    

The first thing I noticed when we walked into the house was how quiet it was. There was a small group of caregivers and residents – let’s use the Green House nomenclature going forward – there was a small group of shabazim and elders gathered around the home’s communal dining table having their lunch. There was none of the institutional bustle you see in larger homes during the mid-day meal. Part of this was simply due to it being a smaller home with fewer people, but there was also a lack of any sense of the kind of meal-time urgency that is imposed on caregivers and residents elsewhere. This was life being lived at the pace of those who actually live there.

I also noted that – and I don’t mean to be disrespectful here – that the elders gathered around the table indeed looked like what, based on 35 years in long-term care, I would think of as skilled nursing residents. Of course, I would have had to spend some time with both the shabazim and elders to get a better sense of the level of care they needed, but this was a definite indication to me that this was not just an extra nice assisted living facility posing as a skilled nursing home.

After a brief greeting, our group moved into an adjoining room which I would describe as a small activity room. There was a smaller table for elders not wishing to eat at the communal dining table. The shelves where lined with books and games, all supplied by the elders and their families. There was also a reasonably sized TV with video games available. The tour guide told us group activities are typically not planned, but do occur spontaneously. Also, they don’t normally invite outside groups in to entertain the elders. Yes, it’s possible: life after 60 can indeed be lived well without bingo.

We proceeded to the kitchen area. This was open to the dining area with a serving island to separate the two spaces. Other than a commercial dishwasher (they originally installed residential dishwasher, but it couldn’t handle the volume) and a commercial stove, it looked like a large country-style kitchen in a residential home. All the meals are prepared by the shabazim on site. Breakfast is served as the elders rise, there is no set time or menu. The island had spaces where elders could “belly up to the bar” and assist the shahbaz with food prep. I believe they could eat there as well if they wanted.

We were shown the walk-in pantry. This was nicely stocked with a variety of items, but not in huge bulky containers like you would see in an institutional setting. More like something you would see at my house. Or yours. The tour guide said she regretted not having a door installed leading from the kitchen directly into the pantry. Not a big deal, unless you live or work there and have to walk around 30 times a day.

Next came the laundry room. The shabazim do the elder’s personal laundry (they do not mix different elders’ clothes in the same load) and the towels and wash clothes are sent out. Another regret from the tour guide: they bought a stackable washer and dryer set to save room, but this actually put the controls of the appliance on top well out of the reach of the typical shahbaz. I’m about 6’ and I think I would have had to go up on my tippy-toes to reach the buttons. A step stool tucked in a corner supported the tour guide’s assessment.

I bring up both the missing door between the pantry and kitchen and the stackable washer & dryer to illustrate a point. These homes are highly individualized. There is no mold or set blueprint. They do share certain characteristics, such as the “Great Room” open floor plan, the large communal dining table (more on this in a future post) and large private bedrooms with full baths. These are physical characteristics that are consistent with the philosophy and core values of the Green House Project. However, since each home is individualized, every home has to work out problems related to specific details of the physical layout and furniture and appliances. They are especially concerned to keep both the interior and exterior décor consistent with the surrounding community. That being said, there is a growing body of practical knowledge in developing and sustaining these homes and the Green House Project has a system in place that allows this knowledge to be shared with the developers and staff in both new and existing homes. This is a dynamic and flexible process, always seeking to grow and improve. There probably won’t be a stackable washer and dryer in the next Green Home they build.

On to the living room. This was also open to the dining area, just around the corner from the kitchen area. This consisted of comfortable looking couches and chairs – maybe recliners, I hope so – situated around a fire place. I didn’t look, but I assume the fire place was fueled by propane. Such a pleasant ambience and I found myself wanting to just put my feet up and hang out for a while.

Instead, we were led out the door (again, marked with regulation warning signs that you wouldn’t see in any other residential home – another minor compromise) and into an enclosed courtyard. The courtyard had a variety of plants and some kind of small fountain. And a cooking grill, which we were told gets frequent use in the warmer months. The elders have free access to the courtyard as they please. There were plenty of windows to make it easy for staff inside the house to observe elders in courtyard as necessary.

We were shown the nurse’s office just off the Great Room area. It was very small and inconspicuous. I did note the presence of nursing charts and, of course, a computer monitor. Other than that, I didn’t see any medical equipment lying about and it appeared no different than any small office in a residential home. We were also told that there was an administrator’s office, another regulatory requirement. Apparently, this office was even smaller than the nurse’s station and no one in the group seemed particularly interested in seeing it.

We then got to see one of the elder’s bedrooms. As promised, it was private, pretty big and had a full bath. Elders new to the home are encourage to bring their favorite chair or other small piece of furniture. There was a pull out wall unit where nursing supplies were kept. The most impressive feature of the room – at least for me – was the “ceiling lift.” Yes, a compact mechanical lift suspended from the ceiling that could be moved along tracks – picture the kind of ceiling tracks used for privacy curtains. There was a space between the ceiling and the top of the wall separating the bathroom from the rest of the bedroom, so that an elder could easily be moved from bathroom to the bed or any other point in the room. If you’ve ever worked direct care, you know what kind time-saver this sort of set up would be.

They don’t use any other lifts in the home. In fact, I didn’t see any medical equipment of any kind anywhere. I’m not sure how they do transfers outside the bedrooms other than a one or two person lift. I’m thinking in some situations that might pose some difficulties or impose some limitations.

That was pretty much it. My overall impression was very favorable. Being there does indeed feel like home and not like you’re in a care facility. You can see what a constant struggle it must be to keep all the institutional implements and habits from creeping back into the home.

I have more to say and much more to explore regarding the Green House Project, but this post has long enough, so I’ll be back in future posts with more on the Green House Project.

For more information on the Green House Project, visit their website at www.thegreenhouseproject.org or check out my recent posts related to the Green House Project: www.cnaedge.com/2015/06/19/something-worth-exploring  and www.cnaedge.com/2015/06/07/imagine-this

Something Worth Exploring

DSC00999

 

Yang

Yesterday, I had the opportunity to visit a local Green House home as part of a six-hour workshop concerning the Green House Project. I’m still processing everything I saw and heard, so this is going to be a very short post. However, I do want to say a few things about my first impression.

First, from a caregiver’s perspective, this is well worth exploring. It’s pretty amazing in fact. In essence, what the Green House Project does is create places where a high level of skilled nursing is done in not just a “home-like” environment, but in an actual home. The kind that anyone would recognize as a home and not a “home for elderly” or a “home for the disabled” or any other qualification you could add. Just a home. How this is done and why we would want to do it – again from a caregiver’s perspective – is going to be the main subject of my posts on this blog for the next few months.

Second, the Green House Project is truly revolutionary.  This is not just Wouldn’t-It-Be-Nice talk about “culture change” or “new paradigms” by people with lots of letters next to their names. It is, in fact, “culture changed.” It is both a physical and philosophical transformation in how we approach the entire long-term care process.

Third, on CNA Edge we talk a lot about the significance of the caregiver-resident relationship.  In my last post, I said that what caregivers want more than anything is to “reach” all of the people in their care. While my natural skepticism prohibits me from becoming a full-fledged Green House Project advocate without taking a closer look, as I listened and watched yesterday, the voice in the back of my mind kept saying “They finally figured it out – this is what we’ve been wanting for so long…”

We’ll see. One of the things I’ll be doing in the coming months is seeking out caregivers who have had experience working in Green House homes and getting a better feel for it from the direct care perspective.

Imagine This

DSC00999

 

 

Yang

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 www.thegreenhouseproject.org