Turning Nursing Homes into True Homes: The Household Model

Skilled nursing facilities have been designed and operated in a hospital-like, institutional style since they proliferated in the 1960s across the United States. But these facilities have been afflicted by quality of care, safety, and infection-control problems for decades. The COVID-19 pandemic spotlighted those problems, with a disproportionate share of people in the U.S. who died from the virus contracting it while living in a nursing home, often in shared rooms. Despite an aging population and a growing need for long-term care, nursing home occupancy rates have fallen since the pandemic emergency period, with surveys showing that many people have negative perceptions about nursing homes.

Background

Starting in the 1990s, long-term care experts began thinking about alternative models of designing and operating nursing homes in ways that are safer and more satisfying for residents, their families, and staff. Family physician Bill Thomas launched the Eden Alternative model at a nursing home in New Berlin, New York, which spawned an international movement. It focused on having residents and staff partner in innovative ways to counter the loneliness, helplessness, and boredom of life in traditional nursing homes.

In the early 2000s, the Robert Wood Johnson Foundation gave Thomas a grant to establish the first model of what he called a Green House nursing home, which is one form of a small-house nursing home model. It opened in 2003 at the Traceway Retirement Community in Tupelo, Mississippi. Each Green House cottage in the facility housed 10-12 residents and featured private bedrooms and a cooking, dining, and living area, with an adjoining outdoor space. A small group of cross-trained workers served each cottage, with nurses, physicians, and other clinicians visiting as needed.

There are now about 400 Green House-style nursing homes in 33 states, with 90 percent operated by nonprofit organizations, according to Susan Ryan, CEO of the Center for Innovation, which promotes the Green House and Household Models.

In 1996, social worker LaVrene Norton and colleagues founded Action Pact as a small consulting and education group to help long-term care providers develop the skills to move toward the Household Model of nursing home care. The Household Model shares the general goals, design, and staffing principles of the Green House model, but offers more flexibility to accommodate provider organizations with varying financial, physical infrastructure, and space resources, Norton said.

Household Model facilities generally feature nursing home units with 14-20 residents. Providers often reconfigure their existing facilities rather than build new facilities, as is more typical with Green Houses. An early example of a Household Model nursing home is Brewster Village in Appleton, Wisconsin.

As a consultant helping organizations convert to the Household Model, Action Pact gives those organizations “more space around what they want to do and how they do it,” said Norton. “They may feel they can embrace the Household Model whereas they may not feel they can afford the Green House model.”

Norton said there are many long-term care providers across the country that have implemented at least parts of the Household Model. For example, in 2016, Bridgewater Retirement Community converted its 127-bed skilled nursing facility in Virginia into a Household Model nursing home. Working with Action Pact, Bridgewater president Rodney Alderfer said his nonprofit organization started looking into an alternative model in 2010 because it wanted to offer nursing home residents just as satisfying an experience as it offered people in its independent living program.

“We want people to live their best life, and the nursing home was the place where that wasn’t happening to our expectation,” Alderfer said. “The impetus was to do better for our people.”

With $20 million of its own funds, charitable donations, and loans, Bridgewater renovated its nursing home facility from 2014 to 2016. Formerly a long three-story building with shared bedrooms and bathrooms, it was rebuilt as a U-shaped structure with six households.

Each household houses about 21 residents, who each have a private bedroom and bathroom, Alderfer said. Each household has its own kitchen, dining room, living room, outdoor patio, and screened-in porch. While most of the food is still cooked in the central kitchen, residents and staff can make breakfast in the smaller household kitchens. They can eat whenever they wake up, rather than having everyone being awakened by staff at a fixed time and brought to a large dining hall.

About one-third of Bridgewater’s nursing home residents are funded by Medicaid, while about two-thirds are private pay.

“The difference it makes when people live in an environment where they can choose what they want for breakfast or lunch, and choose to go on a beach outing — those things mean so much to quality of life for residents,” Alderfer said. “The importance of giving people those choices is underrecognized. They feel honored in a way that brings value to their life.”

Also working with Action Pact, St. Paul Elder Services is planning to convert its 105-bed skilled nursing facility in Kaukauna, Wisconsin into a Household Model nursing home within the next several years. It has begun a culture transformation toward creating a resident-directed living environment.

“While our nursing home is pleasant, the design is more institutional than what we’re comfortable with given our desire to move to a true sense of home,” said Sonda Norder, CEO of St. Paul Elder Services.

The COVID-19 pandemic also played a significant role in her organization’s desire to switch to a model with private rooms. “We were hit very hard by the pandemic,” Norder said. “It was virtually guaranteed that if one person in a semi-private room got COVID, their roommate would get it, too. Private rooms are absolutely best practice now for infection control. And with smaller cohorts of people together, there are less viral vectors.”

In 2024, St. Paul will present to its board a $28 million project to convert its nursing home facility, which currently has four long wings, into a facility with smaller household units, each with 20 residents. Each household will have a living room and kitchen where residents can be involved in meal preparation, Norder said.

About 50 percent of St. Paul’s nursing home residents are funded by Medicaid, and 50 percent are private pay.

“Our staff will be assigned to each of those households as an extended family concept, to create a true sense of living together for eight or 12 hours a day rather than coming to work in someone else’s home,” she said.

Intervention

To effectively adopt the Household Model, transforming the staff roles and culture is at least as important as modifying the nursing home’s physical design, Norton stressed.

Action Pact works with provider organizations to help administrators and staff understand their role as assisting residents in making decisions and directing their own lives. The focus is on giving staff opportunities to develop independent judgment and work as self-directed teams that respond to a wide range of residents’ needs.

Rather than maintaining siloed roles for staff as certified nursing assistants, food workers, activities workers, and maintenance workers, the Household Model encourages cross-training of staff so they can function as “versatile” workers. While staff still work mostly within their defined roles, they are encouraged to help residents as needed with food, activities, activities of daily living, and maintenance and sanitation.

For instance, the “homemaker” works in the kitchen but plays a central part in the household, combining the roles of social worker, concierge, and even daughter, Norton said. Sitting at the kitchen counter, the homemaker can cheer up residents who are feeling sad, and plan activities to engage those who are withdrawn.

Norton said these broader roles are appealing to staff, and can help with recruitment and retention, which have become severe problems for the nursing home industry.

“The biggest old nursing home saying when someone needs something is, ‘It’s not my job,’ because you had so much to do on your list of tasks,” she said. “That goes away in the Household Model. The staff are a self-directed team, they can see what needs to be done, and they can help when another staffer is busy. People learn and grow in this model. It becomes exciting for the staff.”

Along those lines, St. Paul Elder Services currently is surveying the staff to identify their skills, talents, and what they would like to share with residents. For example, a maintenance worker who is a good singer might want to lead musical sessions, said Becky Reichelt, St. Paul’s executive vice president.
 

Implementation

Advocates of the Green House and Household Models acknowledge that national uptake has gone slowly, with only about two percent of the nation’s 15,000 skilled nursing facilities adopting their models.

They hope the catastrophic nursing home experience during the COVID-19 pandemic will speed up the pace of adoption. And they are hearing more interest post-pandemic from providers and policymakers, Ryan said.

Before the pandemic, she said, many nursing home operators took the complacent view that the care they provided and their occupancy rates were good enough and there was no need to invest in better quality care. “But COVID blew that out of the water,” she said.

A major hurdle to implementing the Household Model is inadequate state Medicaid payment rates, which make it difficult for providers to justify the investment in converting to facilities with private rooms, Ryan said. Still, once the construction is done, some providers say per-resident operating costs are little different than in a traditional nursing home, and that there are actually savings in food costs and staff flexibility.

Another factor hampering conversions is the current high cost of construction that has discouraged new building or renovation.

For-profit operators, which run 80 percent of the nation’s nursing homes, have been particularly slow to embrace the newer models. There are a few exceptions, notably Southern Administrative Services, which operates 53 Green House nursing homes in Arkansas. Part of the reason is that, unlike many not-for-profit providers, for-profit providers tend to run nursing homes without the full continuum of private-pay, long-term care services such as independent and assisted living that are more profitable.

A few states including Arkansas, Michigan, Minnesota, and Ohio have encouraged the adoption of Green House and other Household Models by providing financial incentives, Ryan noted. Arkansas offered capital grants and bumped up its Medicaid per-diem rates for nursing home operators that switched to the Green House model, prompting Southern Administrative Services to build Green Houses.

Impact

Research has shown that the Green House and Household Models have produced better outcomes for nursing home residents, with some indications of reduced health care utilization and costs. There has been more evaluation of the Green House model than of other types of Household Models because the Green House model is more standardized and therefore easier to study, said Tetyana Shippee, a health policy professor at University of Minnesota who studies aging.

Residents of Green Houses and other small household model nursing homes were much less likely to be infected and to die from Covid-19 than residents of traditional nursing homes, according to a study published in the Journal of the American Medical Directors Association in 2021.

Residence in a Green House nursing home was associated with a 31 percent decline in all 30-day hospital readmissions and a 30 percent decline in avoidable admissions compared with traditional nursing homes, one study found. In addition, Medicare Part A spending for all residents in a Green House nursing home organization as a whole was lower than spending in traditional nursing homes, another study reported.

An observational study published in Innovation in Aging in 2017 found that compared with traditional nursing homes, staff in Household Model facilities cared for residents in more person-centered ways. That was associated with residents spending more time talking with staff, displaying positive affect, and engaging in more task-oriented interactions.

A case study published in the Journal of Nursing Care Quality earlier this year found that the adoption of the Household Model by Menno Haven in Pennsylvania in 2021 led to improvements in 14 of the study’s 17 measures, compared to the data three months prior to opening the new facility. That included higher scores on resident-directed life and family satisfaction and slower declines in residents’ activities of daily living and incontinence. There was a slight increase in the number of resident falls, however, suggesting that greater independence comes with higher risk.

Despite the documented advantages of the Household Model, advocates acknowledge that it has not yet been made available to many lower-income communities around the country. It is mostly being implemented by nursing home providers in predominantly white and more affluent communities. That is at least partly because providers say that to make the model financially viable, they need a high percentage of private-pay and Medicare-funded residents, with at most half of residents on Medicaid.

“Most of them serve a white, middle-class clientele,” Cohen said, citing low Medicaid payment rates as a major reason. But he thinks that could be remedied by financial incentives to develop more Household Model facilities, such as allowing providers to share Medicaid savings from their residents’ lower hospital and emergency department utilization.

Alderfer thinks nursing home providers should take the leap. Since Bridgewater converted to the Household Model in 2016, the bed occupancy rate has risen, it has been easier to attract and retain quality staff, and there is more engagement from families because it is now a nicer place to visit, he said. Meanwhile, the basic operating costs are about the same, with roughly the same staffing ratios.

Despite the COVID-19 pandemic, the average census in Green House nursing homes from 2021 to 2022 rose from 84.8 to 87.9 percent, compared with a decline in nursing homes nationally from 71.1 to 70.6 percent, according to the Green House Project, which is part of the Center for Innovation.

“It’s not an easy journey, it takes years and dollars,” Alderfer said. “But when you come out the other end, it’s better for residents, team members, families and for the organization. It makes an incredibly deep difference when you are focused on relationships and the autonomy of residents, rather than just trying to get through the day.”

Insights

• The Household Model helps with staff recruitment and retention. “It’s been a definite boost to our ability to recruit and retain, because it’s a better work environment,” Alderfer said.
• The Household Model is financially viable with the right mix of private-pay and Medicaid residents. “We’ve been able to manage the higher level of living for residents without it costing us more,” Alderfer said. “It cost money to invest in the new building, but we also got new revenue because our census is very very high, and private-pay patients are willing to pay more for private rooms.”
• Staff and organizational development necessary to move to the Household Model may take several years. “Move at the speed of trust to get staff buy-in for long-term success,” Norder said “You take this in baby steps that build off each other, so it doesn’t fee like such a drastic change in people’s mindsets or workdays.”
• Spreading the Household Model depends on many factors including state payment and regulatory policies. “It really depends on so many different things — the particular state environment, who owns the nursing home, the heart of the people in charge and their ability to see the big picture,” Norton said. “If you can’t see that you’ll be financially OK, you won’t go in that direction. But those who do see it, they make it happen.”

Acknowledgements

Thank you to LaVrene Norton, Rodney Alderfer, Becky Reichelt, Sondra Norder, Susan Ryan, Marc Cohen, and Tetyana Shippee for helping inform this blog post.

*Author Harris Meyer is a freelance journalist who has been writing about health care policy and delivery since 1986.