LTSS Choice: Small Nursing Homes


Long before the coronavirus pandemic, long-standing issues in traditional nursing homes, such as infection control violations, low staff ratios, and safety concerns, led many people and their families to explore. alternatives. This report, part of the AARP Public Policy Institute’s long-term service and support transformation series called LTSS Choices, discusses an alternative, the Green House model.

What is the green house model?

Unlike traditional large-scale nursing homes, Green House and other small-scale nursing homes are generally free-standing buildings occupied by a small number of residents. With small nursing homes, a group of small homes are usually licensed as a nursing facility, or they may be part of a traditional licensed nursing home. The overall goal of the design is to achieve a better quality of care and life for residents, and higher satisfaction rates among staff and families than those encountered in traditional institutional nursing homes. The model assumes that a person-centered approach to service improves the quality of life of residents. Residents decide the critical aspects of their day-to-day activities, from the types of services they want to the levels of interaction with other residents.

The staffing model is a defining feature of the Green House model, with Certified Practical Nurses (CNA) having more responsibility and more power to achieve quality of care and quality of life for residents. CNAs, who take additional hours of specialized training, including dementia care and culinary education, function as a self-directed work team and are all trained to provide a diverse range of supports, including personal care, meal preparation, laundry and housekeeping. This allows any member of staff to respond to residents’ needs on the spot. In contrast, in large retirement homes, workers typically perform only one or two functions and do so for a large number of residents, which means delays in meeting residents’ needs while waiting for the arrival of new residents. specialized staff members.

Some facts about today’s green houses

There are currently 3,200 Green House residents nationwide

  • Majority receive nursing care
  • The majority pay out of pocket
  • 45% are covered by Medicaid

There are currently 300 licensed homes in 32 states

  • 87% are licensed as qualified nursing facilities
  • 37% are located in rural areas
  • 63% are located in urban areas
  • 82% are non-profit
  • 18% are for-profit
  • 89% remain active in the Green House peer network

The proof: does the green house model lead to better results?

Preliminary evidence suggests that Green Houses are meeting their goals of improved quality of care, quality of life, and higher satisfaction rates among staff and families. Existing studies are of limited scope and more research is needed to confirm the results and determine which elements of the Green House model are most effective. The limited research on other models of small houses such as the household model also makes it difficult to compare them. That said, the results are promising:

  • Prior to the COVID-19 pandemic, studies documented better clinical outcomes for greenhouse house residents than residents of traditional nursing homes.
  • A 2015 study found that residents of Green House homes were 16% less likely to be bedridden, 38% less likely to have pressure ulcers, and 45% less likely to have catheters and had lower readmission rates. hospital lower than those of residents of traditional nursing homes.
  • Other studies have documented the effect of the model on a wide range of measures, including quality of life and quality of care, family satisfaction, and staff satisfaction.
  • Green House homes are faring much better than traditional nursing homes in dealing with COVID-19, with 2.8 confirmed deaths per thousand residents through July 2020, compared to 38 deaths per thousand residents.

Challenges in expanding the availability of small homes

Although they have been around since the early 2000s and have attributes that look very attractive, the adoption rates of the Green House model remain relatively slow, due to factors related to both consumers and suppliers.

The challenges for consumers trying to access small homes are twofold: limited availability and limited cost. The challenges for providers looking to offer or expand small homes are more complex and include: financing the cost of development; regulations, in particular state approvals necessary for the construction of health care facilities; workforce challenges, which result from being a relatively high risk, low wage industry, even though greenhouse houses offer staff compensation, retention and satisfaction above average.

The report ends with four policy recommendations that directly address these challenges. It also has three appendices: Core values ​​and essential elements of the green house; Appendix B – Three Green House Design Models; Six selected studies of green houses.

Suggested citation: Reinhard, Susan and Edem Hado. Choice of LTSS: Small Nursing Homes. Washington, DC: AARP Public Policy Institute, January 6, 2021.

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