The World According to Dr. El

I finally visit a Green House (and it blows my mind!)

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Eleanor Feldman Barbera, Ph.D.
Eleanor Feldman Barbera, Ph.D.

In my last post, I discussed culture change and its positive impact on the mental health of the residents, particularly at Eden Alternative facilities. I recently also had the opportunity to tour a Green House, which I'd heard about but had never seen. While Eden Alternative homes change the culture of care within existing facilities, The Green House Project creates the “ideal” setting from the ground up.

The template of a Green House is a small building that is home to 10 to 12 residents, or “elders,” and two caregiving “Shahbazim,” which is the plural of Shahbaz. A Shahbaz is an aide trained to do almost everything that needs to be done within the house – providing care for the elders, laundering the clothes and bedding, performing light housekeeping, planning meals, cooking, serving the food, engaging the elders in activities, etc.

The house itself is designed to be more like a home, with private rooms off a large common area that includes a living room, dining area and kitchen.

I found this model turned everything I'd known about nursing homes upside down.

Green Hill visit

The first thing I noticed when I pulled up to Green Hill in West Orange, NJ, aside from the impressive entrance to this former hotel, was that there were parking spots reserved for visitors. By contrast, most of the nursing homes I've encountered have reserved spaces for upper level staff. This easily replicable idea offers a person-centered approach even before guests enter the facility.  

Green Hill has four Green Houses in addition to its other levels of care. Ten elders reside in each of these small buildings in the back of the campus.

Walking into the Green House was very much like entering someone's home. As I came through the entryway, there was a small, bright room on my left where I later interviewed one of the elders. On my right was a large, open kitchen. A computer monitor was discreetly tucked in the corner next to a glass cake stand holding a freshly baked cake.

The sunny living room in front of me had couches and chairs around a fireplace and a television. Elders in wheelchairs watched TV, enjoyed the fire, or thumbed through magazines. To the right, between the living room and kitchen, was a large dining table. I was told that on Thanksgiving, family members joined the group and about 30 people crowded around to celebrate a communal meal.

What I didn't see, hear or smell

It was striking that aside from the wheelchairs and the computer monitor, I didn't see any medical equipment. The blood pressure gauge and other necessary items were kept away from sight in a small room off the common area. I didn't smell any of the scents typically associated with long-term care. There were no buzzers, alarms or overhead pages to be heard over the cooking, television, and crackle of the fireplace.

Individual space

Each elder in the house had a private room. I admit I became verklempt when I saw the attached bathroom, with a ceiling lift that allows for easy transport from bed to bath. These elders are spared the common and detestable shower chair ride down the long public halls of traditional nursing homes.

The absence of a medication cart was explained by the locked individualized medicine cabinet set into the wall near the door of each room.

Interviews with staff and elders 

I had a chance to speak privately with members of Green Hill.

“They made me a birthday cake for my 89th birthday,” an elder enthused, though she admitted she doesn't always ask for what she wants to eat because she “doesn't want to bother them.”  She gave me permission to pass along her yearning for cream of tomato soup to Stephanie, one of the house's two daytime Shahbazim. “I'll make some for her,” was Stephanie's immediate response.

Contrast this with a traditional nursing home. As the psychologist hearing a desire for soup, I would have called the dietician. The dietician would make a note in the computer system, which would be picked up by the staff in the kitchen. Sometimes this would result in actually getting the requested soup. And sometimes this would result in the resident getting only cream of tomato soup for the duration of their stay. Residents would then tell me, “I didn't mean I never wanted anything else.”

With a Shahbaz, the elder could ask for something different the following night.

“The house model is more cost efficient than the traditional setting,” administrator Toni Davis told me, “because even though our staff ratio is higher, we don't have the other staff needs like laundry and housekeeping.”

All this and it's cost efficient too?

Concepts to copy

While not every organization is going to be able to start up a Green House tomorrow, there are some ideas to borrow from the model:

  • Set aside a few parking spots for visitors. (Today!)
  • Create a closet to house oxygen tanks, blood pressure gauges, etc. to keep them from view.
  • Encourage staff members to eat with residents, so that there are two people sharing a meal (or at least a cup of tea) rather than one person feeding another.
  • Replace overhead paging with a silent communication system.
  • Enlarge shower areas so that people can come to and from the shower rooms fully clothed.
  • If possible, create more private rooms and fewer shared quarters.

For more on the Green House Project, visit its website

Eleanor Feldman Barbera, PhD, author of The Savvy Resident's Guide, is an accomplished speaker and consultant with over 17 years of experience as a psychologist in long-term care. This blog complements her award-winning website, MyBetterNursingHome.com, which has more on how to create long-term care where EVERYBODY thrives.

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