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Dr. Eleanor Barbera
Dr. Eleanor Barbera

In 2014, I wrote, “I finally visit a Green House (and it blows my mind).” The Green House is designed with a spacious common area, private bedrooms and showers, unobtrusive medical items and universal workers practicing person-centered care. The model shows that it's possible to make dramatic lifestyle improvements in long-term care.

It seemed that Green Houses were the answer, if only there weren't so many traditional facilities already in place. Traditional nursing homes can participate in culture change programs with great success if their leadership is committed to the philosophy through the transition period and beyond. They can retrain staff, add plants and pets and remove nursing stations, but the standard long hallways have remained — until now.

Last week I had the opportunity to speak with Rebecca Priest, LNHA, LMSW, the vice president of skilled services, at St. John's Home in Rochester, NY. She's presiding over one of the most exciting changes in long-term care to come down the pike since, well, Green Houses.

St. John's is taking a conventional nursing home built in the 1960's with 32 beds to a hall and turning it into 22 small homes modeled after the Green House Project. Each floor is being systematically transformed into homelike environments with a large space for cooking, dining and socializing and universal workers called “Shahbazim” who, as with the Green House model, are central to the model's success.

Rather than having aides, housekeepers and laundry workers, the Shahbazim do it all. “The Shahbaz role,” Priest says, “is highly skilled and not for everyone. Shahbazim need to collaborate and be part of a highly sophisticated work team.”

Cross-training staff and flattening the work hierarchy reduces the likelihood that workers will find themselves in “systematically disempowered situations where they are set up to fail.” As a resident I knew used to say, “Amen to that!”

The pay rate for Shahbazim is about 15% higher than a typical CNA rate, which is more than compensated for by reduced turnover and improvements in clinical care and resident and family satisfaction.

Priest emphasizes that transitioning to small homes is “so doable for anybody regardless of finances and business model.” St. John's began by taking a significant portion of their yearly capital and investing it in their first small home. They realized “tangible clinical and financial rewards very quickly,” leading to board approval and grants to fund further renovations.

As if all that isn't enough good news, here are some stats on the project:

•  75% less staff call-ins

•  100% reduction in adverse behaviors

•  45% more direct caregiver hours per patient day

•  Private pay rate doubled in a year's time

“If we look at what's happening with our market demand,” Priest says, “consumers are demanding a different product and employees are demanding it also.” Their lowered turnover rates and full census for the small homes despite the higher private pay fee suggests that this is indeed the case.

As a psychologist, I wondered how they managed to eliminate adverse behaviors. Priest replied, “The model allows for such flexibility that people can respond to needs.”

What about challenging families? “The family grief process gets to a much quicker place of comfort and trust because there are the same staff. They see that their loved one is in good hands.”

How about staff members with bad attitudes? “Instead of bad behavior becoming absorbed into the chaos, the leader of the house can address it much quicker because of the code of ethics. People need to grow or go.” Each house has it's own standards based on inclusivity and diversity and staff members are held accountable to meet these standards.

I can't think of a resident who wouldn't prefer living in a small home or a family member who wouldn't choose it over a traditional nursing home.

Here are some perspectives from Shahbazim about their role and below is a photo of the St. John's small home interior. For more photos, visit my website.

For more information, visit The Greenhouse Project. Rebecca Priest can be reached at rpriest@stjohnsliving.org.

Eleanor Feldman Barbera, PhD, author of The Savvy Resident's Guide, is an Award of Excellence winner in the Blog Content category of the APEX Awards for Publication Excellence program. She also is the Gold Medalist in the Blog-How To/Tips/Service category of the American Society of Business Publication Editors Midwest Regional competition. A speaker and consultant with over 20 years of experience as a psychologist in long-term care, she maintains her own award-winning website at MyBetterNursingHome.com.

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