The Happy Little Nursing Homes Outsmarting Covid-19

Over the summer, housemates Thelma and Dave enjoyed distanced, masked socializing on their patio with family members. Thelma was growing zinnias and marigolds in raised planter beds, while Dave could often be found scooting around the trails surrounding their wood-framed home in Washington’s breathtaking Methow Valley. While many other residents of elder-care homes found themselves confined to their rooms by Covid-19, the ones at Jamie’s Place could continue enjoying many of the small pleasures that bolster well-being and bring meaning to daily life.

Jamie’s Place is one of 300 homes across the U.S. that are part of the Green House Project (GHP), an innovative model for residential care. Green House Project homes house small groups of elders in non-institutional spaces staffed by specially trained “universal workers” known as Shahbazim. Though they aren’t new — GHP and other “small house” elder homes have existed since 2003 — they have garnered attention recently for having deftly weathered the pandemic.

From January through June, GHP homes have reported only 32.5 confirmed cases per thousand residents as compared to 146 cases per thousand residents in all certified skilled nursing homes. As GHP senior director Susan Ryan explains, the very scale and design factors that helped Green House homes lower Covid rates also enabled staff to “get far more creative” in reacting to the pandemic.

“Your home” versus “a home”

The non-profit Green House Project was founded by Dr. Bill Thomas, a Harvard-educated geriatrician who recognized a need to humanize the often sterile environment of traditional nursing homes. Long, monotonous corridors with identical doors are a wayfinding nightmare for dementia sufferers, who rely heavily on cues in their immediate environment, for instance. Visiting facilities across the country in the 1990s that were “aging more quickly than the people living in them,” Dr. Thomas realized that the care reform he envisioned required a radically different architectural form — one that would create an optimal environment for nurturing resident elders and staff, the way a greenhouse nurtures plants. Pilot Green Houses were built in Tupelo, Mississippi, in 2003, with a replication initiative beginning soon after.

But Jamie’s Place, founded in 2007, has its own special origin story. When Methow Valley resident Jamie Finlan was diagnosed with cancer, she bequeathed her estate to a local food bank with the intention of funding community resources to serve her beloved valley. Local leaders identified a need to enable Valley elders to remain close to friends and family as they aged, and worked with GHP to build and run Jamie’s Place according to the Green House philosophy. GHP has facilitated training and design guidance to help senior living providers like Jamie’s Place in 32 states, transforming them through mentorship and guidance rather than operating the homes themselves.

Walking into Jamie’s Place, “You really feel like you’re in your home,” says Thelma Oakley, 85. “Not a ‘home’ home that’s an institution, but that it’s your house.” Inside, a bright, open-plan space showcases a long dining table at the center, surrounded by doors to individual bedrooms on the periphery. Armchairs are clustered around a fireplace nestled between built-in bookshelves, and a stationary bike sits near a half-wall lined with potted plants. A house calendar and homemade artwork hang above a small piano, where, before the pandemic, visiting children from a nearby pre-school used to sing songs with the residents.

Dave (who preferred not to share his surname), has a desk in the common space where he works on his primary passion: digitizing photographs he’s taken in birdwatching visits to 60 countries. Staff keep the space flexible for the varying needs of six elders, but the walls and bookshelves seem to hold a mix of books and knickknacks from different residents — much as one would expect from a busy home for a family of this size.

The 12-person table

At the heart of every Green House is a communal table, where residents and staff normally sit down together to share meals cooked in an adjacent open kitchen. Creating a sense of community around this shared table was critical to determining the ideal scale of the Green House model. Collaborating with architects, GHP and other stakeholders reached the conclusion that going beyond 12 seats at a dining table loses “the fabric of what it’s like to be family,” Susan Ryan explains. This meant capping households at 12 elders each, though facilities may have multiple homes on a single property.

Their hunch about ideal group size finds support in behavioral science, where 20th century researchers such as John B. Calhoun identified 12 as a psychological group-size threshold — the number of significant social interactions we can cope with on a daily, intimate basis, above which stress reactions are common. Further, a body of environmental psychology research known as “staffing theory” has suggested that smaller groupings for institutions like schools and churches foster greater self-efficacy for members. 

In traditional nursing homes, sometimes serving 100 or more older people in one facility, residents may share bedrooms and shower facilities, and often have to adhere to an inflexible group schedule for meals and bedtimes, being woken early for showering to make large operations function efficiently. Greater flexibility was a major factor for Thelma, who likes to sleep in, when choosing Jamie’s Place. Staff have arranged their schedules to make sure she’s the last elder they help to get up in the morning. It’s simple acts of dignity like this that make all the difference. 

Spatially, the Green House model of individual bedrooms and bathing facilities is simply “good infection control practice,”  explains Ryan, who worked as a nurse for many years herself. “Sharing rooms is the last thing you want to do right now,” says Thelma, whose sunny bedroom also features the “big treat” of starry views each night. Decentralized kitchens and laundry services (separate cycles for each elder, with machines sterilized between) also minimize risk. Jamie’s Place, for instance, is actually comprised of two separate homes on one property, each with its own kitchen.

 Empowering Shahbazim

Shahbaz comes from a Persian word for royal falcon, named for a fable in which falcons circling the skies became protectors and nurturers of people in the kingdom below. GHP Shahbazim (the plural) are universal workers—certified nursing assistants who also do cooking, cleaning and laundry, and provide activities for up to 12 elders, instead of task-distinct staff serving a larger group as in traditional facilities. For this reason, the Shahbazim model requires fewer staff per facility, lowering the number of people coming in and out, thereby lowering infection risk during the pandemic.

As Jessica Kulsrud, an administrator at Jamie’s Place explains, this also empowers staff, allowing them to make the best care decisions for each elder, “the way family would.” A 2010 study published in the Journal of the American Geriatric Society found that a Green House Shahbaz spends an average of 24 more minutes per day in direct care activities with elders than certified nursing assistants in traditional skilled nursing facilities.* Given the smaller number of elders to focus on and greater familiarity with each, Jessica believes Shahbazim will be more likely to notice subtle changes in elders’ health during these pandemic times.

Imagine a small high school where most of the 400 students get to play on a sports team and have a leading role in a club or theatrical production, versus a large school where 4,000 students compete for a smaller ratio of valued roles. Staffing theory researchers have found that members of smaller group settings are called upon to perform more meaningful roles than in larger groups, strengthening their confidence. The Green House model consciously assigns more roles to Shahbazim, elevating certified nursing assistants (typically at the bottom of the caregiving pyramid) to “protectors of the flock.”

But this small-group dynamic may also offer more meaningful daily roles for elders like Thelma, who enjoys helping Shahbazim cook dinner and sharing favorite recipes like pea soup and chicken thighs with crushed tomato and ginger. Shahbazim also benefit, learning from elders with a lifetime of cooking experience. When one Shahbaz at Jamie’s Place was struggling to prepare pork chops for the first time, Dave stepped in to prevent a near-miss cooking catastrophe. Today, Thelma says, they have that recipe “down pat.” 

Smaller footprint

Good things are said to come in small packages, and the modest dimensions of Jamie’s Place allow elders easy access to the outdoors, another core Green House principle. “The smaller footprint is better,” explains Ryan, “not only because every square foot costs money… but from a functional mobility perspective.” In larger facilities, elders may struggle to move between sleeping, dining and outdoor facilities, increasing reliance on staff and potentially decreasing personal sense of agency. Within the cozy scale of a family-style home, even many elders with reduced mobility can easily get themselves outside for fresh air and “sunshine” vitamin D (which has been suggested to help combat Covid-19.) 

As for the communal dining table, social distancing modifications have been made to keep elders safe during the pandemic. But thanks to the small scale of Green House homes, staff have been able to adjust flexibly and creatively. At Jamie’s Place, two elders may now sit at either end of the long table, another eats in her room, and others on TV trays in the lounge area, all depending on their needs and preferences. Thelma’s greatest complaint is that she can’t play Scrabble with her son — outdoor distanced visits are limited to half an hour, which isn’t quite long enough for a game. But in the meantime, she’ll still be able to see him, aided by masks and industrial patio heaters for the colder months. When her own mother-in-law went into a nursing home, Thelma gave her a plaque reading, “Bloom where you’re planted.” One of the Shahbazim made a little sign for her with the same phrase — a philosophy she tries to live by at Jamie’s Place.

Gathering gratitude

On November 23, Green House operators and Shahbazim from around the U.S. came together on Zoom for their first “Gratitude Gathering,” sharing stories, tears and thanks in a year when many staff members must forgo in-person Thanksgiving celebrations with their own families. The Green House network has not been spared from tragedy, but staff members from Detroit to New York and Kentucky resoundingly expressed gratitude for a social and architectural model of care they believe has saved lives.

“We’re so grateful to the Green House model for having private rooms for the elders,” as Susan Haley of Village on the Isle, a Florida retirement community partnering with GHP through a new initiative to bring “cultural transformation” to more traditionally constructed facilities, explained. “We truly believe that this has kept our elders safe and healthy during this time.”

*Please note, the majority of Green House homes (87%) are skilled nursing facilities, though Jamie’s Place is not.