Boston — Lunchtime at the Chelsea Jewish Home for the Aging in a Boston suburb looks nothing like the daily drudgery that has become the default existence for the old and ailing in America. Here, on a recent afternoon, the 10 residents of a “household” sit at a long table, laughing and gossiping with each other. Light floods in from floor-to-ceiling windows. A giant brisket rests on a platter and everyone at the table has a bowl — a real ceramic bowl — filled with chicken soup. The nurses’ aides, known to everyone affectionately as “the kids,” are standing nearby, in an open kitchen, having just made the soup and baked the brisket themselves.
Chelsea Jewish Home for the Aging is part of the “Green House” movement, an innovative new approach to elder care that many Jewish homes are embracing in a conscious rebuke to the nearly 17,000 industrial- or hospital-style homes in the United States today. Professionals who run Jewish homes see this new model as the answer to what has been a decade-long period of self-examination about how best to treat the elderly. It’s a shift that will affect a sector of the Jewish non-profit world that receives nearly $6 billion in government funds through Medicaid every year. And now even some of the largest of these traditional nursing homes are converting to this new model. In Manhattan, Jewish Home Lifecare, which manages nursing homes all over the city, is engaged in a deal with developers to swap an existing hospital-style facility on 106th Street for a planned $250 million, 24-story building on West 100th Street that will be constructed as a giant vertical Green House.
“The Green House model is the best standard that we have today,” said Audrey Weiner, president and CEO of Jewish Home Lifecare, which currently has 1,600 seniors in its care. Weiner’s certainty, she said, comes from having seen what happened when some of the Green House ideas were implemented in the traditional nursing home setting. The success of even these few changes led to the decision to start a new project that would be entirely in the Green House model. “It is going to profoundly change what a nursing home is all about,” Weiner said.
The Green House movement is the creation of William Thomas, a geriatrician who realized over a decade ago that what he calls the “fifty-year experiment in the institutional model of care” has been a failure. In a relatively short time he has managed to get major funding to back his ideas for reform, including a grant of $15 million from the Robert Wood Johnson Foundation in 2008 to develop Green Houses all over the country. There are now 94 such homes operating in 27 states.
“The idea of the Green House is to replace institutional settings with small-scale dwellings, households, that are built around the idea that elders are precious human beings who have a need to grow, and it is our duty to help facilitate that growth,” said Thompson. “The institutional model takes the precisely opposite mission, which is to take large numbers of elders and tend to their frailties and weaknesses as efficiently as possible. That doesn’t work very well. It supposes that the most important thing about that elder is her brokenness.”
Thomas’s vision, which he began making a reality when he put together the first Green House in 2002 in Tupelo, Mississippi, is quite radical and idiosyncratic. A home should have no more than six to ten residents, each with his or her own room and bathroom. At the center of every home should be a hearth, to encourage what Thomas calls “convivium.” There is no television in this common space but, instead, one long dining table and an open kitchen. Green houses are designed to look as much like homes as possible, doing away with nurses’ stations and the dominance of medical equipment. Light should flow in and out of the rooms. Thomas also wanted the residents to experience as much independence as possible, allowing them to get up and go to sleep whenever they choose. The nursing assistants — called shahbazim in Green House lingo, a Persian word for “royal falcon” or “king’s falcon” — come in to do all the cooking and cleaning and are an integral part of the household.
It’s a break from the traditional nursing home based on economics of scale, with most containing 100 to 200 patients. The Green House is certainly more expensive to build and slightly more expensive to run. The biggest critique of these new homes is that they are not economically feasible as businesses. It’s an argument that Thomas does not dispute. Only non-profits can seriously consider this type of model, he acknowledges.
The Chelsea Jewish Home for the Aging became the first urban Green House when it opened in February. The organization has been around since 1909 and still runs a traditional nursing home. The non-traditional one is in a new five-floor building called the Leonard Florence Center for Living. It has two households of ten people each on every floor. The building cost $36 million and even includes two households specially outfitted for patients with multiple sclerosis and A.L.S., or Lou Gehrig’s disease. The biggest grant came from the businessman and philanthropist Sheldon Adelson, who has been funding many innovative nursing home projects.
Walking through the Chelsea Green House, the shift from the older model seems dramatic.
“Here in the Green House there is a work station, but there is no nursing station with the chart and all that medical paraphernalia,” said Betsy Mullen, one of the center’s administrators. “The doctors and the nurses are very important, but they should be behind the scenes. You walk in here, and this is a home.”
In a wheelchair at the communal table during lunchtime was Bob Richman, a temporary resident in the Green House, whose decision to convalesce there after suffering from a broken kneecap was telling. Richman, a retired high-school science teacher and coach, had been volunteering for a number of years as what is known in Green House lingo as a “sage,” which he describes as an older and wiser individual who spends time with the residents to get their feedback and improve their quality of life. He chose to become a resident himself in the household reserved for short-term stays.
“Living here as a resident gave me a lot more insight into the place,” Richman said. “But I wouldn’t have decided to stay here if I didn’t already know, from everyone I talk to, that this is a place that everyone feels very warmly about.”
Other Jewish nursing homes have integrated elements of the Green House movement into their designs without taking on every one of Thomas’ recommendations.
“It’s all the same basic philosophy, though it might have different names,” said Marla Gilson, the president and CEO of the Association of Jewish Aging Services, which has 115 members. “Whether they call it Green House or culture change or a patient-centered approach, the point is that Jewish homes have always been leaders in innovation and quality, and right now this movement towards smaller and home-like atmospheres is taking off.”
One nursing home that was designed with some of these new elements in mind is Hebrew SeniorLife, also established earlier this year. It’s part of the sprawling NewBridge on the Charles campus on the outskirts of Boston, which includes housing units for independent and assisted living and a Reform Jewish day school for 300 children. The building that contains the nursing home has a medical center overseen by staff from the Harvard Medical School. Sheldon Adelson has also been a large donor to this facility.
The home is much larger than the one in Chelsea — with a total of over 200 beds — but it is animated by a similar spirit. There are households with hearths and kitchens. And every effort is made so that the rooms feel as “normal” as possible. One feature that illustrates this point: each room has a framed painting that slides up to reveal any medical equipment.
Len Fishman, the CEO of Hebrew SeniorLife, said he was inspired by nursing home communities in Northern Europe, which seemed much more humane to him than what he was seeing in the United States.
“We came to the conclusion ten years ago that the state of long-term care in this country was terrible in a dramatic way,” Fishman said. “We had half a century of building cookie-cutter nursing homes. They are built on a hospital template. Long corridors and double-bedded rooms and linoleum tiles, institutional meals. We went through a painful public project of acknowledging that this wouldn’t pass as adequate. We weren’t going to pretend that this was an acceptable way to treat the elders of our community.”
The changes that are part of the new model have real impact on the residents’ quality of life, Fishman said. Take the issue of food. When all the meals are prepared in an industrial kitchen, he explained, then all 200 residents of a large facility need to be awake and showered and ready for breakfast at the same time in order to get a warm meal. Sometimes that means waking up residents at 6 in the morning to prepare them to receive food at 9 o’clock. By contrast, when the meals are prepared and served in each household, the residents can get up whenever they please.
“When you can decide when you wake up in the morning, when you want to eat, what you want to eat at the time that you are eating or when you go to sleep, that makes you feel like you have control over your life,” Fishman said. “That’s the independence we were shooting for.”
His observation is one that has been backed up by research, most notably by the work of Rosalie Kane at the School of Public Health at the University of Minnesota. She has been studying Green Houses since their inception and, as she wrote in a recent study, this research has led to the conclusion that residents at these homes “were found to experience better quality of life.”
Though Fishman said that his nursing home is trying to chart its own path, it is very much in line with Thomas’ ideas.
“Our duty is not just to tend to them the way you would tend to livestock,” Thomas said. “We need to care for elders in a way that meets their spiritual needs as human beings.”