Effects of Green House® nursing homes on residents' families

Health Care Financing Review, Winter, 2008 by Terry Y. Lum, Rosalie A. Kane, Lois J. Cutler, Tzy-Chyi Yu

EFFECTS OF GH[R] NURSING HOMES

This article presents results of a quasi-experimental study that examined how a dramatically changed small-house nursing home model affected behavior and outcomes for residents' family members. The model of nursing home care developed in the GH[R] in Tupelo, Mississippi, created opportunities and challenges for family members, and was expected to result in more positive family interactions with residents, and greater family engagement with and satisfaction with the nursing homes.

BACKGROUND

Family members are instrumental to the psychosocial well-being of nursing home and assisted living residents, and provide the major means for residents to retain their social affiliations and relationships outside the nursing home (Kane, 2004). Families typically are integrally involved in the decision of older people to move to a residential setting, and their choice of facility (Reinardy and Kane, 1999; 2003). If reformed models of nursing homes do not meet with family approval, they are unlikely to be chosen. Further, family members are also a major source of emotional support to elderly people receiving long-term care in all settings, including group residential settings such as nursing homes and assisted living (Gaugler, Kane, and Kane, 2002; Gaugler and Kane, 2007). Family members continue to provide both tangible and emotional support to residents after so-called institutional placement (Kane et al., 1999). Family members also often take on a watchdog role, looking after their relatives' interests and promoting their quality of care (Bowers, 1988). However, the roles of family members in relationship to the nursing home are sometimes ambiguous, fraught with poor communication and misunderstandings between nursing home personnel and family members about mutual expectations (Friedemann et al., 1998).

Although family members typically remain engaged with their members who are nursing home residents, nursing home visits can be difficult and stilted experiences. The setting appears medical and unnatural, engendering uncertainties about what relatives are permitted to do. Also family members may feel guilty and sad because they felt the need to encourage a nursing home admission. Visits may, therefore, become brief and limited to a few relatives, with children and extended family members reluctant to visit or to risk taking the nursing home resident out of the setting to participate in community life.

The movement toward culture change and individualized services in nursing homes has led to new configurations of nursing homes that are more normalized and utilize household models (Weiner and Ronch, 2003). Little is known about how family members perceive the safety and care of the residents and the demands or benefits for themselves, when their relatives live in nursing homes with transformed housing arrangements. This article examines how family members of GH[R] nursing homes (compared to families of residents in conventional facilities) reacted to their relatives' moves to a radically changed nursing home.

Intervention

GH[R]s are self-contained dwellings for 7-10 residents needing nursing home levels of care. The physical environment is residential, offering residents opportunities for privacy (with private rooms and full bathrooms) and participation in community life, with a residential-style kitchen where meals are prepared on site, a dining area with a large communal dining table, a living room with a fireplace (collectively known as the hearth area), a sun room, and accessible patio and outdoor space. The GH[R] avoids nurses' stations, medication carts, and public address systems. The frontline care staff members, who are CNAs assigned to a single GH[R], have broadened roles, including, cooking, housekeeping, personal laundry, personal care to residents, implementation of care plans, and assisting residents to spend time according to their preferences. This CNA with an expanded role is called a Shabbaz in GH[R] parlance, a Persian term meaning royal falcon that William Thomas used "... to connote the importance of the role of the individuals who watch over the elders [Rabig, 2008]."

All professional personnel mandated in nursing home regulations (e.g. nurses, physicians, social workers, dietician, pharmacist, therapy staff, and activity personnel) form visiting clinical support teams that provide specialized assessments and order and supervise care within their spheres of expertise. The elder assistants report to an administrator (called a guide) rather than to a nurse. Philosophically, the GH[R] model emphasizes individual growth and development and a good quality of life under normal rather than therapeutic circumstances. A group of GH[R]s on a campus or scattered in a residential neighborhood operates under a nursing home license and within a State's usual Medicaid reimbursement amounts, though a redistribution of expenditures could occur.

The first GH[R]s in the U.S. were built in Tupelo, Mississippi, on the campus of a faith-based non-profit retirement complex, comprised of independent housing, assisted living, and a nursing home (Cedars) licensed for 140 beds. In June 2003, the first four GH[R]s were opened and occupied by residents from the sponsoring nursing home; two of these GH[R]s were initially earmarked for residents in the locked dementia care unit (which was then closed) and the others were occupied by residents from the general nursing home population from residents volunteering to move in and chosen in order of the length of time that the residents had been on the campus. Vacancies arising in the GH[R]s after the initial move-in were similarly filled by residents already in the nursing home or on the campus, again in order of length of time on the campus. Training to become an elder assistant was offered to staff at Cedars, supplemented by new hires from the community; staff who assumed these new GH[R] roles varied in age and length of experience in long-term care, but on average had the same demographic characteristics as nursing home CNAs regarding sex, race, education, and prior experience as all CNAs in Mississippi. Fuller descriptions of the general model, its theoretical rationale, and its first implementation in Mississippi have been published (Thomas, 2004; Rabig et al., 2006).