The Big Idea Behind A New Model Of Small Nursing Homes.

Long-term care facilities have been devastated by COVID-19, with one exception: a group of small facilities called Green Houses.

with multiple nursing facilities. But the similarities largely end there. Their architecture, philosophy, and organization couldn't be more different. For elderly residents, those distinctions have created radically different experiences that deeply affect the way they livedand, in some cases, died-before and during the coronavirus disease 2019 (COVID-19) pandemic.
The Green House Cottages of Wentworth Place, which opened in 2008, looks like a suburban subdivision. Six ranch-style cottages each have a driveway, a front lawn, and a rear patio. Inside, twelve private rooms are arrayed around a large open room with a cooking, dining, and living area outfitted with couches, a fireplace, and a television. Each bedroom has a private bath.
The Wentworth facility largely dodged the coronavirus for months. It had a few cases in August 2020 and didn't experience a major surge until mid-November. But by January 3, 2021, according to data from the Centers for Medicare and Medicaid Services (CMS), fifty-four residents and forty-nine workers at the Green House Cottages had confirmed COVID-19 cases, and three residents were dead. 1 Just down the road, The Springs of Magnolia is a more typical US nursing home than Wentworth. The Springs has a main building, a central entrance, and rooms that line the hallways to each side. Most residents at the 140-bed facility live in "semi-private" rooms, sharing their rooms and bathrooms with another resident.
The Springs of Magnolia felt the impact of the coronavirus sooner than Wentworth did. At first it was spared. Then, starting the week of June 15, 2020, the virus swept through The Springs. CMS data show that six residents and five employees tested positive that first week, twenty-eight residents and sixteen workers the next. By July 19, the end of a five-week span, fortyseven residents and twenty-three staff members had been infected, and nine residents had died. As of January 3, 2021, a total of forty-five residents and forty-seven staff members had confirmed infections, and thirteen residents had died. 1 The figures, at first glance, seem comparable: a similar number of infections among a similar population of residents. Yet there is at least one striking difference. The three Wentworth Place residents who died from the virus represented less than a quarter of the deaths at The Springs. Look closer and another difference comes into view: the way people lived.

'Uniquely Human'
Since COVID-19 swept through the Life Care Center in Kirkland, Washington, in late February 2020-the first major outbreak in the US-nursing homes have emerged as the most vulnerable and deadly places in a country that leads the world in COVID-19 cases and deaths. Within a month of entering the Life Care facility, the virus had infected dozens of workers and 81 of 120 residents; 35 residents died. 2,3 The unique properties of nursing homes as we know them-places where large numbers of fragile older people live in close quarters and often share bedrooms, bathrooms, and dining areas-have made them easy prey for a virus that thrives on close contact and shared air. Making matters worse, the people entrusted to care for seniors are undertrained and poorly paid, earning in 2020 an average $14.14 an hour. 4 As a result, many staff work multiple jobs, often in other senior facilities.
The results have been devastating. Fewer than 1 percent of people in the US live in long-term care facilities, but they made up 38 percent of all COVID-19 deaths through the end of 2020, according to the COVID Tracking Project. 5 Looking solely at nursing homes, data compiled by CMS show that more than half a million residents have been infected by COVID-19, and almost 102,000 have died. 6 Yet one unique type of nursing home appears to have done a far better job of protecting residents: the 300 or so Green House homes, loosely affiliated but independently owned, that operate in 32 states and serve some 3,200 elders. In just-released research, a team at the University of North Carolina's (UNC's) Program on Aging, Disability, and Long-Term Care has found that residents of Green Houses are far less likely to be infected and to die than residents of traditional nursing homes. 7 "There is something beneficial about small nursing homes and Green House homes in particular when it comes to COVID," says Sheryl Zimmerman, a UNC professor who codirects the aging program.
Long before COVID-19 cast a spotlight on nursing homes, researchers who study aging viewed Green Houses as a uniquely human form of housing and care for vulnerable elders that provide better quality of life while reducing hospital admissions, Medicare spending, and staff turnover. 8,9 They were the standouts in an industry where unaccountable owners, underpaid workers, and miserly government reimbursement practices have incentivized some nursing home owners to cut corners and operate large facilities. Now, as policy makers consider ways to rebuild and transform a nursing home industry that has failed so spectacularly to protect vulnerable patients and workers, these unique small homes are getting a deeper look.

'We Pivot'
When I arrived at 9 a.m. in Magnolia, Arkansas, for a planned tour of the Green House Cottages of Wentworth Place, N95 respirator in place, the virus was surging. It was the chilly last day of November 2020, and two residents had already tested positive for COVID-19 that morning. John Montgomery, vice president of strategic operations for Wentworth's owner, Southern Administrative Services, texted me to stay in my car until he arrived. We met in the parking lot, then went to the administrative offices for a temperature check.
In the weeks before my visit, infections at Wentworth had started to rise, so staff converted the south wing of the forty-room traditional nursing home into an isolation area. Infected elders from across the campus moved there, staying until they tested negative and had no symptoms, at least twenty-one days. With my tour canceled, Montgomery and I chatted in an office.
"This is how our health system has been since March," Montgomery told me. "It's changing daily.We know something, we pivot, and the next day we pivot again." We walked around the campus, peering in the cottage windows. "Stop. Do not enter. No visitors," said a large sign outside Headen Cottage. Inside, elders sat on couches and in wheelchairs.
Montgomery suggested another pivot, and we each got in our cars and drove two hours north to another company facility, the Green House Cottages of Poplar Grove in Little Rock. Up to that point, few Poplar Grove residents had tested positive, so Montgomery and his team decided I could enter.
Inside Melder House, a gas fire blazed, and a television played soundlessly. Two caregivers-known in Green House lingo as shahbazim-worked in the kitchen, but the space seemed otherwise empty. Montgomery said, "Hello, darlin'," to a resident hovering near the entrance to her room. As the on-site administrator for this complex until last summer, he knew most of the elders.
Montgomery knocked on the door of Dorothy Foot, an eighty-three-year-old who'd been living in the cottage for two years. She greeted him excitedly and said she was happy to speak with me. She was dressed in a green plaid shirt over a white blouse, wavy gray hair framing her face.
"The Lord has really blessed me in going to the Green House," she said. "The fact that every one of us has our own room gives us dignity. And I have my own bathroom. In my mind, it's my apartment. I'm not going through the feelings of the woman that got dropped off in a nursing home. And even though I am a Medicaid patient, I still hold my head high." Her daughter, one of her four children, suggested the Green House after Foot had back surgery. "My daughter said, 'Mother, it's not just like an old nursing home.' And 'Mother, you're gonna like it.' And 'Mother, it's got a place where you could sit by the fire.'" Her children eventually convinced her to move, and she was glad they did. "I know my kids couldn't take care of me," Foot said. "I want them to have their lives, and I need my life. Poplar Grove gives me the ability to do that." Caregiving instincts run strong in her; she had spent a lifetime looking after her sister, who was stricken with polio as a child and lost use of her legs but still reached the age of seventy-nine. In the Green House, she told me that she has to restrain herself from helping too much.
"I thought I could be an aide here," Foot said. "I wanted to push everybody in their wheelchair." "Can I interrupt?" Montgomery asked. "You always do," Foot bantered. The two commiserated about life before COVID-19. Montgomery said that he missed seeing the women sitting around the table. "It's hard because I know where each of you ladies sat," he said. "Y'all would laugh. Y'all would cut up, tell me jokes." Foot said that she and her friends also miss Montgomery, a youthful thirty-six-year-old with soft eyes and light brown hair, who was promoted over the summer and gained companywide responsibilities. "He would come in and every little lady sitting around the table-their eyes would just pop open," she said. "Now, everyone stays in their room. There's nothing going on." Later, Montgomery told me about visiting his own grandfather at a traditional nursing home in 2010. "He was a big man, but the last time I saw him he seemed to be almost a victim of institutionalized practices," he said. "He was sitting low in his wheelchair, a shell of what he was." When Montgomery first stepped inside a Green House, "I was blown away, thinking about what could have been" for his grandfather.

'Empowered'
Today, fifty-eight organizations around the county operate seventy-eight Green House campuses. Most, such as Wentworth and Poplar Grove, use ranch-style homes to house residents; a few in urban areas such as Chelsea, Massachusetts, or St. Paul, Minnesota, have created highrise structures containing multiple Green Houses.
To call themselves a Green House and be listed on the Green House Project website, homes must follow a model developed by Bill Thomas. Thomas was a recently minted family medicine doctor in 1991 when he started his first job-as medical director of Chase Memorial nursing home in tiny New Berlin, New York. He'd been in a nursing home just once, as a student at Harvard Medical School.
"I didn't know anything about nursing homes," he says. "I hadn't been properly trained." And that, he says, turned out to be a blessing.
Chase Memorial did things by the book and hadn't been cited for a deficiency for seven years, Thomas says. "They did everything right," he recalls. "But I walked in and-I'm going to use the word 'horrified.' I had a horror at what was going on, and I was now quasi-responsible for it." He saw elderly residents who had lost control over their lives. They were awakened and took meals at times dictated by staff. They sat for hours in the TV room or in wheelchairs in the hallway. They had little of meaning to do.
"I watched people wither and die," Thomas recalls. His key observation, which would motivate his efforts over the next thirty years, was that old people living in nursing homes and other forms of long-term care are stripped of their autonomy and dignity.
Thomas "wanted to remake the nursing home," Harvard physician and author Atul Gawande wrote in his 2014 book, Being Mortal. 10 At Chase Memorial, Thomas led a sometimes comical upheaval, bringing four dogs, two cats, a colony of rabbits, and one hundred parakeets into the building to combat boredom and spark spontaneity and joy. The parakeets were delivered without cages, dogs pooped on the floor, and the staff had to improvise a plan to feed the birds. The place was enlivened, and infections, the use of psychotropic drugs, and staff turnover declined. He called his new program the Eden Alternative, and it morphed into a movement and global nonprofit. Hundreds of nursing homes adopted its principles; tens of thousands of people took part in Eden trainings.
Eden envisions the people living and working in long-term care as "care partners" and identifies "loneliness, helplessness, and boredom" as the principal enemies of elders and care workers alike. "It's almost an Alcoholics Anonymous thing," Thomas says. "Until you can say out loud that these people I care about are suffering from loneliness, helplessness, and boredom, nothing changes. If you can't say it, you can't change it." In 1999 Thomas went on tour with his wife, five children, and parents, performing a one-man play based on a novel he'd written. He called it the Eden Across America tour and gave twentyseven performances, visiting nursing homes in each city. All of them, he realized, "were operating under tremendously burdensome architecture. When you see the same thing all across the country, you're like: We have to fix the architecture." At the time, the Robert Wood Johnson Foundation (RWJF) had spent years searching for ways to improve nursing home quality, but "we had not found a way, and moved on," says Nancy Barrand, a senior adviser at the foundation. "We didn't think we could change them." Then, in 2001, Thomas visited the foundation's New Jersey office and shared his idea for turning the nursing home from an institution into something that feels like a family home. Intrigued, the staff gave him a small grant to develop the first Green Houses.

The First Green House
Steve McAlilly, the president and CEO of Methodist Senior Services, a social services agency in Tupelo, Mississippi, was also intrigued by Thomas. After hearing him speak, he connected with Thomas to get his opinion on a matter: McAlilly was agonizing about an old nursing home his agency operated and had hired architects to design a large new facility. Thomas's response was understated but brutal: "He just said, 'I don't know if that's what we ought to be building anymore,'" McAlilly remembers. "It knocked the wind out of my sails." A year later Thomas reached out and enlisted McAlilly in his scheme. McAlilly convinced his board that a new 140-bed nursing home would be "obsolete the day we open the doors" and halted the project he'd raised more than $3 million to build. Instead, the money, plus funding from the RWJF, would create the first Green House homes in the country. They opened in 2003 at Traceway Retirement Community in Tupelo.
The architectural innovation was to design each Green House with private bedrooms and the large cooking, dining, and living area that serves as the center of life in the home. An adjoining patio or balcony provides outdoor access. "The elders wake when they want to and hear the sounds of home," says McAlilly. "They hear dishes rattling in their kitchen. They smell bacon frying. They wander out of their bedroom, like they would at home, and eat what they want at their breakfast table." The organizational advance is the staffing. The workforce at traditional nursing homes is large and segmented, with certified nursing assistants (CNAs), janitors, cooks, and dishwashers all performing a narrow range of functions and interacting with many residents in homes that serve one hundred or more people. Green House staffing is flat. A small group of universal workers, the shahbazim, licensed as CNAs, work in just one cottage and en-gage closely with ten to twelve residents. Nurses rotate among the houses, with each resident getting about an hour a day of nursing care. Doctors, occupational therapists, and other clinicians visit as needed.
In traditional nursing homes, "you've got so many people to [wake] up and not enough people to do it, so in order to meet your quota-I hate to say it that way-you start at 4 and 5 a.m. getting people up," says Marie Mister, a CNA who was one of the original employees in Tupelo. "At the Green House, you get up when you're ready." The staff and elders "have personal conversations. You learn things about them, they learn things about you." The shahbazim in each cottage form self-managed teams and decide for themselves how to allocate their work. Mister worked as a shabaz for many years, advancing to become a mentor and trainer. Now she's a "guide," responsible for assisting shahbazim and helping them schedule. "I've been here twenty-three years, and there wasn't a day I didn't want to come," Mister says.
The structure of Green Houses creates some efficiencies. Their small size means that staff members don't spend time wheeling residents down long hallways. A shahbaz can chat with residents while cooking dinner or washing dishes; residents may join by helping cook or prep food. "Think about what you're able to do in in your own home while folding laundry," says Susan Ryan, senior director of the Green House Project, the national umbrella group of Green House homes.
Ryan, with a background in nursing and administration, joined the Green House Project in 2008 after the RWJF awarded it a five-year, $10 million replication grant to fund technical assistance, support for architects, and evaluations. Under her leadership, the number of Green Houses grew rapidly, reaching 100 in 2010, 200 in 2016, and 300 in 2020.
Studies began to suggest solid outcomes. A 2012 comparison found that residents of Green House homes in Minnesota and Washington State spent less time in hospitals than a matched group in traditional homes, saving $1,300-$2,300 per resident in annual costs to Medicaid and Medicare. 11 A 2016 package of studies found, among other things, that residents in 15 Green House homes had lower rates of hospitalization than those in 223 traditional nursing homes. The Green House elders were also 45 percent less likely to need catheters, 38 percent less likely to have bedsores, and 16 percent less likely to be bedridden. 9 Others have found that residents and families expressed greater levels of satisfaction in Green House homes than traditional nursing homes. 8,12 David Grabowski, a professor of health care policy at Harvard Medical School who was part of the team that conducted the 2016 evaluations, says that his visits to a Green House surprised him.
"I was blown away by the facility, and I've been in a lot of nursing homes," Grabowski says. In most traditional nursing homes, staff members, especially nurse aides, "feel undervalued and don't feel like part of the team. In the Green House nursing homes, the shahbazim felt empowered." Grabowski recalls being impressed by "how happy the residents were in terms of their quality of life-just speaking to them and seeing their smiles. Too often, with big institutional models of care, it's about the needs of the facility, and this was really about the needs and preferences of the residents themselves."

'Heart And Soul'
Despite their high marks, Green House homes make up only 2 percent of the 15,000 nursing homes in the country and care for fewer than 1 percent of their residents. They also serve a predominantly white, middle-class clientele. What keeps them from gaining traction, diversifying, and taking off?
They're more expensive, for one thing. Daily rates in Green Houses range from $246 to $495, making them unaffordable to middle-class people who don't qualify for Medicaid-until they "spend down" their assets to the point that Medicaid will cover them. Although rates vary among states, Medicaid pays around $200 a day for a room, usually shared, and basic services for as long as the person needs care. Self-paying clients may pay as much as 30 percent above Medicaid rates. And nursing homes that provide skilled nursing can tap into richer Medicare rates of $900 or $1,000 a day to serve patients coming out of the hospital for rehabilitation. Medicare will pay the full cost for twenty days, but patients must pay 20 percent after that.
The complexity means that Green House operators must try to achieve a mix of self-paying residents and those paid for by Medicaid and Medicare. But to qualify as a Green House, they must also agree to accept residents for life-and not kick out elders who start as self-paying and then become eligible for Medicaid. That means that some won't always accept self-paying applicants who seem likely to convert to Medicaid.
While the nursing home industry overall is dominated by for-profit companies, more than 80 percent of Green Houses are owned by nonprofits. 13 Southern Administrative Services is one of just a dozen or so for-profit companies operating Green Houses. Since opening Wentworth Place in 2008, the company has built three more Green House complexes and has two more under construction, for a total of almost 600 beds.
"It would be challenging-no question" to operate a Green House with only Medicaid patients, says Southern Administrative Services founder and managing director John Ponthie. His investors want a 10 percent return, and he says he delivers that, operating at near-full capacity with a payer mix that is 55-60 percent Medicaid, 15-18 percent Medicare, and the remaining 20-30 percent self-paying. He's able to do that partly because Arkansas is a poor state with cheap land, construction, and labor costs.
Green Houses cost more to build but can be operated for about the same cost as traditional homes, Ponthie says. Having kitchens in each cottage, instead of a centralized kitchen for a whole campus, for example, adds expense but creates high satisfaction that translates into waiting lists for new cottages. Surveys by the Green House Project show that during 2020 Green Houses reported monthly occupancy rates of 86-95 percent, while occupancy among traditional homes declined from 73 percent to 69 percent.
The company, which has 3,200 employees and revenue of about $200 million, also operates twenty-four tradi-tional nursing homes but plans to focus its future growth on Green Houses. "We believe in the model heart and soul, but we also believe it's the right economic investment," Ponthie says. "It's what people want." In St. Paul, Minnesota, where costs are higher, Marvin Plakut says he "just breaks even" on the cost of running The Gardens at Episcopal Homes, a complex of six ten-room Green Houses, even though 60 percent of residents are selfpaying. "If you do everything right, it will cover total costs and have no profit," says Plakut, the organization's CEO. "That's OK with us.We don't have to feed investors." Perhaps the biggest shortcoming of Green Houses is their lack of diversitythey serve a largely white population from middle-and upper-middle-class backgrounds. African Americans make up 38 percent of people in Mississippi, for example, but only 10 percent of Green House elders, McAlilly estimates.
Ryan from the Green House Project and others acknowledge the problem and say the reasons are varied, including failures of outreach. High construction and land costs are a barrier to urban developments, as are the low rates paid by Medicaid. Ryan wants to see more urban Green Houses and is working to help launch one in the Baltimore, Maryland-Washington, D.C., area aimed at the large Black community. It could also be a showcase that would be visible to Washington policy makers and build support for increased funding.

'Let's Don't Waste A Good Pandemic'
The intense scrutiny now facing nursing homes-and the desire to avoid future mass-infection tragedies-presents Green Houses with an opportunity. "I keep saying, 'Let's don't waste a good pandemic,'" McAlilly says. COVID-19 "has shined a burning light on the weaknesses of the way we've done things. I'm trying to stimulate a policy conversation, to say we've got to do a better job." The research from UNC's Zimmerman, biostatistician John Preisser, and their team may be Exhibit A. They gathered data on COVID-19 infections and deaths from forty-three Green House organizations (including other small homes with similar models) and compared those data to CMS data on traditional nursing homes operating nearby. For all of them, the researchers calculated rates of infection per 1,000 resident days and rates of death for every 100 residents infected with COVID-19. 7 The rates of both were significantly lower in Green House homes. Because many nursing homes had no cases or deaths, the team looked at nursing homes in the highest 50 percent of infections and highest 20 percent of deaths and recalculated the numbers so they could be expressed as cases per 100 resident-years (100 residents, each followed for one year).
Using this method, they found that the median infection rate in the upper half of Green House homes was 2.92 per 100 resident-years. Large traditional homes-those with more than fifty residents-had an infection rate of 27.00 per 100 resident-years, more than nine times the rate of the Green Houses. In the small homes, with fifty or fewer residents, the rate was 5.48-nearly double that of the Green Houses.
More ominously, among the facilities of each type with the highest death rates, the traditional nursing homes had two to four times the rate of deaths. Median mortality in the Green Houses was 24 for every 100 COVID-19 cases compared to 80 in small traditional homes and 53 in large ones.

'We Need To Realign'
Analysts say that major policy change is needed, not only to protect nursing home residents from the next virus but also to close the enormous gaps between the high-end forms of long-term care that are available to the wealthy, on the one hand, and the understaffed and often decrepit facilities where lowincome people and people of color are often relegated, on the other.
Perhaps the most important potential change, with broad support among nursing home researchers and providers, is to raise reimbursement rates to nursing facilities, while requiring better performance. This would also make it easier for nonprofits and for-profits alike to invest in higher-cost, higherquality Green Houses. "We need to realign our whole payment structure," Grabowski says. "This idea of overpay-ing on the Medicare side, underpaying on the Medicaid side, and hoping to balance one another really doesn't work, especially during a pandemic." Higher rates should be accompanied by rules that bar, rather than incentivize, room sharing by frail older adults, who can easily spread infections. "Whoever thought that was a good idea?" McAlilly asks.
An equally important change is to increase pay to caregivers, who shoulder the burden of day-to-day operations and are disproportionately women of color and immigrants. "Paying close to minimum wage suggests a real indifference towards older adults and those who provide services for them," Grabowski says. "It says everything about the problems we're in today." One way to do that, Grabowski and others say, is to allow Green House operators to keep some of the savings they generate for Medicaid and Medicare that occur if elders they serve are transferred to hospitals at lower rates than other nursing homes. "Why not share back some of the savings with the facilities?" Grabowski asks.
Finally, advocates say, state and federal regulators should start aggressively eliminating the bad actors and poor performers in the nursing home industry. That would have the added ad-vantage of freeing up the limited number of licensed beds allowed under many states' certificates of need so that they can be used by Green Houses and other small nursing homes.
"States need to close the worst 5 percent of the nursing homes in their state, every year," Thomas says. "And by close, I mean, take away the keys, take away the license, put them out of business. That's how we create turnover." 'A Family Atmosphere' Doris Lurline Waller spent her final four years at Monroe House, one of the Green House Cottages of Wentworth Place. Before the pandemic she had maintained a rich social life, her daughter, Linda Mullins, told me. Family members visited frequently. Her granddaughters continued a tradition of visiting on the first day of school each year to take a picture with Grandma. She played Bingo with the staff and other residents.
"The employees, the ones that came every day to prepare the meals-they kept a family atmosphere," Mullins said.
As Waller, who died from a heart condition, neared the end in the early summer, there had been only two suspected COVID-19 infections among residents of Wentworth Place. As a result, up to three family members with no symptoms or temperature were allowed to enter the cottage and go directly to her room. Additional relatives could gather outside her window. No staff members could be in the room with the visitors.
When she died last July 4, at age ninety-seven, she had the kind of death most people would want, said Mullins, the mayor of nearby Emerson. Her four children were gathered around her bed or just outside her window. Most of her fifteen grandchildren and twenty-six great-grandchildren had been able to come say goodbye.
During the final week of her life, one of her children was always with her, Mullins said. "She was surrounded by family," in the Green House that was her home. ▪ This article is part of a series on transforming health systems published with support from The Robert Wood Johnson Foundation. This is an open access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt, and build upon this work, for commercial use, provided the original work is properly cited. See https://creativecommons.org/ licenses/by/4.0/. Rob Waters (robwaters2@gmail.com) is an independent journalist in Oakland, California, who writes about health and science and has contributed to Kaiser Health News, STAT, Mother Jones, and Psychotherapy Networker, among other publications. The author thanks Alex Soltany for his research assistance.