The Green House Model of Nursing Home Care in Design and Implementation

Palliative care in small-scale living facilities: a scoping review

BACKGROUND

Innovative small-scale facilities for dementia focus on providing quality of life and maintaining the functional abilities of residents while offering residents a home for life. To fulfill the home-for-life principle, palliative care approaches are necessary to maintain quality of life in these facilities. Few studies have reported on how palliative care is provided to residents in small-scale facilities. The aim of our review is to determine the extent to which palliative care approaches are reported in small-scale facilities.

METHODS

A scoping review of the literature using recommended methods from the Joanna Briggs Institute. Four databases, CINAHL, PubMed, PsycINFO, and Web of Science, were searched for studies published from 1995 to 2023. One reviewer completed the title, abstract and full-text screening and data extraction; two additional team members piloted the screening and extraction process and met with the main reviewer to make decisions about article inclusion and ensure consistency and accuracy in the review process. The extracted data was open-coded and analyzed using thematic analysis. The data was then synthesized into themes using palliative care domains for dementia.

RESULTS

Of the 800 articles obtained in the search, only ten met the inclusion criteria: six from Japan, two from the Netherlands, and one each from Austria and the United States. In most small-scale facilities, palliative care is important, with facilities prioritizing family involvement and person-centred care, minimizing resident discomfort and enhancing residents' remaining abilities until the end of life. The included studies did not discuss palliative care policies or professional staff training in depth.

CONCLUSIONS

This study provides an overview of the literature on palliative care in small-scale facilities for individuals with dementia. Most facilities focus on residents' wishes at the end of life to enhance comfort and provide a home-like environment. However, more research is needed to further understand the quality of palliative care approaches in these homes.

The Greenhouse Model of Nursing Home Care: A Scoping Review

The study aimed to comprehensively review and assess evidence-based outcomes of the Greenhouse model. We systematically reviewed, assessed, and reported on relevant literature using the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines for the scoping review. We identified qualitative or quantitative studies that met our inclusion criteria from PubMed, Medline, CINAHL, and EBSCOhost. The review yielded 41,515 articles published between January 2015 and December 2022; eleven articles met the inclusion criteria and were included in the analysis. The emerging themes were organizational culture, clinical outcomes, and business effects. The Greenhouse model offers a favorable organizational culture with opportunities to enhance clinical and business outcomes. The scoping review was registered in Prospero: CRD42023389048.

Revealing the divide: Contrasting COVID-19 outcomes in Green Houses and traditional nursing homes in the United States

INTRODUCTION

This study compares COVID-19 case and mortality rates in Green Houses (GHs) and traditional nursing homes (NHs) during the COVID-19 pandemic.

METHODS

CMS data from 10 states (June 2020 to September 2022) were analyzed for GHs (n = 19), small NHs (n = 266), and large NHs (n = 2,932). Multivariate Poisson regressions with GEE were used.

RESULTS

Participants (mean age 73.4) were predominantly female (57.8 %) and White (78.2 %). Small and large NHs had a significantly higher COVID-19 case risk (RR = 1.61; 95 % CI 1.25-2.08 and RR = 1.75; 95 % CI 1.36-2.24, respectively) compared to GHs. Large NHs also had an increased mortality risk (RR = 1.67; 95 % CI 1.01-2.77) compared to GHs, with no difference found between GHs and small NHs.

CONCLUSION

After adjusting for age, gender, and ADL disability, GHs demonstrated lower COVID-19 case and mortality rates than traditional NHs, likely due to their unique features, including person-centered care, size, and physical structure.

Residential Long-Term Care and the Built Environment: Balancing Quality of Life and Infection Control

OBJECTIVES

This article explores expert insights into residential long-term care (RLTC), specifically regarding the built environment, its impact on infection control (IC) measures and on resident, staff, and family member quality of life.

DESIGN

The interviews discussed in this report form part of a larger mixed methods research design, examining the planning, design, and operation of RLTC. Specifically, this report discusses findings from one aspect of this research, a series of semistructured interviews.

SETTING AND PARTICIPANTS

Interviews were conducted online through video conferencing platform Zoom. The project's steering committee were asked to suggest key organizations involved in IC and RLTC provision and policy, with 23 representatives (17 organizations) being invited to interview. Where representatives were unable to participate, they suggested alternate representatives.

METHODS

The research team conducted 20 interviews with key representatives or "experts" from different aspects of RLTC provision, policy, and IC. A thematic analysis was employed to analyze and generate key themes.

RESULTS

For brevity, the codes that had been mentioned by >5 interviewees, specific to the built environment, IC and quality of life were prioritized, resulting in 16 prioritized themes grouped according to spatial scale.

CONCLUSIONS AND IMPLICATIONS

This research demonstrates the growing awareness of the built environment as a critical partner in the RLTC health and social care model, as well as illustrating the need for a holistic design approach across all key spatial scales to support the health and well-being of older people in RLTC. Further research is needed on various aspects of RLTC, including the impact of care models and setting size on IC, quality of life, and cost implications. RLTC policy needs a more integrated approach to planning and design, specifically around RLTC location. This research suggests that RLTC providers look to evidence-based, inclusive design guidelines to inform the design and retrofit of RLTC. Additionally, the operation and management of space should be considered by providers.

An overview of innovative living arrangements within long-term care and their characteristics: a scoping review

BACKGROUND

Within long-term care, a culture change (e.g. focus on increasing autonomy in everyday life) is leading to the development of innovative living arrangements for older adults. Insight into characteristics of innovative living arrangements, which are described as an alternative to regular nursing homes, is lacking. This review aims to provide an overview of innovative living arrangements and to describe their defining characteristics.

METHODS

A scoping review was performed following the framework of Arksey and O'Malley. The preferred reporting items for systematic reviews and meta-analyses with extension, for scoping reviews (PRISMA-ScR) was also followed. The databases PubMed, PsycInfo, CINAHL, and Web of Science were searched. Articles, published between 2012 and 2023 were included when they presented an innovative living arrangement as an alternative to regular nursing homes. A thematic analysis was performed, describing the physical, social, and organizational environment of the innovative living arrangements.

RESULTS

Fifty-six articles were identified describing seven types of distinct innovative living arrangements: small-scale living, the green house model, shared housing arrangements, green care farms, dementia villages, group homes, intergenerational living, and an 'other' category. The themes included supporting autonomy and creating a small-scale and/or homelike environment, which were emphasized in most innovative living arrangements. Other themes, such as involvement of the community, focus on nature, integration of work tasks, and involvement of family members, were emphasized in a subsection of the described living arrangements. Twenty-eight articles reported on the effects of the innovative living environment on residents, family members, or staff members. Most articles (N = 22) studied resident-related outcomes, focusing mainly on quality of life and aspects of daily life.

CONCLUSION

More insight into the mechanisms of the social and organizational environments is needed, which may lead to greater transparency and homogeneity regarding the description of living arrangements. This review shows that more knowledge is needed about the potential key elements of innovative living arrangements, especially related to their social and organizational environment. This may provide a better guide for developers within long-term care.

Residential Environments for Older Persons: A Comprehensive Literature Review (2005-2022)

BACKGROUND

Independent noninstitutional and institutional residential long-term care environments for older persons have been the subject of significant empirical and qualitative research in the 2005-2022 period. A comprehensive review of this literature is reported, summarizing recent advancements in this rapidly expanding body of knowledge.

PURPOSE AND AIM

This comprehensive review conceptually structures the recent literature on environment and aging to provide conceptual clarity and identify current and future trends.

METHOD AND RESULT

Each source reviewed was classified as one of the five types-opinion piece/essay, cross-sectional empirical investigation, nonrandomized comparative investigation, randomized study, and policy review essay-within eight content categories: community-based aging in place; residentialism; nature, landscape, and biophilia; dementia special care units; voluntary/involuntary relocation; infection control/COVID-19, safety/environmental stress; ecological and cost-effective best practices; and recent design trends and prognostications.

CONCLUSIONS

Among the findings embodied in the 204 literature sources reviewed, all-private room long-term care residential units are generally safer and provide greater privacy and personal autonomy to residents, the deleterious impacts of involuntary relocation continue, family engagement in policy making and daily routines has increased, multigenerational independent living alternatives are increasing, the therapeutic role of nature and landscape is increasingly well-documented, ecological sustainability has increased in priority, and infection control measures are of high priority in the wake of the coronavirus pandemic. Discussion of the results of this comprehensive review sets the stage for further research and design advancements on this subject in light of the rapid aging of societies around the globe.

Organizational Innovation in Long Term Care Enabled by Collaboration Between Government Agencies: A Critical Realist Case Study

Long term care for older people is a highly regulated sector providing accommodation, health, and social care to vulnerable older adults. Older adults in New Zealand are among the highest users of long term care services globally. Traditionally those requiring specialist care for dementia are housed apart from other residents. In an example of organizational innovation, 1 provider relocated residents to a secure village where residents requiring specialist dementia care would be desegregated. We utilized a critical realist case study to explain the role of intersectoral collaboration among government agencies in supporting the transition while managing risk and ensuring regulatory compliance.

Nursing Home Adoption of CDC and ASHRAE COVID-19 Built Environment Recommendations: A Characterization Study of Colorado Nursing Home Facilities

BACKGROUND

During the COVID-19 pandemic, the Centers for Disease Control and Prevention (CDC) and ASHRAE provided infection control recommendations for the built environments and ventilation systems of nursing homes (NHs). The level of adoption of the suggested strategies is unknown, as little information has been obtained from NHs identifying the strategies that were implemented.

OBJECTIVE

The primary goal of our study was to characterize the built environments of Colorado NHs during the COVID-19 pandemic to assess the level of adoption of CDC and ASHRAE recommendations. Our secondary goal was to identify opportunities and barriers that NHs face as they work to create health-protective built environments in the future.

METHOD

We used the Nursing Home Built Environment survey to obtain data related to three main categories of CDC and ASHRAE recommendation for Colorado NHs: Resident Isolation, Improved Indoor Air Quality, and Staff Separation/Support.

RESULTS

Key findings included: (1) On average, NHs had 34% of their beds located in single-occupancy rooms; (2) seven (9%) NHs had designated COVID-positive "neighborhoods"; (3) 14 (20%) NHs had common area ventilation systems that were utilizing filters with a minimum efficiency reporting value 13 rating, or higher.

CONCLUSION

Most Colorado NHs did not fully implement the COVID-19 built environment strategies recommended by CDC and ASHRAE. While there are barriers to the adoption of many of the strategies, there are also opportunities for immediate improvements that can support the health of vulnerable NH populations as we continue to see high rates of aerosolized infectious disease spread in NH facilities.

Perspectives of certified nursing assistants and administrators on staffing the nursing home frontline during the COVID-19 pandemic

Objective

To identify best practices to support and grow the frontline nursing home workforce based on the lived experience of certified nursing assistants (CNAs) and administrators during COVID‐19.

Study setting

Primary data collection with CNAs and administrators in six New York metro area nursing homes during fall 2020.

Study design

Semi‐structured interviews and focus groups exploring staffing challenges during COVID‐19, strategies used to address them, and recommendations moving forward.

Data collection

We conducted interviews with 6 administrators and held 10 focus groups with day and evening shift CNAs (n = 56) at 6 nursing homes. Data were recorded and transcribed verbatim and analyzed through directed content analysis using a combined inductive and deductive approach to compare perceptions across sites and roles.

Principal findings

CNAs and administrators identified chronic staffing shortages that affected resident care and staff burnout as a primary concern moving forward. CNAs who felt most supported and confident in their continued ability to manage their work and the pandemic described leadership efforts to support workers' emotional health and work–life balance, teamwork across staff and management, and accessible and responsive leadership. However, not all CNAs felt these strategies were in place.

Conclusions

Based on priorities identified by CNAs and administrators, we recommend several organizational/industry and policy‐level practices to support retention for this workforce. Practices to stabilize the workforce should include 1) teamwork and person‐centered operational practices including transparent communication; 2) increasing permanent staff to avoid shortages; and 3) evaluating and building on successful COVID‐related innovations (self‐managed teams and flexible benefits). Policy and regulatory changes to promote these efforts are necessary to developing industry‐wide structural practices that target CNA recruitment and retention.

Transforming Direct Care Jobs, Reimagining Long-Term Services and Supports

The diverse array of individuals who receive long-term services and supports share one common experience, which is the need for assistance with personal care and/or other daily activities. The direct care workers (including nursing assistants, home health aides, and personal care aides) who provide this assistance play a critical role in keeping individuals safe, supporting their health and well-being, and helping prevent adverse outcomes. Yet despite decades of research, advocacy, and incremental policy and practice reform, direct care workers remain inadequately compensated, supported, and respected. Long-standing direct care job quality concerns are linked to high turnover and job vacancy rates in this workforce, which in turn compromise the availability and quality of essential care for older adults and people with disabilities-which has never been more evident than during the COVID-19 pandemic. This special article makes the case for transforming direct care jobs and stabilizing this workforce as a centerpiece of efforts to reimagine long-term services and supports system in the United States, as a public health priority, and as a social justice imperative. Drawing on research evidence and examples from the field, the article demonstrates that a strong, stable direct care workforce requires: a competitive wage and adequate employment benefits for direct care workers; updated training standards and delivery systems that prepare these workers to meet increasingly complex care needs across settings, while also enhancing career mobility and workforce flexibility; investment in well-trained frontline supervisors and peer mentors to help direct care workers navigate their challenging roles; and an elevated position for direct care workers in relation to the interdisciplinary care team. The article concludes by highlighting federal and state policy opportunities to achieve direct care job transformation, as well as discussing research and practice implications.

Interpreting COVID-19 deaths among nursing home residents in the US: The changing role of facility quality over time

A report published last year by the Centers for Medicare & Medicaid Services (CMS) highlighted that COVID-19 case counts are more likely to be high in lower quality nursing homes than in higher quality ones. Since then, multiple studies have examined this association with a handful also exploring the role of facility quality in explaining resident deaths from the virus. Despite this wide interest, no previous study has investigated how the relation between quality and COVID-19 mortality among nursing home residents may have changed, if at all, over the progression of the pandemic. This understanding is indeed lacking given that prior studies are either cross-sectional or are analyses limited to one specific state or region of the country. To address this gap, we analyzed changes in nursing home resident deaths across the US between June 1, 2020 and January 31, 2021 (n = 12,415 nursing homes X 8 months) using both descriptive and multivariable statistics. We merged publicly available data from multiple federal agencies with mortality rate (per 100,000 residents) as the outcome and CMS 5-star quality rating as the primary explanatory variable of interest. Covariates, based on the prior literature, consisted of both facility- and community-level characteristics. Findings from our secondary analysis provide robust evidence of the association between nursing home quality and resident deaths due to the virus diminishing over time. In connection, we discuss plausible reasons, especially duration of staff shortages, that over time might have played a critical role in driving the quality-mortality convergence across nursing homes in the US.

Dementia-Friendly "Design": Impact on COVID-19 Death Rates in Long-Term Care Facilities Around the World

Persons with dementia (PWD) make up a large portion of the long-term care (LTC) population the world over. Before a global pandemic swept the world, governments and healthcare providers struggled with how to best care for this unique population. One of the greatest challenges is a PWD's tendency to "walk with purpose" and exhibit unsafe wayfinding and elopement, which places them at risk of falls and injury. Past solutions included increased use of restraints and pharmacological interventions, but these have fallen out of favor over the years and are not optimal. These challenges put enormous strain on staff and caregivers, who are often poorly trained in dementia care, underpaid, overworked, and overstressed. PWD are impacted by these stresses, and unmet needs in LTC places an even greater stress on them and increases their risks of morbidity and mortality. The physical design of their environments contributes to the problem. Old, institutionalized buildings have poor lighting, poor ventilation, long dead-end hallways, poor visual cues, lack of home-like décor, shared bedrooms and bathrooms, and are often dense and overcrowded. These design elements contribute to the four 'A's' of dementia: apathy, anxiety, agitation, and aggression, and they also contributed to the rapid spread of COVID-19 in these facilities the world over. In this review, we present current "dementia friendly" design models in the home, community, and LTC, and argue how they could have saved lives during the pandemic and reduced the stresses on both the dementia resident and the caregiver/staff.

Proceedings from an International Virtual Townhall: Reflecting on the COVID-19 Pandemic: Themes from Long-Term Care

Residents of long-term care (LTC) homes have suffered disproportionately during the COVID-19 pandemic, from the virus itself and often from the imposition of lockdown measures. Provincial Geriatrics Leadership Ontario, in collaboration with interRAI and the International Federation on Aging, hosted a virtual Town Hall on September 25, 2020. The purpose of this event was to bring together international perspectives from researchers, clinicians, and policy experts to address important themes potentially amenable to timely policy interventions. This article summarizes these themes and the ensuing discussions among 130 attendees from 5 continents. The disproportionate impact of the COVID-19 pandemic on frail residents of LTC homes reflects a systematic lack of equitable prioritization by health system decision makers around the world. The primary risk factors for an outbreak in an LTC home were outbreaks in the surrounding community, high staff and visitor traffic in large facilities, and crowding of residents in ageing buildings. Infection control measures must be prioritized in LTC homes, though care must be taken to protect frail and vulnerable residents from their overly blunt application that deprives residents from appropriate physical and psychosocial support. Staffing, in terms of overall numbers, training, and leadership skills, was inadequate. The built environment of LTC homes can be configured for both optimal resident well-being and infection control. Infection control and resident wellness need not be mutually exclusive. Improving outcomes for LTC residents requires more staffing with proper training and interprofessional leadership. All these initiatives must be underpinned by an effective quality assurance system based on standardized, comprehensive, accessible, and clinically relevant data, and which can support broad communities of practice capable of effecting real and meaningful change for frail older persons, wherever they chose to reside.

"From living in a hotel to living in a home": Stakeholders' views about living and working in a nursing home which is undergoing culture change

Culture change models are intended to improve the quality of life and care of nursing home residents. Using longitudinal qualitative methodology, this study evaluated the effectiveness of implementing culture change on the main stakeholders living and working in an Israeli nursing home. Eight focus groups with nursing home residents, family members and staff members (N = 57) were conducted at two-time points: one year after and two years after implementing a culture change model. Using thematic content analysis and comparing the experiences of each group and across time, the results revealed that implementing culture change in a nursing home is a complex process, which requires am adaptation in the values, expectations, and perceptions of care of all those involved. Particular attention should be paid to the unique needs of each stakeholder group, while ensuring their engagement and cooperation in the change process.

The Homestead: Developing a Conceptual Framework through Co-Creation for Innovating Long-Term Dementia Care Environments

Alternative care environments for regular nursing homes are highly warranted to promote health and well-being of residents with dementia that are part of an age-friendly and dementia-friendly city and society. Insight is lacking on how to translate evidence-based knowledge from theory into a congruent conceptual model for innovation in current practice. This study reports on the co-creation of an alternative nursing home model in the Netherlands. A participatory research approach was used to co-create a conceptual framework with researchers, practitioners and older people following an iterative process. Results indicate that achieving positive outcomes for people with dementia, (in)formal caregivers, and the community is dependent on how well the physical, social and organizational environment are congruently designed. The theoretical underpinnings of the conceptual model have been translated into "the homestead," which is conceptualized around three main pillars: activation, freedom and relationships. The Homestead Care Model is an illustrative example of how residential care facilities can support the development of age-friendly communities that take into consideration the needs and requirements of older citizens. However, challenges remain to implement radical changes within residential care. More research is needed into the actual implementation of the Homestead Care Model.

"It's a lot!" the universal worker model and dementia care in assisted living

The culture change movement aims to create a more home-like environment in long-term care settings, promote person-centered care, and support the well-being of staff and residents. One feature of Culture Change is the Universal Worker (UW) model where direct care workers (DCWs) are responsible for housekeeping, laundry, and activities in addition to administering medication and personal support. The longitudinal approach in the ethnographic study on which this paper is based compares data collected from one assisted living across three NIA-supported research grants. This paper focuses on modifications to the UW model following the implementation of culture change over a period of ten years. As DCWs cared for residents with increasing levels of dementia, time constraints under the UW model led to sporadic attention to housekeeping chores and challenged person-centered care. Modifying the UW model, by using dedicated cleaning staff and other support workers, better preserves the intent of the culture change movement.

Nursing Home Design and COVID-19: Balancing Infection Control, Quality of Life, and Resilience

Many nursing home design models can have a negative impact on older people and these flaws have been compounded by Coronavirus Disease 2019 and related infection control failures. This article proposes that there is now an urgent need to examine these architectural design models and provide alternative and holistic models that balance infection control and quality of life at multiple spatial scales in existing and proposed settings. Moreover, this article argues that there is a convergence on many fronts between these issues and that certain design models and approaches that improve quality of life, will also benefit infection control, support greater resilience, and in turn improve overall pandemic preparedness.

Development of a New Tool for Systematic Observation of Nursing Home Resident and Staff Engagement and Relationship

Purpose of Study

To develop a structured observational tool, the Resident-centered Assessment of Interactions with Staff and Engagement tool (RAISE), to measure 2 critical, multi-faceted, organizational-level aspects of person-centered care (PCC) in nursing homes: (a) resident engagement and (b) the quality and frequency of staff-resident interactions.

Design and Methods

In this multi-method psychometric development study, we conducted (a) 120 hr of ethnographic observations in one nursing home and (b) a targeted literature review to enable construct development. Two constructs for which no current structured observation measures existed emerged from this phase: nursing home resident-staff engagement and interaction. We developed the preliminary RAISE to measure these constructs and used the tool in 8 nursing homes at an average of 16 times. We conducted 8 iterative psychometric testing and refinement cycles with multi-disciplinary research team members. Each cycle consisted of observations using the draft tool, results review, and tool modification.

Results

The final RAISE included a set of coding rules and procedures enabling simultaneously efficient, non-reactive, and representative quantitative measurement of the interaction and engagement components of nursing home life for staff and residents. It comprised 8 observational variables, each represented by extensive numeric codes. Raters achieved adequate to high reliability with all variables. There is preliminary evidence of face and construct validity via expert panel review.

Implications

The RAISE represents a valuable step forward in the measurement of PCC, providing objective, reliable data based on systematic observation.

Beyond "Home-Like" Design: Visitor Responses to an Immersive Creative Space in a Canadian Long-Term Care Facility

This study examined the benefits of expanding upon the "home-like" design by introducing an immersive creative space for residents, staff, and visitors to explore in a long-term care facility in Eastern Ontario, Canada. Data were collected through guestbook comments ( N = 93) and coded for themes according to guidelines for thematic analysis. Selected themes included visitors' enjoyment of the winter aesthetic, expressions of gratitude to the artists, time spent socializing with family and visitors in a creative milieu, and the experience of remembering in an evocative space. The results indicate that residents and visitors benefited from the experience of a creative space that was neither institutional, nor "home-like." Implications for future research are discussed.

Launching Medical Foster Home Programs: Key Components to Growing This Alternative to Nursing Home Placement

Objective

The objective of this research was to examine and explain elements that enhanced or thwarted program growth of the United States Veterans Health Administration Medical Foster Home program.

Methods

This qualitative study was conducted nationally through individual interviews over the phone and in-person (n = 22) with coordinators (n = 15 at slow-growth programs; n = 6 at fast-growth programs), program support assistants (PSAs) (n = 1 at slow-growth program), and home-based primary care team members (n = 3), as well as three in-person focus groups (n = 28 total participants) with home-based primary care team members. All participants (N = 53) were involved with programs in existence for at least two years.

Results

Facilitators and barriers that enhanced or thwarted program growth emerged around four themes: A full-time coordinator; Unmitigated home-based primary care team engagement; Pursuit and receipt of appropriate referrals; and Match between caregiver, home, and Veteran.

Conclusions

To facilitate program growth, program leaders should consider themes identified and how to foster situations and shape policies that put themes into practice.

Caregivers Create a Veteran-Centric Community in VHA Medical Foster Homes

The Veteran's Health Administration's Medical Foster Home program offers a unique long-term care option for veterans who require nursing-home- or assisted-living-level care. Veterans in a medical foster home reside with community-based caregivers who provide 24-hr-a-day care and monitoring. The veterans often remain in the medical foster home until end of life. Support and oversight is provided to the caregiver from the Veteran's Health Administration's community-based medical team. This qualitative descriptive study is based on secondary analysis of interviews with 20 medical foster home caregivers from 7 programs across the United States. The study's research aims are to describe and explain (a) the type of care backgrounds and skills these caregivers possess, (b) caregivers' primary motivations to open their homes to veterans who often have complex medical and social needs, and (c) how caregivers function in their role as primary caregiver for veterans. Findings indicated that caregivers interviewed had worked in long-term care settings and/or cared for family members. A strong desire to serve veterans was a primary motivation for caregivers, rather than financial gain. The caregivers' long-term care skills aided them in building and sustaining the unique medical foster home family-like community.

The Factors Influencing the Sense of Home in Nursing Homes: A Systematic Review from the Perspective of Residents

Purpose. To provide an overview of factors influencing the sense of home of older adults residing in the nursing home. Methods. A systematic review was conducted. Inclusion criteria were (1) original and peer-reviewed research, (2) qualitative, quantitative, or mixed methods research, (3) research about nursing home residents (or similar type of housing), and (4) research on the sense of home, meaning of home, at-homeness, or homelikeness. Results. Seventeen mainly qualitative articles were included. The sense of home of nursing home residents is influenced by 15 factors, divided into three themes: (1) psychological factors (sense of acknowledgement, preservation of one's habits and values, autonomy and control, and coping); (2) social factors (interaction and relationship with staff, residents, family and friends, and pets) and activities; and (3) the built environment (private space and (quasi-)public space, personal belongings, technology, look and feel, and the outdoors and location). Conclusions. The sense of home is influenced by numerous factors related to the psychology of the residents and the social and built environmental contexts. Further research is needed to determine if and how the identified factors are interrelated, if perspectives of various stakeholders involved differ, and how the factors can be improved in practice.

Inside the Green House "Black Box": Opportunities for High-Quality Clinical Decision Making

OBJECTIVE

To develop a conceptual model that explained common and divergent care processes in Green House (GH) nursing homes with high and low hospital transfer rates.

DATA SOURCES/SETTINGS

Eighty-four face-to-face, semistructured interviews were conducted with direct care, professional, and administrative staff with knowledge of care processes in six GH organizations in six states.

STUDY DESIGN/DATA COLLECTION

The qualitative grounded theory method was used for data collection and analysis. Data were analyzed using open, axial, and selective coding. Data collection and analysis occurred iteratively.

PRINCIPAL FINDINGS

Elements of the GH model created significant opportunities to identify, communicate, and respond to early changes in resident condition. Staff in GH homes with lower hospital transfer rates employed care processes that maximized these opportunities. Staff in GH homes with higher transfer rates failed to maximize, or actively undermined, these opportunities.

CONCLUSIONS

Variations in how the GH model was implemented across GH homes suggest possible explanations for inconsistencies found in past research on the care outcomes, including hospital transfer rates, in culture change models. The findings further suggest that the details of culture change implementation are important considerations in model replication and policies that create incentives for care improvements.

Green House Adoption and Nursing Home Quality

OBJECTIVE

To evaluate the impact of the Green House (GH) model on nursing home resident-level quality of care measures.

DATA SOURCES/STUDY SETTING

Resident-level minimum data set (MDS) assessments merged with Medicare inpatient claims for the period 2005 through 2010.

STUDY DESIGN

Using a difference-in-differences framework, we compared changes in care quality and outcomes in 15 nursing homes that adopted the GH model relative to changes over the same time period in 223 matched nursing homes that had not adopted the GH model.

PRINCIPAL FINDINGS

For individuals residing in GH homes, adoption of the model lowered readmissions and several MDS measures of poor quality, including bedfast residents, catheter use, and pressure ulcers, but these results were not present across the entire GH organization, suggesting possible offsetting effects for residents of non-GH "legacy" units within the GH organization.

CONCLUSIONS

GH adoption led to improvement in rehospitalizations and certain nursing home quality measures for individuals residing in a GH home. The absence of evidence of a decline in other clinical quality measures in GH nursing homes should reassure anyone concerned that GH might have sacrificed clinical quality for improved quality of life.

The Impact of Green House Adoption on Medicare Spending and Utilization

OBJECTIVE

To evaluate the impact of the Green House (GH) model of nursing home care on Medicare acute hospital, other hospital, skilled nursing facility, and hospice spending and utilization.

DATA SOURCES/STUDY SETTING

Medicare claims and enrollment data from 2005 through 2010 merged with resident-level minimum data set (MDS) assessments.

STUDY DESIGN

Using a difference-in-differences framework, we compared Medicare Part A and hospice expenditures and utilization in 15 nursing homes that adopted the GH model relative to changes over the same time period in 223 matched nonadopting nursing homes. We applied the same method for residents of GH homes and for residents of "legacy" homes, the original nursing homes that stay open alongside the GH home(s).

PRINCIPAL FINDINGS

The adoption of GH had no detectable impact on Medicare Part A (plus hospice) spending and utilization across all residents living in the nursing home. When we analyzed residents living in GH homes and legacy units separately, however, we found that the adoption of the GH model reduced overall annual Medicare Part A spending by $7,746 per resident, although this appeared to be partially offset by an increase in spending in legacy homes.

CONCLUSIONS

To the extent that the GH model reduces Medicare spending, adopting nursing homes do not receive any of the related Medicare savings under traditional payment mechanisms. New approaches that are currently being developed and piloted, which better align financial incentives for providers and payers, could incentivize greater adoption of the GH model.

New Evidence on the Green House Model of Nursing Home Care: Synthesis of Findings and Implications for Policy, Practice, and Research

OBJECTIVE

To synthesize new findings from the THRIVE Research Collaborative (The Research Initiative Valuing Eldercare) related to the Green House (GH) model of nursing home care and broadly consider their implications.

DATA SOURCES

Interviews and observations conducted in GH and comparison homes, Minimum Data Set (MDS) assessments, Medicare data, and Online Survey, Certification and Reporting data.

STUDY DESIGN

Critical integration and interpretation of findings based on primary data collected 2011-2014 in 28 GH homes (from 16 organizations), and 15 comparison nursing home units (from 8 organizations); and secondary data derived from 2005 to 2010 for 72 GH homes (from 15 organizations) and 223 comparison homes.

PRINCIPAL FINDINGS

Implementation of the GH model is inconsistent, sometimes differing from design. Among residents of GH homes, adoption lowers hospital readmissions, three MDS measures of poor quality, and Part A/hospice Medicare expenditures. Some evidence suggests the model is associated with lower direct care staff turnover.

CONCLUSIONS

Recommendations relate to assessing fidelity, monitoring quality, capitalizing opportunities to improve care, incorporating evidence-based practices, including primary care providers, supporting high-performance workforce practices, aligning Medicare financial incentives, promoting equity, informing broad culture change, and conducting future research.

Workforce Characteristics, Perceptions, Stress, and Satisfaction among Staff in Green House and Other Nursing Homes

OBJECTIVE

To compare workforce characteristics and staff perceptions of safety, satisfaction, and stress between Green House (GH) and comparison nursing homes (CNHs).

DATA SOURCES/STUDY SETTING

Primary data on staff perceptions of safety, stress, and satisfaction from 13 GHs and 8 comparison NHs in 11 states; secondary data from human resources records on workforce characteristics, turnover, and staffing from 01/01/2011-06/30/2012.

STUDY DESIGN

Observational study.

DATA COLLECTION METHODS

Workforce data were from human resources offices; staff perceptions were from surveys.

PRINCIPAL FINDINGS

Few significant differences were found between GH and CNHs. Exceptions were GH direct caregivers were older, provided twice the normalized hours per week budgeted per resident than CNAs in CNHs or Legacy NHs, and trended toward lower turnover.

CONCLUSIONS

GH environment may promote staff longevity and does not negatively affect worker's stress, safety perceptions, or satisfaction. Larger studies are needed to confirm findings.

Sustaining Culture Change: Experiences in the Green House Model

OBJECTIVE

To describe conditions that influence how Green House (GH) organizations are sustaining culture change principles and practices in a sample of GH skilled nursing homes.

DATA SOURCES/STUDY SETTING

Primary data were collected at 11 skilled nursing GH organizations from 2012 to 2014. These organizations have adopted the comprehensive and prescriptive GH model of culture change.

STUDY DESIGN

To develop an understanding of sustainability from the perspective of staff who are immersed in GH daily work, grounded theory qualitative methods were used.

DATA COLLECTION METHODS

Data were collected using semi-structured interviews with 166 staff and observation of house meetings and daily operations. Data were analyzed using grounded dimensional analysis.

PRINCIPAL FINDINGS

Organizations varied in their ability to sustain GH principles and practices. An organization's approach to problem solving was central to sustaining the model. Key conditions influenced reinforcement or erosion of GH principles and practices.

CONCLUSIONS

Reinforcing the GH model requires a highly skilled team of staff with the ability to frequently and collaboratively solve both mundane and complex problems in ways that are consistent with the GH model. This raises questions about the type of human resources practices and policy supports that could assist organizations in sustaining culture change.