Dignity by Design

Innovative nursing facility uses architecture to give residents privacy, autonomy, and a place to call home

As 10 o’clock approaches, James Johnson is still working on a hearty breakfast of eggs, bacon,

and toast with jelly. The two women who sit at the long dining-room table with him, Cynthia Dunn and Vance Tate, finished eating hours ago.

“There’s not that many here who eat this late,” Mrs. Tate says with a wink.

Mr. Johnson immediately protests that he is going to start getting up early the very next day. But the skepticism of his companions suggests he’s said that before.

While eating breakfast at 10 a.m. might not seem remarkable, it is considering that Mr. Johnson (67), Mrs. Dunn (83), and Mrs. Tate (95) are residents in a nursing home.

Traditional nursing homes are formidable, often impersonal buildings with long corridors, shared bedrooms, and cavernous dining halls that serve meals with military precision to accommodate all the residents.

But the Green Houses at Traceway is a very different kind of nursing home, one that uses architectural design to help it achieve its mission of providing care that offers privacy, dignity, and choices for its elderly residents. A set of 10 small homelike structures make up the Green Houses. Each building is home to 10 to 12 elderly residents, who have private rooms that surround a central hearth. The center space includes adjoining living, eating, and kitchen areas. Each building also has a fenced-in backyard and patio, which give residents safe access to the outdoors.

The appeal of the garden became apparent almost as soon as the houses opened. The original residents in the first two Green Houses had been living in a locked Alzheimer’s unit. Staff members say the residents were so happy to be outside after the move that they wouldn’t come back in, sending the employees on an emergency trip to Wal-Mart for sunscreen and straw hats.

The smaller size of the buildings allows for a relaxed pace that is shaped by the residents, rather than the schedule of the people who take care of them, says Steve McAlilly, chief executive officer of Mississippi Methodist Senior Services, the Tupelo charity that runs the development.

“It’s setting the elders free, breaking them out of the institution,” he says. The Green Houses let residents “live in a home again and make decisions over things like when they wake up, when they go to bed, what they do for activities, what they eat — things that you and I take for granted.”

$10-Million Project

The first four Green Houses in Tupelo opened in May 2003. Six more opened in 2005. They were built to largely replace the Cedars Health Center, an aging 140-bed nursing home. Twenty-eight residents remain at Cedars, and the organization is looking for another use for the rest of the building, perhaps as a pharmacy or doctors’ offices.

The total construction cost to build the Green Houses was $10-million, a little less than the projected $12-million price tag for the replacement nursing home Mississippi Methodist originally had been planning.

The idea of building small nursing homes was developed by William Thomas, a Harvard-educated geriatrician. He chose the name Green House to evoke a sense of continued growth and enjoyment.

The development in Tupelo was the first of its kind in the United States, but the Robert Wood Johnson Foundation, in Princeton, N.J., hopes to promote the widespread adoption of the approach with a five-year, $10-million grant it announced in November.

The Green House Project at the National Cooperative Bank Development Corporation, a national organization in New York that is promoting the idea, will provide consulting help and pre- development loans to organizations that want to establish Green Houses of their own. The project’s goal is to set up at least one Green House in every state within the next five years, which can, in turn, serve as models for others interested in the idea.

Presbyterian Villages of Michigan plans to open two Green Houses on its Redford campus this summer, and more than 20 other organizations have projects in the works.

Medical Gains

In addition to giving residents more privacy and greater autonomy, the design of the Green Houses has led to significant medical benefits, says Judith Rabig, co-director of the Green House Project.

“Almost 80 percent of the people who are in nursing homes who use wheelchairs have no diagnosis related to their neuromuscular system,” says Ms. Rabig. “They’re simply frail and somewhat weak, and they can’t navigate the long distances” required to move throughout more traditional nursing-home buildings.

The smaller scale of the Green Houses, she says, has allowed some residents to become less reliant on their wheelchairs or give them up altogether. Not only has that reduced the medical problems associated with immobility — such as pressure sores and a greater chance of developing pneumonia or urinary-tract infections — but the increase in exercise has led to other health benefits.

By expending more energy walking, says Ms. Rabig, residents have been sleeping better and eating more. When the first four Green Houses opened, some frail residents who moved in from the old nursing home gained several pounds that first week; previously many of them struggled just to maintain their weight.

When Mr. Johnson came to the Green House after having a stroke, staff members worried about how thin and gaunt he was. But he has since gained 20 pounds — and will proudly tell visitors that his pants size has gone from a 32-inch waist to a 36.

An independent study found that residents in the Green Houses fell less often, and therefore sustained fewer injuries, than residents in traditional nursing-home settings. The finding was a surprise, says Ms. Rabig. She and her colleagues had expected that because residents were walking more and, in some cases, had abandoned their wheelchairs, they would fall more often.

She suspects that the increased exercise, better nutrition, and improved sleeping habits also increased residents’ strength, which helped protect them against falls.

Ms. Rabig recalls how when residents first moved in, many were not able to pass serving dishes during lunch and dinner, which are served family-style. Staff members improvised, using regular plates and dishes to serve food at the start. But gradually many residents got to the point where they could pass regular serving dishes.

When the next set of Green Houses opens in Michigan, she says, residents will take a strength test when they first move in so the project can document changes in their strength levels.

Creating a Home

Rethinking and literally redesigning what a nursing home should look like wasn’t easy.

Richard McCarty is a Tupelo architect and chief executive officer of the architectural firm that worked with Mississippi Methodist Senior Services. He says his first drawing for the Green Houses was a “duplex-type concept” with two groups of 10 rooms on either side of a shared kitchen, dining, and service area. “It was actually a small facility,” he remembers with a chuckle.

The charity’s leaders and officials from the national Green House Project encouraged him to take the duplex apart and start thinking about the project as a home.

“The mantra of the whole design team from start to finish was, ‘Would you do that in your home?’” says Mr. McCarty. “So every time the facility mindset started to creep back into the process, someone on the team would raise a flag and ask that question.”

Hoping to encourage other charities to follow its lead, Mississippi Methodist was determined to design the Green Houses without requesting any waivers of the state regulations that govern nursing homes. But at the same time, the organization wanted to eliminate any building features that would make the Green Houses seem institutional. To meet both objectives, the designers had to be creative.

For example, the state code requires that all nursing-home rooms have a light outside above the door to signal that the patient has called for a nurse. In most nursing homes, says Mr. McCarty, that means a bright red light over the door, “just a terrible-looking little thing.”

Mr. McCarty and his team dug into the code and found that the unattractive lantern was not required, only the light inside it. So the design team took the required light, recessed it into the wall above the door, and created glass art pieces with floral designs as light covers.

In the Green Houses, the state-required nurses’ stations are housed in a den. Most medications are kept locked in small wooden cabinets in each patient’s room. And nurses use tea carts, rather than large institutional medical carts, to deliver any drugs that have to be kept at the nurses’ station, such as narcotics and medicine that requires refrigeration.

Improving the Culture

While the design of the Green Houses, compared with traditional nursing homes, is important, even more critical is the way they are run, says Mr. McAlilly of Mississippi Methodist Senior Services.

“My architect cringes when I say this, but what goes on in the Green House is only 30 percent design and 70 percent the culture,” he says.

Certified nurse aides work with nurses in self-managed teams to run the houses. In addition to providing the patient care they would in a traditional nursing home — such as assisting residents who need help dressing — the aides also cook meals, do laundry, and order supplies.

Despite the extra responsibilities, the pace is more humane at the Green Houses, both for staff members and elderly residents, says Marie Fields, who has been a certified nurse aide in one of the Green Houses since it opened and before that worked for more than five years at Cedars, the traditional nursing home that the Green Houses replaced.

She says that the ties between staff members and residents are also much stronger in the Green Houses. In the old nursing home, she says, “you rotated around so much that it was hard to get to know the elders. You might be here today, over there tomorrow.”

According to Mr. McAlilly, the greater responsibility the aides have taken on has allowed Mississippi Methodist to cut the number of managers it needs and increase the pay for aides, all while keeping operating costs roughly the same as they were at Cedars. The organization worked hard to keep costs within the amount Mississippi Medicaid would cover. Currently, 80 percent of the 112 residents rely on Medicaid to pay for their expenses.

Nurses, doctors, physical therapists, and others employed by the charity move between the houses as needed.

The new staffing structure was a difficult adjustment for the nurses, who in the old nursing home were used to being in a position of authority over aides, but in the Green Houses must work collaboratively with them on teams, says Mr. McAlilly.

Most of the registered nurses who worked at the Cedars have since left Mississippi Methodist. But, says Mr. McAlilly, the organization has hired new ones who are more open to the new system.

And turnover among aides has been negligible. During the first year of the Green Houses’ operation, Mississippi Methodist lost only three of the 40 frontline workers, and none were employees who simply stopped coming to work, something that wasn’t unusual at Cedars, Mr. McAlilly says. Nationally, the average rate of turnover among aides at nursing homes is 71 percent, according to the final report of the National Commission on Nursing Workforce on Long-Term Care published last year. He estimates that the cost of replacing a worker is about $3,000, and says the low rate of turnover has been a big cost savings.

Another reason morale has improved: fewer injuries on the job. Each bedroom in the Green Houses is equipped with a lift, which has significantly reduced the number of costly back injuries to staff members.

‘Granddaddy’s Green House’

Mr. McAlilly is careful to point out that the Green Houses aren’t a panacea. Residents still age, get sick, and eventually die. But he believes that the new approach has helped to reduce the feeling of isolation that often accompanies the aging process.

He remembers one little boy who refused to visit his grandfather at Cedars. But after the man moved to the new development, says Mr. McAlilly, “he was in his granddaddy’s Green House so much that he learned the name and the room of every elder who lived there.”

The Green Houses are located on Mississippi Methodist’s campus, which also includes independent-living cottages and apartments, as well as assisted-living apartments. Mr. McAlilly says that previously the residents in independent living never visited the nursing home, even if they had friends living there. But they are now frequent visitors in the Green Houses.

Several people in the independent living cottages have come up to him, he says, and said, “You know, when I get to where I can’t live here by myself, I want to go straight to a Green House. I don’t want to go through assisted living.”

Adds Mr. McAlilly: “I can guarantee you, nobody has ever said, ‘One day I want to move into a nursing home.’”