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Service Delivery Innovation Profile

Home-Like, Self-Directed Environment Provides Superior Quality of Life Than in Traditional Nursing Homes and Assisted Living Facilities

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THE GREEN HOUSE® model provides elders with an alternative to nursing homes and traditional assisted living facilities. These communities provide groups of 7 to 10 elders a comfortable, warm, home environment and staff who provide the highest level of clinical care while nurturing relationships and elders’ autonomy. Evaluations suggest that GREEN HOUSE® elders receive equal or higher quality of care and report better quality of life than residents of nursing homes.

Evidence Rating (What is this?)

Moderate: The evidence consists of a nonrandomized comparison with traditional nursing homes on key outcome measures, including quality of care, quality of life, and family and staff satisfaction.
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Developing Organizations

Eden Alternative; Mississippi Methodist Senior Services
Mississippi Methodist Senior Services, Inc., is located in Tupelo, MS. Eden Alternative is located in Wimberley, TX.end do

Use By Other Organizations

Information provided in April 2010 indicates that there are now 24 GREEN HOUSE® model replication sites in 15 states. An additional 19 projects are in development in 11 states, with new projects opening in 2010.

Date First Implemented

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Patient Population

Age > Aged adult (80 + years); Vulnerable Populations > Frail elderly; Age > Senior adult (65-79 years)end pp

Problem Addressed

Traditional nursing homes or assisted living facilities are often very large, have rigid schedules, and provide little opportunity for autonomy, leaving both residents and staff feeling dissatisfied.
  • Limitations of traditional facilities: It is difficult and expensive to make homelike changes to the physical environment of the typical nursing home, which is limited by long corridors, nurses’ stations, medication carts, and fluorescent lighting. Large institutional facilities are often difficult for the elderly to navigate, particularly those who are unsteady on their feet, causing them to be more reliant on wheelchairs.1 In addition, schedules and routines are typically directed by the medical staff, and the residents have little or no choice but to comply.
  • Limited prospects for improvement: Efforts to improve residents’ quality of life in traditional long-term care facilities, including changing the culture, have not gone far enough to transform care. Many also believe that the physical layout of traditional facilities is an insurmountable barrier to improving care.1
  • Negative implications for residents and staff: Residents in traditional facilities often report loneliness, boredom, and helplessness.1 Nursing home staff, including certified nursing assistants, frequently report low levels of job satisfaction and have high turnover rates.

What They Did

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Description of the Innovative Activity

THE GREEN HOUSE® model seeks to enhance the quality of elders’ lives by giving them control over their days in a physical environment that bears a greater resemblance to a home than an institution. Key elements of the model include the following:
  • Restructuring of resident and staff roles to respect autonomy: Residents are referred to as "elders" as a way to show respect for their years, including recognition that they know what is best for themselves and therefore should keep their own schedules. The staff, consisting primarily of certified nursing assistants, are called "Shahbaz," which means "royal falcon, a bird with mystical powers" in Persian. Shahbazim (the plural of Shahbaz) are empowered to build nurturing partnerships with the elders and to assist them in making their own schedules and choices. The goal for Shahbazim is to protect, nurture, and sustain elders.
  • Self-managed staff teams: Shahbazim work in self-directed teams with assistance from the Guide (see below), and meet on a weekly basis to discuss their progress in meeting goals. Team functions include:
    • Coordinating staff schedules
    • Ordering food, planning menus, and cooking
    • Communicating and acting as partners with the clinical support team (see below)
    • Coordinating care
    • Housekeeping
  • The "Guide": The person responsible for the administration of the home is known as the "Guide." Equivalent to a nursing home administrator, this individual works directly with self-managed work teams and empowers them to succeed.
  • Clinical support team: Each home has a clinical support team that includes nurses, social workers, therapists, physicians, activity and dietary professionals, and pharmacists. Nurses from the clinical support team serve each home 24 hours a day, with one nurse typically covering two homes during the day and evening and up to three homes at night. The other clinical professionals on the team visit the house regularly much like home health providers.
  • Environmental design: GREEN HOUSES® are designed to feel like a home. All residents have private bedrooms and bathrooms decorated with their own belongings, which are built around the hearth with a fireplace, dining room, and open kitchen. Because homes have 10 elders or fewer, they are easier for elders to navigate. The homes are built to be:
    • Warm: By using comfortable homelike furnishing and an open floor plan, the homes foster a feeling of warmth. This feeling is reinforced through the emphasis on building close relationships between elders and staff and the community.
    • Smart: The homes use cost-effective "smart" technology, including electronic ceiling lifts, wireless pagers, and other adaptive devices.
    • Green: The homes are designed to maximize exposure to sunlight and access to the outdoors. Plants are also included in the interior design. Using environmentally sound building materials is encouraged.
  • Individually developed daily schedules: Elders are encouraged to follow their "natural rhythms" when choosing how to structure their days.
    • Dining: Elders and Shahbazim eat meals together at one long table. Meals are relaxed and flexible, not scheduled for a particular amount of time; rather, their duration follows the natural inclination of the elders. Elders have access to food and snacks at anytime of the day.
    • Activities: Activities are not structured, but instead depend on what individual elders enjoy doing and when they prefer to be active. For example, two or three people may sit together and play cards or other games, while other elders sit and read by the fireplace.

Context of the Innovation

Mississippi Methodist Senior Services is a religiously affiliated, nonprofit organization that serves more than 1,600 elders throughout the state of Mississippi in 11 independent living, personal care, and skilled nursing care settings. When the organization wanted to build a new 140-bed facility, the chief executive officer turned to William Thomas, MD, a Harvard-trained geriatrician who, after serving as medical director of a nursing home in upstate New York, developed an alternative model for institutional care (known as Eden Alternative) that more closely resembles normal life for elders. During their conversation, the two individuals realized that further changes were needed, which led to the development of an entirely new concept that ultimately evolved into THE GREEN HOUSE® model. Currently, THE GREEN HOUSE® Project team works with NCB Capital Impact, a nonprofit organization, to provide assistance to organizations that want to replicate the model. (See the Funding Sources section for more details.)

Did It Work?

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Information provided in April 2010 indicates that three evaluations conducted between 2003 and 2009 revealed that GREEN HOUSE® elders exhibit improved quality of life, quality of care, and family satisfaction when compared to other nursing home residents. These evaluations also showed improved staff-related outcomes among GREEN HOUSE® homes when compared to other nursing home sites.

GREEN HOUSE® Elders Relative to Comparison Group of Nursing Home Residents2,3

  • Improved quality of life: GREEN HOUSE® elders reported more improvement in seven domains of quality of life (privacy, dignity, meaningful activity, relationship, autonomy, food enjoyment, and individuality) and emotional well-being.
  • Improved quality of care: GREEN HOUSE® elders maintained self-care abilities longer with fewer experiencing decline in late-loss activities of daily living. Additionally, fewer GREEN HOUSE® elders experienced depression, being bedfast, and having little or no activity.
  • Improved family satisfaction: GREEN HOUSE® families were more satisfied with general amenities, meals, housekeeping, physical environment, privacy, autonomy, and health care.

GREEN HOUSE® Homes Relative to Nursing Home Comparison Sites4

  • Improved staff satisfaction: GREEN HOUSE® staff reported higher job satisfaction and increased likelihood of remaining in their jobs. Direct care staff in GREEN HOUSE® homes also reported less job-related stress.
  • Higher direct care time: GREEN HOUSE® staff spent 23 to 31 minutes more per resident per day on direct care activities in GREEN HOUSE® homes. This additional time did not result in an overall increase of staff time spent on the job.
  • Increased engagement with elders: The study found more than a fourfold increase in staff time spent engaging with elders outside of direct care activities in GREEN HOUSE® settings.
  • Lower incidence of pressure ulcers: Elders in GREEN HOUSE® homes experienced fewer in-house–acquired pressure ulcers.

Additional Outcomes relating to the Role of Direct Care Workers in GREEN HOUSE® Homes5

  • Comparable quality: Restructured staff roles and the removal of formal nurse supervision of direct care workers did not compromise the quality of patient care.
  • Timely intervention: Due to the high level of familiarity with elders, direct care workers were able to identify very early changes in elders' conditions and facilitate timely intervention.

Evidence Rating (What is this?)

Moderate: The evidence consists of a nonrandomized comparison with traditional nursing homes on key outcome measures, including quality of care, quality of life, and family and staff satisfaction.

How They Did It

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Planning and Development Process

The planning and development process included the following:
  • Meeting with regulators: As noted, facilities are designed to look like homes, eliminating traditional "institutional" features while ensuring that all regulations are followed. To that end, designers met with the department of health to ensure that the facility met all current regulations without the use of waivers. Nurses stations were eliminated, with regulations met by adding a locked medicine cabinet in each elder’s bathroom. Access to the outdoors was made possible by fencing in outdoor space to allow for safe wandering. To enhance safety, visual sight lines were added to allow workers to see from the kitchen to the majority of the hearth area, bedrooms, and outdoor space.
  • Shahbazim training: The Shahbazim received 120 hours of training that covers the following: cardiopulmonary resuscitation, first aid, culinary skills, safe food handling, and household operations (including basic maintenance and emergency response). Shahbazim also received THE GREEN HOUSE® education curriculum, including philosophy of care, The Eden Alternative® communication skills and protocols, how to work in self-managed work teams (including problem-solving and conflict resolution), and other policies and procedures.

Resources Used and Skills Needed

  • Staffing: Shahbazim are the core staff of the home. In each house, the Shahbazim provide a total of 40 hours of elder care per day; that is, 4 hours of staff time per elder per day.
  • Costs: Initial cost estimates are comparable to traditional care, but financial modeling is currently underway with open GREEN HOUSE® homes.
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Funding Sources

Mississippi Methodist Senior Services did not receive any external funding for the pilot project.

Potential adopters may be able to obtain funding from THE GREEN HOUSE® Project Predevelopment Loan Fund, which is designed to provide hard-to-obtain predevelopment dollars to help organizations assess project feasibility, obtain a site, and fund architectural, engineering, and other third-party expenses. The fund is administered by NCB Capital Impact in Arlington, VA, a mission-based, nonprofit organization specializing in creating and supporting projects that serve people with low incomes. The fund is available to nonprofit organizations that have been accepted into The GREEN HOUSE® Project through an application process. These GREEN HOUSE® sponsoring organizations must apply separately to the loan fund program and may use the funds for environmental reports, market studies, architects' fees, permits, project management, and related costs. The predevelopment loan, up to $125,000 per project, is to be matched by other grant funds or cash that the sponsor has available to spend on the project.

Funding for the replication project is provided by the Robert Wood Johnson Foundation.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Attend a workshop: Organizations interested in adopting this model would likely benefit from attending a GREEN HOUSE® workshop. These daylong workshops provide the opportunity to explore and learn about the model (including its finances) and to speak with staff, elders, leadership, and members of a clinical support team, as well as spend time in GREEN HOUSE® homes.
  • Plan ahead: The typical timeframe from application to opening is approximately 3 years.
  • Emphasize coaching and training: Overcoming resistance from clinical and administrative staff who are used to working in a traditional medical model requires significant investment in coaching and training.
  • Work with regulators: Work with department of health regulators at the beginning to make sure that the design meets all current regulations.
  • Think small: A central tenet of the philosophy is, "smaller is better." Elders are able to navigate their environment much more easily if it is small. Small supports the culture of home.

Sustaining This Innovation

  • Take the lead: The Guide is critical to the home’s success, including the ability of the self-managed work teams to provide quality services to residents.
  • Clearly articulate the clinical support team’s role: This team acts as educators and partners with the Shahbazim and elders.
  • Commit to the model: Leaders must make their commitment to the model visible to everyone, as it represents a radical shift from traditional long-term care.
  • Pay frontline staff as generously as possible: Lower rates of administrative overhead than in traditional facilities allows for higher compensation to Shahbazim.

Use By Other Organizations

Information provided in April 2010 indicates that there are now 24 GREEN HOUSE® model replication sites in 15 states. An additional 19 projects are in development in 11 states, with new projects opening in 2010.

More Information

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Contact the Innovator

Scott Brown
Director of Marketing
Capital Impact Partners
2011 Crystal Drive
Suite 750
Arlington, VA 22202
Phone: (703) 473-4937

Innovator Disclosures

Mr. Brown has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

THE GREEN HOUSE® Project [Web site]. NCB capital impact. Available at:

Lum TY, Kane RA, Cutler LJ, YU TC. Effects of Green House® nursing homes on residents’ families. Health Care Financing Review. 30(2):35-51, Winter 2008-2009.

March A. Case study: Elder homes replace nursing homes in Tupelo, Miss. New York: The Commonwealth Fund, March 12, 2007. Available at:

Kane RA, Lum TY, Cutler LJ, et al. Resident outcomes in small-house nursing homes: a longitudinal evaluation of the initial green house program. J Am Geriatr Soc. 2007;55(6):832-39. [PubMed]


1 March A. Case study: Elder homes replace nursing homes in Tupelo, Miss. New York: The Commonwealth Fund, March 12, 2007. Available at:
2 Kane R, Lum TY, Cutler LJ, et al. Resident outcomes in small-house nursing homes: a longitudinal evaluation of the initial Green House Program. J Am Geriatr Soc. 2007;55(6):832-839. [PubMed]
3 Lum TY, Kane RA, Cutler LJ, et al. Effects of Green House® nursing homes on residents’ families. Health Care Financing Review. 30(2):35-51, Winter 2008-2009.
4 Sharkey S, Hudak S, Horn S. Analysis of staff workflow in traditional nursing homes and THE GREEN HOUSE® project sites. Unpublished, 2009.
5 Bowers B, Nolet K. Exploring the role of the nurse in implementing THE GREEN HOUSE® Model. University of Wisconsin, Unpublished, 2009.
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: April 14, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: July 30, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: August 30, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.