Reformers Seek to Reinvent Nursing HomesNursing homes are often thought of as grim places. But a new approach is being tested. Instead of an institutional setting, the goal now is to provide a homelike — but safe — atmosphere for residents.
Bill Thomas, right, stands with Steve McAlilly of Mississippi Methodist Senior Services outside one of the new nursing homes built on the Green House Project model in Tupelo, Miss.
Joseph Shapiro, NPR
Joseph Shapiro, NPR
Cover of What Are Old People For? How Elders Will Save the World by William Thomas.
In Green House nursing homes, aides are called shahbaz.
Many people think of nursing homes as grim places where residents often seem bored, lonely and sad. But now some reformers are experimenting with a new kind of nursing home. Instead of an institutional setting, they want to provide a homelike atmosphere for residents.
Among the leading proponents of this kind of nursing home reform is Dr. William Thomas, who calls his vision the Green House Project. It's based on a simple idea: Older people will thrive in a nursing home if it's built to resemble living in one's own house. Others have tried to make existing nursing homes more homelike. The Green House Project makes the nursing home over from scratch, the goal being to give residents more privacy and more control over their lives.
The first such nursing home is currently being built in Tupelo, Miss., by Mississippi Methodist Senior Services. The brand new houses with driveways, barbeque grills and green lawns look like a housing community, but they are nursing homes, with just 10 people in each house. Residents sleep in private bedrooms, share family-style meals and have more freedom of movement than in traditional nursing homes, where staff usually decide most aspects of residents' schedules, including when they eat, sleep and shower.
"I believe that in [nursing homes] in America, really every year, thousands and thousands of people die of a broken heart," Thomas says. "They die not so much because their organs fail, but because their grip on life has failed."
"At the center of the Green House is quality of life -- meaning worth and dignity. At the Green House, we put those things at the center of life."
Thomas writes about long-term nursing care in his book What Are Old People For? Read excerpts from the book:
Excerpted from the chapter title " The Green House":
There is a staggering sameness in the design of long-term care facilities all over the industrialized world. The similarity derives in large part from a nearly universal emphasis on operational efficiency. The financial and organizational power that accompanies that goal will always tempt those who create Green Houses with the siren song of size and economy. After all, we have spent four decades "perfecting" the design of long-term care facilities, and the consensus of most experts in long-term care is that small intentional communities for elders cannot be cost-effective. The design of the Green House must face up to the difficulties of creating operational efficiencies without resorting to the logic of a large institution. The legacy of the nursing home will never be able to tell us what a Green House should be, but it can show us what it must never become.
The architecture of long-term care facilities reflects -- in steel, brick, and tile -- their fundamentally medical intention. Though the term homelike is often invoked, nursing home design actually gives its most careful attention to maximizing the efficient use of labor. Owners and operators of new and refurbished nursing homes take great pride in their equipment and facilities and, when a staff member gives a tour to a family member, these features are highlighted. The people who work there -- often overworked, usually underpaid -- are given far less attention.
These buildings give those within their walls little reason to suspect that elderhood can be a rich, rewarding phase of human development. Long corridors disable frail people, forcing them into wheelchairs. Massive dining rooms are impersonal and intimidating and promote anxiety. There is limited access to outdoor space. Double rooms (laughably called "semiprivate" rooms) and shared bathrooms invade privacy. Furniture, floor coverings, and drapery are matched consistently throughout, as if the place were a chain hotel rather than the home it is meant to simulate. The grim institutional appearance damages the well-being of staff and residents alike.
Rural, suburban, or urban, Green Houses are dwellings that house six to ten people. They belong in residential settings and should be good architectural neighbors. Some will be built into high-rise apartment buildings; others will be free-standing houses. Whatever form they take, there should always be as little distinction as possible between a Green House and the other housing nearby. In an ideal situation, a person looking for a Green House might pass it by because it is so inconspicuous. Inside the building, furnishings and decorations reflect the preferences of the elders of that community. Elders fill the house, to the greatest extent possible, with their own furniture, art, and decorations. At its best, the interior of a Green House closely resembles the homes of other elders in the vicinity.
We know that people find pleasure in the company of animals, the laughter of children, and the growth of green plants, so every Green House must offer elders opportunities to be in contact with the living world that surrounds us all. We also know that privacy is important to life satisfaction, and so the design of a Green House must ensure that privacy is plentiful. In fact, every elder must be able to have his or her own room. Because they are smart, these houses take full advantage of unobtrusive technology that promotes well-being. Ceiling-track lifts help create a safe environment that is good for elders and helps protect the people who work with them from injury. Communications technologies can improve health through tele-health and tele-nursing. The intelligent use of adaptive devices helps those living and working in a Green House be more at ease.
During the years I searched for the best design elements for a Green House, I visited many people and places. All of them influenced me. In Saskatoon I was fascinated by the Sherbrooke Community Center and inspired by its village model of community living. In Boston I toured the Hearthstone facilities created by John Zeisel. As we bumped and juddered over the city’s back streets, he told me that focus was Latin for "hearth." When we focus on something, we make it the center of our attention. The hearth is the center of a home, the place around which we arrange our living. Every Green House must have a center, a hearth around which the affairs of daily living may be arranged. Our deepest cultural memories suffuse the hearth with the twin pleasures of food and fire. The hearth includes an open kitchen and a large table around which meals are shared. The importance of having such an arrangement is confirmed by research showing that people living with dementia benefit from taking their meals in communal settings. Because the hearth is the center of the design, each elder’s room opens onto this space. There are no long corridors.
Professional nurses enter into and work within the Green House using the home health care metaphor and thus have no need for a fixed base of operations. Indeed, there is no evidence of the permanent presence of professional nurses. The nurses’ station, long a fixture of the long-term care institution, has no place in a Green House. The medication cart is obsolete because elders’ pills are kept in their rooms. There is no treatment cart and no chart rack because such things would be out of place in a private residence. The people of the Green House counter the tendency to medicalize their home by asking, "Can we find this in our neighbors’ homes?" If not, then its use in the Green House must be seriously questioned. It is important to remember, though, that the Green House is not a private family home. Its design is meant to support a distinctive form of intentional community. It is a vessel that sails through time, taking the people who share its spaces ever further into the realm of elderhood.
Excerpted from the chapter "Convivium":
Wants Versus Needs
The elements required for human survival are simple and few. A person can get along with a couple thousand of calories a day, a liter of water, a sprinkling of vitamins and minerals, and a steady supply of air to breathe. Shelter that offers protection from the extremes of the weather and predatory activity (human and animal) is important as well. More than we might suppose, though, human life also depends on easy access to affection. It is affection that brings meaning and purpose to the mundane affairs of daily life.
Even after many years of working with older people, I continue to be amazed at the way advanced age prunes the overgrown wants and desires of adulthood. Very old people rarely, if ever, covet material symbols of status, rank, and wealth. Chasing after the totems of adulthood grows wearisome with age and is often given up entirely. Those living in the late decades of life are not like the young. They can easily be content with far less than what the average adult demands. Still, we hear the constant and often bitter complaint that the needs of the elderly are bound to bankrupt us. The old, some say, are a luxury the young can ill afford.
Ageist rhetoric aside, what can we say about sustaining our elders? This is a question that a shahbaz [a "midwife to elders"] studies carefully. The second duty of the shahbazim (the first being to protect) is to sustain the elders with whom they work. Fulfillment of this duty requires an understanding of what makes life worth living.
Some people eat to live. Others live to eat. Those in the first group regard food as fuel; those in the second group know better than that. Good food has always offered people much more than just calories, fat, carbohydrates, and protein. At its best, food nourishes us -- body and soul. A meal can embody powerful symbols of love and acceptance. The bond between comfort and food, which begins at the breast, is fortified throughout childhood and gains renewed strength in the late decades of life. Properly prepared, the meals we cook and serve to our elders should be drenched in memory, ritual, and culture.
Reacting to case reports of actual starvation among nursing home residents, the government has established significant penalties for facilities that allow residents to lose weight "unexpectedly." As a result, nursing homes struggle constantly to increase the dietary intake of their residents. Just how challenging a task they have undertaken becomes obvious when you look at how these facilities prepare and serve food.
They shop from industrial food catalogues and unload the groceries from a tractor trailer parked at the loading dock. Meals are prepared in vast industrial kitchens that are deliberately isolated from the people who will eat what they produce. Some long-term care facilities, like airlines do, outsource food production entirely and take delivery of dinners by the truckload. In a down-to-the-minute ballet, food is rushed upstairs in huge rumbling carts. Staff members distribute it to waiting residents as quickly as they can. It is a never-ending challenge to serve hot food when it is still hot and cold food when it is still cold.
The people involved do their best. The realities of large-scale food service demand, however, that the material characteristics of the food -- its color, viscosity, temperature, and nutritional content -- become its most important descriptors. The emphasis on consistency and low cost is constant. Food is shorn of meaning, leaving only numerical measurements. The lifelong rhythm of good food shared within the circle of family life is absent. It is just not possible to imbue six hundred meals a day with the essence of love.
The Romans had a special term for the particular pleasure that accompanies sharing good food with people we know well. They called this experience convivium. The word has enjoyed a revival recently. The "slow food" (an alternative to fast food) movement has seized on the word as a way of describing dining experiences that are rich in meaning. Fresh, local ingredients prepared according to authentic regional recipes are served to people eager to share. They use smell, taste, and texture as a springboard to good conversation and vital relationships. The shahbazim foster a convivium that enriches the lives of elder and shahbaz alike.
The relationship between people and the food that sustains them begins with the planning that by necessity must precede each meal. The idea that meals can and should be planned with loving care and then prepared with loving hands will strike the typical food service manager as little more that wishful thinking. For the rest of us, it is simple common sense confirmed by our own experiences in our own homes. The suffering created by the industrialization of food in long-term care institutions deserves more than passing attention. Nursing homes are canaries in the mine, warning us of the assembly-line approach to food that is spreading across our social landscape. We are all losing our grip on convivium. Institutions may be able to blame their mechanical approach to food on their own gigantic size, but we can see the erosion of convivium all around us, even in our own lives.
The ability to create and maintain convivium demands an appreciation of the long, languorous meal and is one of the core competencies of a shahbaz. Time must be taken because food tastes better when it is soaked in anticipation. Elsewhere, soup may be purchased in bulk, heated, and then served. The shahbaz insists that soup be made fresh and be allowed to simmer all morning long with ingredients added slowly as the hours pass. In an institution, mealtime is a mad rush. For the shahbaz it is an opportunity to create and then deepen meaning. The spirit of convivium calls upon us to linger, to savor, and to draw strength not just from the food we are blessed to eat but also from the people with whom we are blessed to share our meal.
The conventional long-term care facility has struggled with, but never satisfactorily resolved, its split personality. As Mr. Hyde, it poses as a home. In its propaganda, the long-term care facility tells its staff members that "this is the residents’ home; we just work here." Meanwhile, Dr. Jekyll maintains, with full professional authority, that the facility is actually a "health care services workplace." Despite the rhetoric about home, Dr. Jekyll rules this roost. The proof is easy to come by. Just watch the employees and note the way they control space, time, and people in their building. Imagine a similar group of well-meaning professionals entering your bedroom while you are sleeping and carrying on their work without regard for your desire for privacy or rest. Staff rules.
I highlight this conflict because in a time when protecting people from wind, rain, snow, and the heat of the summer sun poses little challenge, the real difficulty lies with creating an effective social shelter. In an affluent society, housing is available to all but the most unfortunate (and could be made available to them as well). A social shelter, though, is much more difficult to come by. The tension between the formality of the institution and the ease of a home is familiar to a shahbaz. Just as the shahbaz transcends "food service," choosing to practice convivium in its place, the shahbaz has a similar devotion to the art of homemaking.
Few social institutions have fallen as far and fast as homemaking. Once the object of glorification (as a female pursuit), homemaking is now belittled. Many no longer regard it as a legitimate pursuit for skillful people. The identification of homemaking with unpaid female labor inside the nuclear family too often served as a prop for the sexist denial of equal rights for women in the workplace. The sustained attack on homemaking as an unnatural sexist institution has created its own collateral damage. It has obscured some of the craft’s very real virtues. There is much to be gained by retrieving homemaking from the ash heap of history (or at least popular opinion), dusting it off, and putting it to a new use.
By medicalizing old age, the cult of adulthood has degraded an ancient commitment to sustaining elders. The injection of massive government funding into the field of aging has benefited millions but has also forever altered the family’s relationship with its elders. Long-term care’s obsessive concern with medical treatment springs from society’s deliberate equation of aging with illness. In the early 1960s, advocates for the elderly faced a situation in which millions of older people were both poor and sick. They made a strategic decision to channel needed resources through the health care system rather than the welfare system. Medicare and Medicaid were given dominion over the care of the aged, and these programs pumped trillions of dollars into improving the health of older Americans.
Along the way, a powerful industry has grown up around these programs. Being fed by health care dollars, this industry has little reason to imagine that the most important aspects of elderhood might have little to do with medical and surgical therapies. So complete is the medical-industrial domination of aging that people who need long-term assistance can be compelled, for purely economic and political reasons, to live out their lives within the sick role, tended to in medical facilities.
This is how the concept of "professional distance" came to be injected into the lives of millions of elders. An unquestioned assumption held by millions of professionals, this idea holds that unnecessary closeness and undue affection for patients is to be avoided. Doctors and nurses have long held that personal attachment to a patient could cloud one’s thinking and lead, at a critical moment, to an error of judgment. This logic continues to reign, virtually unquestioned, in the acute care and hospital sectors of our health care system. Even so, it is spectacularly ill suited to the needs of our elders and those who work with them.
Rightly claiming that the aged are much more likely than the young to fall ill, health care professionals continue to perpetuate the fallacy that old age is mostly a medical problem. The need for medical and nursing services is assessed with precision and then used to justify payments made by the government to the long-term care facility. As I have noted, the need for health care services is rarely if ever the only reason an elder is made to leave home and enter an institution. The old, like the young, do fall ill. But, unlike the young, the old can be compelled to make illness the center point of their lives. Old age, like all the other phases of our lives, should be about life and living.
Treating aging as a medical condition that must be managed with the professional distance prescribed by the medical model is wrong and leads to terrible suffering. Virginia Bell and David Troxel have written powerfully about this in their book The Best Friend’s Approach to Alzheimer’s Care. They argue persuasively that the proper metaphor for organizing our thinking in this area is not the distant clinical reserve of the professional but the open and engaged warmth of a best friend.
Shahbazim develop their relationships with elders within the distinctly nonmedical framework of befriending. This perspective creates daunting challenges that require both skill and maturity to overcome. The idea of befriending elders is sure to raise the hackles of medical professionals. They can object, with some justification, that encouraging the bond of friendship between elders and shahbazim opens a door to abuse and manipulation. Preventing "overinvolvement" and manipulation of residents by facility staff members is one of the primary aims of the medical model of care. Anyone who has worked, even briefly, in a long-term care facility knows how diligently the boundary between staff and residents is patrolled.
Even so, the deliberate separation of residents from the staff creates its own brand of suffering. Imagine yourself surrounded by people ostensibly pledged to care for you but discouraged from knowing you as a person. Nor are they permitted to share their humanity, their story, with you. Imagine living with a burning thirst and being denied the crisp, cool water that is kept intentionally just beyond your reach.
There is one other objection that can be raised against befriending as an organizing concept for the shahbazim. Getting close to elders who are, admittedly, themselves close to the end of their lives is said to be a prescription for burnout. Professionals tell us that, as much as they might like to do so, they cannot afford the luxury of having deep feelings for people under their care. Because this work demands that they spend a great deal of time with frail and elderly people, having emotional attachments to patients could lead to a paralyzing grief with each death. This notion turns the "It is better to have loved and lost" adage on its head and concludes, quite forcefully, that it is better not to have loved at all.
Recent surveys of people who work with elders have found that the number one reason people stay in the field is the opportunity to create and sustain meaningful relationships with elders. This is a remarkable finding, considering that the weight of professional practice and regulatory enforcement is balanced against this tendency. It hurts to lose a friend, but the pain of not befriending is even greater. The true cause of burnout is the deadening effect of closing one’s emotions to people who are in obvious need of a human connection. Human life is sustained by affection.
The purest form of friendship is found among equals. So it is with the shahbazim. They leave the cloak of professional authority and distance for others to wear, knowing that they are and will remain the equals of the elders. Shahbazim have a duty to sustain the elders with whom they work through the practices of convivium, homemaking, and befriending.
Excerpted from What Are Old People For? How Elders Will Save the World, by William H. Thomas, M.D. Reprinted by permission of VanderWyk & Burnham, Acton, Mass. Copyright 2004 by William H. Thomas.