A Nursing Home: Lessons from the Greenhouse Model of Care

By Noah Nunnelly

*Names and details have been changed to protect privacy.

Mary* (not her real name) has been working at a nursing home as a certified nursing assistant (CNA) for many years; she cares deeply for her patients, takes pride in her facility, and does hard work. Sometimes, her shift will last 16 hours. Judy* is one of Mary’s patients. She loves to sew, and according to Mary, is an “absolute firecracker.” One day this spring, a bored Judy began pestering Mary. Mary smiled, and left the room to tear a hole in her sweater; she returned swiftly to Judy, held up the garment, and exclaimed, “Look at my sweater! It’s ruined. Is there any chance you could fix it?”

Stories like this one, where aides create moments of connection and meaning for older adults, occur every day and, in the midst of a pandemic, are more important than ever.

As of mid-September 2020, the COVID-19 pandemic has infiltrated more than 19,900 long-term care facilities in the US, killing more than 80,000 older adults and accounting for 41% of all COVID-19 deaths in the country. The appalling numbers and constant media coverage have caused many of us to think about our own parents, grandparents, or family members who are in danger of contracting the virus. COVID-19 has also cast a spotlight on the structural problems that exacerbated the catastrophe and inspired the motivation to do something about them.

For the last six months, a team at Ariadne Labs has been unpacking the structural problems within nursing homes and generating solutions to support them. This “unpacking” process began with extensive research and a series of interviews with nursing home administrators and staff, which is where I first learned about Judy* and Mary*.

In order to understand and address the challenges that long-term care facilities face, Ariadne Labs began examining the positive outliers. We wanted to know: who has gotten it right? What facilities have been able to maintain low COVID-19 cases? The Greenhouse model emerged as a type of long-term care facility that has so far, successfully mitigated COVID-19 infections within their systems. Of the 245 Greenhouse homes nationwide, with 2,653 residents total, nine locations have had COVID-19 cases, resulting in six deaths as of May 2020. That is an order of magnitude fewer deaths (assuming there are approximately 1.3 million long-term care residents across the U.S.), and a significant reduction in the likelihood of the virus entering a home. So what makes the Greenhouse model unique?

“It is better to live in a house than a warehouse”

— Bill Thomas, Founder of the Greenhouse model

Founded in 2003, the Greenhouse model advocates small homes that they say promote the autonomy, individuality, and dignity of the residents. A few key features of the model lend themselves particularly well to infection mitigation, including private rooms, more access to outdoor spaces, open floor plans that allow for social distancing, and a staffing model that limits the number of people with whom each resident interacts.

First, the residences are smaller. Compared with the average of 160 residents per nursing home, Greenhouse locations have only 6–12 residents per home. Their small size reduces the number of people (transmission vectors) going in and out the building, thereby limiting infections. The number of beds in the facility was the second most predictive of infections. Residents live in private rooms with private showers, again limiting the risks associated with close-contact exposure in the face of COVID-19. Residents have direct access to outdoor spaces, and open floor plans in shared areas allow for group activities while maintaining a safe distance from one another. The Greenhouse model is geared towards freedom, agency, and individuality. It is where your uniqueness will not be drowned out by your co-habitants. Bill Thomas, a geriatrician and the founder of the Greenhouse model, says his homes rest on two pillars: “It is better to live in a house than a warehouse,” and “People should be the boss of their own lives.”

“When we’re talking about whole care… full person well-being… They [the shahbazim] understand.”

— Greenhouse Administrator

The second fundamental difference is what the Greenhouse model calls “the shahbazim.” The word comes from Persian mythology, where a “shabazz” was a giant bird who watches over and encourages humanity. The shahbazim are the direct care workers in the Greenhouse; they are the CNA counterpart, but by no means is it the same job. On a Greenhouse campus where there might be six homes, the shahbazim do not rotate among houses, which facilitates more contact with the same residents and therefore deeper understanding. This detail became particularly important during COVID-19, as reducing the number of people who interact with a resident reduces the number of opportunities for infection.

The shahbazim are paid 10–15% more than CNAs and have a larger purview; in addition to the traditional care responsibilities of a CNA, the shahbazim cook, do laundry, and perform various janitorial and maintenance duties — again, a particularly important aspect of their success in managing COVID-19 risks, as fewer people needed to interact with the residents to accomplish the same tasks. What’s more, all of these additional responsibilities don’t hinder patient care — quite the opposite, in fact. In a study of 240 CNAs and shahbazim, the shahbazim spent on average 24 more minutes every day in direct patient care. A more recent study estimates the shahbazim spends 4.2 hours with patients, compared with 2.16 hours for a traditional CNA.

So the shahbazim spend more time with the residents and do more things, but is the care actually better? As one shahbazim said on the Greenhouse website: “I’ve also had the privilege of working in the Greenhouses in Palmyra, Penn., for the past four years, and truly feel this is how long-term care should have been modeled all along.” One Greenhouse administrator we interviewed agrees: “When we’re talking about whole care…full person well-being…They [the shahbazim] understand.” They understand that while nursing homes have clinical teams, medical care is auxiliary to helping patients live the way they want to. They understand that while they are there to help keep patients clean and change sheets, those responsibilities are secondary to happiness and life fulfillment. They understand the resident is a person, not a widget.

“Our ultimate goal, after all, is not a good death but a good life to the very end.”

— Atul Gawande

Of course, we can’t discuss an exemplary model of long-term care without addressing the systemic inequity that may prevent many from accessing this type of facility. Frequently, insurance and funding structures dictate what type of institution an individual may have access to, and often, those relying on public insurance versus self-pay or private insurance face added limitations to their choice. While the Greenhouse model may not currently be accessible to all, there are themes and innovations within the model that are worth exploring and scaling, and that can be implemented within the context of existing facilities without the need to build new, expensive buildings to reach more of our older adult population. It can serve as a positive model as other long-term care facilities work to address the structural challenges that left residents vulnerable as COVID-19 took hold.

If you remember, Mary tore a hole in her sweater to make a resident feel better. This is a vital and unfortunately overlooked piece of care; it is the care that reflects the “person not widget” understanding. One of the things that the Greenhouses do best is empower the shahbazim to elevate this part of the care: the shahbazim spend more time with the same residents, know them better, and incorporate this knowledge into tearing sweater holes. As a vaccine is developed for COVID-19 and the spotlight on nursing home care dims, let’s not squander the opportunity to change the way we live at the end of our lives.

Noah Nunnelly interned in the Office of the Chief Medical Officer at Ariadne Labs this summer.Header illustration by Maltiase / iStock