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Creating an Eden for SeniorsBy Susan Levine
Washington Post Staff Writer
Friday, November 21, 1997; Page A01
Nothing is particularly unusual about that scene in Fairfax City -- except that it's unfolding at a nursing home, a setting more typically associated with loss and dying than joy and living.
Across Virginia and indeed across the country, more and more people are asking why long-term-care facilities can't be like the Fairfax Nursing Center, the boxy, red-brick building on busy Main Street where Bella and Diva monitor the front door by night and an administrator occasionally roller-skates through the halls by day.
Nursing homes, they insist, can be places where laughter and spontaneity abound, where the elderly give as well as receive care, where a diversity of species -- canine and feline, feathered and planted, toddler on up -- create a natural habitat.
The idea once sounded like a kooky impossibility. But inspired by a Harvard-trained, Birkenstock-shod family physician from rural New York, it's a growing movement known as the Eden Alternative, the name William Thomas gave his vision six years ago.
"You've got to change the culture of a nursing home," Thomas says. Anything else "is just decorating."
"Edenized" homes are popping up in places such as Virginia Beach, where each Tuesday the Seaside Health Center hosts a local Brownie troop meeting, and the Methodist Home in Charlotte, N.C., which offers canaries and finches for any interested resident's room. In Waverly, N.Y., on the Pennsylvania border, the Tioga Nursing Facility built an on-site kindergarten to maximize the opportunities for young and old to mix.
A precise definition does not exist, but all those facilities share a commitment to change the system, and not just through fur and feathers. Supporters say an Eden home emphasizes quality of life as much as quality of care and encourages residents and employees alike to play a role in making that happen. It requires a willingness to experiment, especially on the part of management.
"The care that a resident receives is usually done in three or four hours of the day," noted Robert Bainum, Fairfax Nursing Center's owner. "They have 20 hours left to live a life."
State and federal regulators initially were skeptical about the prospect of, say, several hundred birds living in a nursing home. But many have become believers, especially with research beginning to show lower medication use, fewer infections and less employee absenteeism and turnover at Eden sites.
Still, some experts say that in an industry often resistant to change and under tremendous pressure to cut costs, companies will not rush to adopt the Eden Alternative unless it proves to be both cost-effective and practical.
Some of the best evidence already around comes from women such as Arless Almany and Virginia Wagner, both residents at the Fairfax City facility.
For months, Almany has had her own pet project: fattening up a snow-white cat that inexplicably adopted her. Almost any day or night, Angela can be found curled into a perfect ellipse on her mistress's bed or wheelchair. "If she stays here, I'm content, and if I stay here, she's content," said Almany, 72.
Wagner's affections lie elsewhere, but her bottom line is the same. "Don't let anything happen to those dogs," the 77-year-old woman cautioned, turning to glimpse Bella. "They make it more like home."
The Eden Alternative is the latest reform effort for nursing homes, which have come a long way since repeated scandals in the 1970s and '80s revealed care that was inadequate at best and criminal at worst. Patients' rights now are written into law. Ombudsman programs operate in every state. The use of physical restraints has dropped dramatically.
People fear the system still is broken. A study last summer of seriously ill hospital patients found that one-fourth of them were "very unwilling" to move permanently to a nursing home and that 30 percent said they would rather die. And yet, 1.6 million increasingly fragile Americans live in long-term-care facilities, a number that will rise sharply as the country ages.
"They have not been homes to people; they have been institutions," said Mary Tellis-Nayack, vice president of clinical services for Beverly Health and Rehabilitation Services, the country's largest nursing-home chain. Beverly and Genesis Elder Care, another large national company, are planning several Eden pilot projects. Both say they agree with Thomas that nursing homes -- only a tiny percentage of which are Edenized -- must be managed far differently.
"We can't afford not to," Tellis-Nayack said.
From the start, Eden's goal has been to vanquish the three "plagues" that Thomas and his wife and partner, Judy, believe afflict nearly all long-term-care facilities. They recite them like a mantra: loneliness, helplessness and boredom. "These people are intensely lonely," William Thomas said in an interview. "These people have vast stretches of nothingness."
According to the couple, for whom Eden is both a mission and a business, nursing homes must stop treating every situation like a medical condition and worry more about nurturing emotional needs. End the rigid hours residents must keep for meals, baths and bedtime; let them sleep in some mornings if they choose, Judy urges. Throw out the time clock and let workers schedule themselves, William says, then go further and get housekeepers and aides as involved in care as nursing supervisors.
Many people call the Thomases pioneers, one of four or five groups in the country that are on the cutting edge in their field.
"I think they have an enormous contribution to make," said social worker Carter Williams, of Rochester, N.Y., who is nationally known for her opposition to the use of restraints in nursing homes. She, too, has a physician-husband who works in geriatrics: Frank Williams, a former director of the National Institute on Aging, who talks about how Eden has "caught fire."
"It's the rare place that has shown much imagination in going beyond regulations," Williams said.
The Eden movement remains loosely organized, spreading largely by word-of-mouth or the two books William Thomas, 38, has published in the last few years. In Shelburne, N.Y., about an hour southeast of Syracuse, he, Judy and two employees work out of a modest office within the one-room schoolhouse that the couple built for their two sons and several neighbors' children.
They keep informal track of the many facilities that have contacted them for information or sent officials to week-long training conferences -- usually booked months in advance. They say they know with certainty of more than 100 Eden homes from Massachusetts to California, although the number could be greater. None is located in Maryland or the District.
With charismatic energy, William Thomas travels an ever-widening speaking circuit these days. His Ivy League MD degree and teaching position at New York's Upstate Medical Center are part of the reason people are paying attention, and he's beginning to be able to offer them more than just anecdotes.
In Texas, research being conducted by Southwest Texas State University at six Eden facilities has shown some dramatic results in the last year, with use of anti-anxiety and antidepressant drugs dropping 33 percent and employee absenteeism decreasing 44 percent at five sites.
"There's no arguing that the kind of environment described by Dr. Thomas is preferable," said Timothy Case, a senior adviser at the American Health Care Association, which represents 11,000 nursing homes. "We've created institutions that are certainly sanitary and well run and sterile -- and very unconducive to normal, natural life and a carrying on of human existence."
At Chase Memorial Nursing Home in Berlin, N.Y., just down the road from Shelburne and the first Eden facility in the country, medication usage per resident remains half that of its pre-Eden days. Despite its current menagerie of three dogs, five cats and more than 100 birds, which warble from community aviaries or individual rooms, allergies and infection rates are lower, too. Credit usually goes to the hundreds of plants that create lush mini-arboretums in the halls.
Every weekday afternoon this fall, students from the elementary school only a baseball's throw from Chase's back porch arrived for a junior-senior horticulture program. Margaret McDonald, 76, could be counted on to be there, as could Regina McCabe, 94, with a story ready for the younger gardeners.
"It brings us very close together," McDonald said. "It's like family in here."
Other states are coming around, with North Carolina declaring unofficially that it is an Eden Alternative state. It assembled a special Eden coalition (with a veterinary school as consultant), and in September, officials organized a conference that attracted 450 people from as far away as Nebraska and Arizona. It is even dangling grants of as much as $25,000 to encourage facilities to adopt Eden techniques.
In the Midwest, Missouri Lt. Gov. Roger B. Wilson was so struck by the stories he heard that he asked his state's Division of Aging to help promote Eden. About 60 facilities there are in the process of implementing programs.
"Eden's the way to go, no question in my mind," said Norman Andrzejewski, an area administrator for the New York state health department. He has watched since 1991, when the 80-bed Chase Memorial, with Thomas as its new medical director, risked both regulators' wrath and community ridicule by trying to reinvent itself along Eden lines.
"There's much more activity, much more noise," Andrzejewski said. "And the noise isn't people calling out. It's the noise of conversation and laughter. There's bustle."
"It's a real friendly place, homey," said Irene Taylor, a nursing aide at Chase, where nearly one-fifth of the staff has participated in a payroll deduction plan that supports Eden activities. "Everybody is more than willing to help," she said, even with such chores as changing cat boxes and cleaning bird cages. "After a while, you get used to it. You find the time for it."
Early naysayers predicted that cost constraints or union contracts would limit Eden's potential. But supporters say employees frequently seem happier in Eden homes, as evidenced by lower turnover, and the savings from that and decreased medication use can be substantial.
Moreover, facilities are finding creative ways to afford their animals. At the Methodist Home in Charlotte, a vet provides services at cost, and local nurseries donated cuttings. Staff members at Seaside in Virginia Beach hold car washes and craft sales to cover pet supplies.
At the 200-bed Fairfax Nursing Center, about half a dozen children in a mother's play group arrive the first Friday of each month. Initially, they played while the seniors watched, but the two sides are warming up to each other. This month, one resident read "The Hungry Caterpillar" to 3-year-old Ryan Cerny, of Fairfax City.
"It's a totally different environment," said Lori Cerny, who organized the group because all of Ryan's grandparents live out of town and she wanted her son to have regular contact with seniors. Little did she know they'd also meet three dogs, five cats and a dozen or so birds. "It doesn't feel like you've got these elderly people sitting around waiting to die," she said. "It's a living area."
Margaret Larkin, 86, has few complaints. After spending a lifetime in Pennsylvania, she moved to Fairfax City to be close to one of her sons. "I like it here," she said one afternoon last month, sitting near the goldfish pond, where ducklings make springtime appearances, and listening to a guitar-led medley of oldies so golden they should be on an endangered tunes list.
"It's my kind of life," Larkin said with a smile, "and I don't want to make any changes."