These facilities, part of a national movement to create less-institutionalized long-term care, stand out in a pandemic that has killed more than 61,000 nursing home residents since March. At “Green House” homes, the best-known nontraditional model, residents are one-fifth as likely to get the coronavirus as those who live in typical nursing homes — and one-twentieth as likely to die of the disease it causes.
For Harvard-trained doctor Bill Thomas, who specializes in geriatrics, the contrast is bittersweet.
He has spent two decades calling for the “abolition” of standard nursing homes in favor of the Green House model, which allows the elderly to live in groups of eight to 10 in settings that resemble homes rather than hospitals.
The model has been praised by academics and doctors and seems far better suited than traditional facilities to stave off the spread of infection and the isolation that has devastated the elderly in recent months. But it remains on the fringes of a $137 billion industry.
As of this year, the 2,500 Green House residents represent just 0.2 percent of the 1.3 million nursing home residents nationwide. Of the 10 largest nursing home chains in the country, which collectively operate 2,000 facilities, none have adopted the Green House model.
Some in the movement say corporations and government leaders have been unwilling to take the necessary steps, such as revamping the reimbursement system for Medicare and Medicaid or slashing paychecks for executives. Others fault what they see as a national tolerance of injustice toward the elderly and the mostly immigrant and minority workers who care for them.
As the pandemic tore through facilities earlier this year, killing 37 at a nursing home in Kirkland, Wash., 40 at Canterbury Rehabilitation & Healthcare Center outside Richmond, and 37 at Sagepoint Senior Living in La Plata., Md., Thomas, 60, and other advocates — many now senior citizens themselves — wondered whether the Green House model’s time had finally come.
They began collecting data on coronavirus cases and fielding questions from policymakers and union leaders. The Green House project was invited to speak to three national organizations in October and plans to host a virtual town hall early next year. The Pioneer Network, a coalition of eldercare advocates, is convening a work group to push for more funding for alternative nursing homes. Writing in the prestigious New England Journal of Medicine, scientists have called for the United States to invest in these new models.
“We’ve been waiting,” said Rose Marie Fagan, 77, a former nursing home ombudsman for New York state who became the first director of the Pioneer Network. “All this time, we’ve been waiting for a moment where we could capture people’s imagination on everything wrong with this system.”
A decade of faith
The concept of the traditional American nursing home became widespread in the 1950s and ’60s. Fueled by billions in federal funding, private companies built institutions modeled after hospitals, with long hallways, shared rooms and one nurse to dozens of patients.
Stories of abuse quickly emerged, along with calls to improve conditions. There were campaigns on Capitol Hill to increase government oversight, but these rarely made a dent in the experiences of residents. The 1986 Nursing Home Reform Act, which was supposed to set a visionary new framework for the industry, was never really enforced.
In 1997, a group of 33 administrators, ombudsmen and geriatricians who had been independently researching alternative models of skilled nursing care met at Fagan’s home in Rochester, N.Y., to join forces in a unified overhaul effort.
Among others, there were Bill and Jude Thomas, founders of the Eden Alternative in Ithaca, N.Y.; Barry and Debby Barkan from the Live Oak Institute in Berkeley, Calif.; Joanne Rader, a geriatric nurse from Oregon; and Charlene Boyd, a nursing home administrator from Seattle.
Inside a red-brick building that housed a historic women’s club, attendees outlined what nursing homes should look like: small, localized facilities where employees had enough time and resources to develop personal relationships with each resident. Staff members would provide support for mental as well as physical health, and let residents make their own decisions when possible. Residents would be seen foremost as people, not patients.
“Everyone was meeting each other for the very first time,” Fagan said. “And we learned that what we were trying to do — it was all the same thing.”
On the last day, attendees gathered in the solarium, some on chairs, others sprawled out on the floor. It was snowing, Fagan remembered, and Rochester was blanketed in white. They agreed to call themselves the Pioneer Network and planned another meeting the next year.
“Those were the most exhilarating three days of my life,” Fagan said.
The annual gatherings grew larger, drawing dozens of converts who embraced the concept of “culture change” in the nursing home industry. Thomas and others ran workshops, spoke at conferences and attended meetings, including one hosted by the federal Centers for Medicare and Medicaid in Washington, D.C. In seven years, the Green House project went from adding one or two homes a year to more than a dozen; by 2010, there were 104 such facilities.
“All of us believed we could do it,” Thomas remembered. “We really believed, and I mean we believed it deep in our hearts.”
But faith wasn’t enough.
After the Great Recession, interest began to peter out. Smaller operators went under as ownership increasingly shifted to large, multistate corporations. Conference attendance shriveled. Contract requests to the Green House project slowed.
Even after the nation started to recover, most private providers, it turned out, were not willing to gut their facilities and rebuild them. This was especially true for the increasing number of facilities bought by out-of-state private equity firms, said Lori Smetanka, executive director of the National Consumer Voice for Quality Long-Term Care.
David Grabowski, a Harvard researcher who studies the economics of long-term care, said the movement was also stunted by a lack of financial and regulatory support from state and federal governments.
“The imperative to manage costs gained the upper hand,” Thomas said. “Our moment passed.”
A diagnosis of failure
Nontraditional nursing homes are more likely to be situated in wealthier areas, research shows, and owned by nonprofit organizations or private companies with deep pockets. Few are Medicaid-reliant facilities, which disproportionately serve low-income Black and Latino residents.
Take Goodwin House’s complex in Alexandria, Va. — built in 2017 and financed in part by revenue from the nonprofit owner’s independent and assisted-living facilities. It is not a trademarked Green House but bears many of the same features: Residents live in groups of 10, with a staff-to-resident ratio of 1 to 5. Although Alexandria was hit hard by the coronavirus, the facility has had zero cases, spokeswoman Lindsay Hutter said.
On a recent afternoon, Ruth Deardorff, 97, sat by the orchids and other potted flowers that she had chosen to line her windowsill. After decades of tending to a yard in the suburbs of New Jersey, she finds comfort in having flowers in her room.
“I’ve certainly felt safe here,” she said, “especially when I read in the paper what has happened in other nursing homes.”
In Florida, the Woodlands at John Knox Village is the only skilled nursing facility built in the Green House model. Its only coronavirus patient, a short-term rehab patient, recovered in two weeks.
At a time when many nursing home residents have been isolated in their rooms for months, the senior citizens who live at the Woodlands gather daily in a light-filled living room, where the walls are decorated with photos and art. They wake up when they want to, often to the smell of fresh coffee or sizzling bacon wafting from the open kitchen. Less than 8 percent of employees leave their jobs each year, compared with about 55 percent industry-wide.
The Woodlands used revenue from its parent company’s other senior living communities, and $6 million raised by residents, to cover the $35 million cost of converting a traditional skilled nursing facility in 2016, said administrator Mark Rayner. Eighty-five percent of the 150 or so residents paid $400,000 to move into the retirement community; less than 5 percent are reliant on Medicaid.
“Unfortunate as it is,” said Hutter, the Goodwin House spokeswoman, “the nursing home industry was not set up to be a charity.”
In 2012, a Green House home opened near the old Memorial Stadium in East Baltimore, with officials touting how valuable it would be for the predominantly Black, Medicaid-reliant residents in the neighborhood. Five years later, the Nursing and Rehabilitation Center at Stadium Place was sold to a for-profit company that chose not to renew the Green House trademark or abide by its standards.
The facility was cited twice for infection-related deficiencies in the next few years; in June, it was among four Maryland facilities fined for failing to test all employees and residents for the coronavirus. As of early November, 23 residents and staff members had been infected, and five had died.
“I think about this story a lot because at a high level, it’s about failure,” said Grabowski, the Harvard researcher. “There’s such an opportunity to grow this model, but having the resources to do it and sustain it is very challenging.”
The American Health Care Association, which represents 14,000 nursing homes, said many cannot provide private rooms because they rely on Medicaid, which is “notorious for underfunding actual cost of care.”
“There are many long term care providers who would love to explore more innovative models, but the way government reimburses long term care does not always make this viable,” the association said in a statement.
Watchdog groups and consumer advocates, however, say any additional taxpayer dollars going into privately run nursing homes should be closely scrutinized.
“There are billions and billions of dollars that have already gone into this industry,” said Smetanka, chief executive of the consumer advocacy group. “If operators are saying they can’t provide quality care because there isn’t enough money in the system, then we need to really look at where that money is going.”
Smetanka noted that amid the pandemic, some corporations have bought new facilities and evicted low-income residents. A Washington Post report found that more than a dozen companies that received millions in “no strings attached” coronavirus relief aid previously faced allegations of Medicare fraud.
In a letter to members in June, the American Health Care Association said nursing homes had been “blamed” for the pandemic’s high toll and announced a $15 million media campaign to “fight back.” Chief executive Mark Parkinson urged members to support state and federal lobbying efforts to secure immunity clauses that would shield facilities from lawsuits alleging negligence.
In more than 26 states, long-term care facilities have accounted for at least a third of coronavirus deaths, data shows. Deaths from Alzheimer’s disease and dementia have also spiked, a likely effect of the prolonged isolation at many nursing facilities.
Barkan, the Berkeley-based activist, said these trends illustrate what Pioneer Network advocates have been trying to say for decades: “No piecemeal approach has ever worked. The whole system has got to change.”
A suspension of disbelief
More people than ever before are interested in alternative models of skilled nursing care, experts say. On Sept. 14, the World Health Organization’s emergencies chief exhorted developed countries to “fundamentally rethink the relationship we have with older generations.”
The week before, the Trump administration’s commission on nursing homes declared: “The time has come for a turning point in nursing home care.”
But the commission’s recommendations to the Trump administration mostly focused on testing, visitation, and how and whether to isolate patients. There was little mention of the long-term changes that Fagan, Thomas and others urged the panel to consider, which is why they’re fired up, but wary.
Calls and emails to the Green House project have surged, but as of early November, just a handful of providers have contracts with the organization to build or renovate their facilities, said the project’s director, Susan Ryan. And it doesn’t appear as though elected officials are actively weighing legislation urging them to do so.
Part of this may be because many facilities are still in “response mode,” dealing with the resurgence of the virus in their midst, said Penny Cook, head of the Pioneer Network. Operators are still clamoring to stockpile masks and gowns, not thinking about redesigning their buildings.
“That’s my biggest fear,” Ryan said. “That once we have a vaccine, we’ll go back to normal. That we’ll have, essentially, wasted a crisis of this proportion.”
These days, Thomas finds himself thinking back to the period in the early 2000s when he realized there was a limit to what people were willing to change when it came to the elderly.
“The pessimistic side of me always remembers that people living in nursing homes are the lowest of the low — the oldest, sickest, frailest,” he said, speaking from his home in Ithaca, N.Y. “Imagining that America can sustain righteous indignation on behalf of these people requires some suspension of disbelief.”
“Nonetheless,” he added, “I’m willing to do it.”