The Big Idea Behind A New Model Of Small Nursing Homes

Leading To HealthNursing Homes Health AffairsVol. 40, No. 3: Nursing Homes, COVID-19 & More The Big Idea Behind A New Model Of Small HomesRob Waters Affiliations This article is part of a series on transforming health systems published with support from Robert Wood Johnson Foundation. an open access distributed in accordance the terms Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt, and build upon this work, for commercial use, provided original work properly cited. See https://creativecommons.org/licenses/by/4.0/. Rob ([email protected]) independent journalist Oakland, California, who writes about science has contributed Kaiser News, STAT, Mother Jones, Psychotherapy Networker, among other publications. author thanks Alex Soltany his research assistance.PUBLISHED:March 2021Open Accesshttps://doi.org/10.1377/hlthaff.2021.00081AboutSectionsView PDFPermissions ShareShare onFacebookTwitterLinked InRedditEmail ToolsAdd favoritesDownload CitationsTrack CitationsPermissionsDownload Exhibits AbstractLong-term care facilities have been devastated by COVID-19, one exception: group small called Green Houses.TOPICSNursing homesElder CareElder patientsCOVID-19PandemicsCoronavirusMedicaidLong-term services supportsMedicareMedicaid servicesMedicaid patientsStaff: Unlike workforce at traditional nursing homes, House staffing structure flat. universal workers licensed as certified assistants, shahbazim, just cottage engage closely ten twelve residents.Photographs courtesy ProjectThe two homes sit less than miles apart city Magnolia, Arkansas, twenty north Louisiana border. In some ways, Cottages Wentworth Place Springs Magnolia are similar. Each same number beds; each owned for-profit operator multiple facilities. But similarities largely end there. Their architecture, philosophy, organization couldn’t be more different. For elderly residents, those distinctions created radically different experiences that deeply affect way they lived—and, cases, died—before during coronavirus disease 2019 (COVID-19) pandemic.The Place, opened 2008, looks like suburban subdivision. Six ranch-style cottages driveway, front lawn, rear patio. Inside, private rooms arrayed around large room cooking, dining, living area outfitted couches, fireplace, television. bedroom bath.The facility dodged months. It had few cases August 2020 didn’t experience major surge until mid-November. January 3, 2021, according data Centers Medicare Medicaid Services (CMS), fifty-four residents forty-nine confirmed three were dead.1Just down road, typical US home Wentworth. main building, central entrance, line hallways side. Most 140-bed live “semi-private” rooms, sharing their bathrooms another resident.The felt impact sooner did. At first it was spared. Then, starting week June 15, 2020, virus swept through Springs. CMS show six five employees tested positive week, twenty-eight sixteen next. By July 19, five-week span, forty-seven twenty-three staff members infected, nine died. As total forty-five infections, thirteen died.1The figures, glance, seem comparable: similar infections population residents. Yet there least striking difference. died represented quarter deaths Look closer difference comes into view: people lived.Privacy: typically laid out serves center life home.‘Uniquely Human’Since Life Care Center Kirkland, Washington, late February 2020—the outbreak US—nursing emerged most vulnerable deadly places country leads world deaths. Within month entering facility, infected dozens 81 120 residents; 35 died.2,3The unique properties we know them—places where numbers fragile older close quarters often share bedrooms, bathrooms, dining areas—have made them easy prey thrives contact shared air. Making matters worse, entrusted seniors undertrained poorly paid, earning average $14.14 hour.4 result, many jobs, senior facilities.The results devastating. Fewer 1 percent long-term facilities, but up 38 all COVID Tracking Project.5 Looking solely compiled half million almost 102,000 died.6Yet type appears done far better job protecting residents: 300 or so loosely affiliated independently owned, operate 32 states serve 3,200 elders. just-released research, team University North Carolina’s (UNC’s) Program Aging, Disability, Long-Term found Houses likely die homes.7“There something beneficial particular when COVID,” says Sheryl Zimmerman, UNC professor codirects aging program.Long before cast spotlight researchers study viewed uniquely human form housing elders provide quality while reducing hospital admissions, spending, turnover.8,9 They standouts industry unaccountable owners, underpaid workers, miserly government reimbursement practices incentivized owners cut corners facilities.Now, policy makers consider ways rebuild transform failed spectacularly protect patients these getting deeper look.‘We Pivot’When I arrived 9 a.m. planned tour N95 respirator place, surging. chilly last day November already morning. John Montgomery, vice president strategic operations Wentworth’s owner, Southern Administrative Services, texted me stay my car he arrived. We met parking lot, then went administrative offices temperature check.In weeks visit, started rise, converted south wing forty-room isolation area. Infected across campus moved there, staying negative no symptoms, twenty-one days. With canceled, Montgomery chatted office.“This how our system since March,” told me. “It’s changing daily. something, pivot, next pivot again.” walked campus, peering windows. “Stop. Do not enter. No visitors,” said sign outside Headen Cottage. sat couches wheelchairs.Montgomery suggested got cars drove hours company Poplar Grove Little Rock. Up point, positive, decided could enter.Inside Melder House, gas fire blazed, television played soundlessly. Two caregivers—known lingo shahbazim—worked kitchen, space seemed otherwise empty. said, “Hello, darlin’,” resident hovering near entrance her room. on-site administrator complex summer, knew elders.Montgomery knocked door Dorothy Foot, eighty-three-year-old who’d years. She greeted him excitedly she happy speak dressed green plaid shirt over white blouse, wavy gray hair framing face.“The Lord really blessed going House,” said. “The fact every us own gives dignity. And bathroom. mind, it’s apartment. I’m feelings woman dropped off home. even though am patient, still hold head high.”Her daughter, four children, after Foot back surgery. “My daughter ‘Mother, old home.’ you’re gonna it.’ place you fire.’”Her children eventually convinced move, glad “I kids take me,” want lives, need life. ability do that.”Caregiving instincts run strong her; spent lifetime looking sister, stricken polio child lost use legs reached age seventy-nine. restrain herself helping too much.“I thought aide here,” wanted push everybody wheelchair.”“Can interrupt?” asked. “You always do,” bantered. commiserated COVID-19. missed seeing women sitting table. hard because ladies sat,” “Y’all would laugh. Y’all up, tell jokes.”Foot friends also miss youthful thirty-six-year-old soft eyes light brown hair, promoted summer gained companywide responsibilities. “He come little lady table—their pop open,” “Now, everyone stays There’s nothing on.”Later, visiting grandfather 2010. big man, time saw victim institutionalized practices,” low wheelchair, shell what was.” When stepped inside blown away, thinking been” grandfather.‘Empowered’Today, fifty-eight organizations county seventy-eight campuses. Most, such Grove, house urban areas Chelsea, Massachusetts, St. Paul, Minnesota, high-rise structures containing Houses.To call themselves listed Project website, must follow model developed Bill Thomas. Thomas recently minted family medicine doctor 1991 job—as medical director Chase Memorial tiny Berlin, York. He’d once, student Harvard Medical School.“I anything homes,” says. hadn’t trained.” that, says, turned blessing.Chase did things book cited deficiency seven years, “They everything right,” recalls. “But and—I’m word ‘horrified.’ horror on, now quasi-responsible it.”He control lives. awakened took meals times dictated staff. TV wheelchairs hallway. meaning do.“I watched wither die,” His key observation, motivate efforts thirty forms stripped autonomy dignity.Thomas “wanted remake home,” physician Atul Gawande wrote 2014 book, Being Mortal.10 Memorial, led sometimes comical upheaval, bringing dogs, cats, colony rabbits, hundred parakeets building combat boredom spark spontaneity joy. delivered without cages, dogs pooped floor, improvise plan feed birds. enlivened, psychotropic drugs, turnover declined. He new program Eden Alternative, morphed movement global nonprofit. Hundreds adopted its principles; tens thousands trainings.Eden envisions working “care partners” identifies “loneliness, helplessness, boredom” principal enemies alike. Alcoholics Anonymous thing,” “Until can say loud suffering loneliness, boredom, changes. If can’t it, change it.”In 1999 wife, parents, performing one-man play based novel he’d written. Across America gave twenty-seven performances, city. All them, realized, “were operating under tremendously burdensome architecture. see thing country, like: fix architecture.”At time, Foundation (RWJF) years searching improve quality, “we way, on,” Nancy Barrand, adviser foundation. “We think them.” 2001, visited foundation’s Jersey office idea turning institution feels Intrigued, grant develop Houses.The First HouseSteve McAlilly, CEO Methodist Senior social agency Tupelo, Mississippi, intrigued After hearing speak, connected get opinion matter: McAlilly agonizing operated hired architects design facility. Thomas’s response understated brutal: ‘I don’t if that’s ought anymore,’” remembers. “It wind sails.”A year later enlisted scheme. board “obsolete doors” halted project raised $3 build. Instead, money, plus funding RWJF, create country. 2003 Traceway Retirement Community Tupelo.The architectural innovation bedrooms An adjoining patio balcony provides outdoor access. wake hear sounds McAlilly. dishes rattling kitchen. smell bacon frying. wander bedroom, home, eat breakfast table.”The organizational advance staffing. segmented, assistants (CNAs), janitors, cooks, dishwashers narrow range functions interacting people. CNAs, Nurses rotate houses, hour care. Doctors, occupational therapists, clinicians visit needed.In “you’ve [wake] enough order meet your quota—I hate way—you start 4 5 up,” Marie Mister, CNA Tupelo. “At ready.” “have personal conversations. You learn you.”The shahbazim self-managed teams decide allocate work. Mister worked shabaz advancing become mentor trainer. Now she’s “guide,” responsible assisting schedule. “I’ve here wasn’t come,” says.The creates efficiencies. size means spend wheeling long hallways. shahbaz chat cooking dinner washing dishes; may join cook prep food. “Think able folding laundry,” Susan Ryan, Project, national umbrella homes.Ryan, background administration, joined 2008 RWJF awarded five-year, $10 replication fund technical assistance, architects, evaluations. Under leadership, grew rapidly, reaching 100 2010, 200 2016, 2020.Studies began suggest solid outcomes. 2012 comparison Minnesota Washington State hospitals matched saving $1,300–$2,300 per annual costs Medicare.11 2016 package studies found, things, 15 lower rates hospitalization 223 homes. 45 catheters, bedsores, 16 bedridden.9Others families expressed greater levels satisfaction homes.8,12 David Grabowski, School conducted evaluations, visits surprised him.“I away I’ve lot Grabowski members, especially nurse aides, “feel undervalued feel team. empowered.”Grabowski recalls being impressed “how life—just speaking smiles. Too often, institutional models care, needs preferences themselves.”‘Heart Soul’Despite high marks, make only 2 15,000 fewer predominantly white, middle-class clientele. What keeps gaining traction, diversifying, taking off?They’re expensive, thing. Daily $246 $495, making unaffordable qualify Medicaid—until “spend down” assets point will cover them. Although vary states, pays $200 room, usually shared, basic person Self-paying clients pay much 30 above rates. skilled tap richer $900 $1,000 coming rehabilitation. full cost days, 20 that.The complexity operators try achieve mix self-paying paid Medicare. agree accept life—and kick eligible Medicaid. That won’t applicants convert Medicaid.While overall dominated companies, 80 nonprofits.13 dozen companies Houses. Since opening built complexes construction, 600 beds.“It challenging—no question” patients, founder managing Ponthie. investors 10 return, delivers near-full capacity payer 55–60 Medicaid, 15–18 Medicare, remaining 20–30 self-paying. He’s partly Arkansas poor state cheap land, labor costs.Green Ponthie Having kitchens cottage, instead centralized kitchen whole example, adds expense translates waiting lists cottages. Surveys reported monthly occupancy 86–95 percent, declined 73 69 percent.The company, revenue million, operates twenty-four plans focus future growth believe heart soul, right economic investment,” want.”In higher, Marvin Plakut “just breaks even” running Gardens Episcopal ten-room Houses, 60 “If right, profit,” Plakut, organization’s CEO. “That’s OK us. investors.”Perhaps biggest shortcoming lack diversity—they middle- upper-middle-class backgrounds. African Americans elders, estimates.Ryan acknowledge problem reasons varied, including failures outreach. High construction land barrier developments, Ryan wants help launch Baltimore, Maryland–Washington, D.C., aimed Black community. showcase visible increased funding.‘Let’s Don’t Waste Good Pandemic’The intense scrutiny facing homes—and desire avoid mass-infection tragedies—presents opportunity. keep saying, ‘Let’s waste good pandemic,’” “has shined burning weaknesses we’ve things. trying stimulate conversation, job.”The UNC’s biostatistician Preisser, Exhibit A. gathered forty-three (including models) compared nearby. calculated infection 1,000 days death COVID-19.7The both significantly Because deaths, looked highest 50 recalculated resident-years (100 followed year).Using method, median rate upper 2.92 resident-years. Large homes—those fifty residents—had 27.00 resident-years, 5.48—nearly double Houses.More ominously, rates, Median mortality 24 53 ones.‘We Need Realign’Analysts needed, enormous gaps between high-end available wealthy, hand, understaffed decrepit low-income color relegated, other.Perhaps important potential change, broad providers, raise requiring performance. easier nonprofits for-profits alike invest higher-cost, higher-quality realign payment structure,” “This overpaying side, underpaying hoping balance doesn’t pandemic.”Higher should accompanied rules bar, rather incentivize, frail adults, easily spread infections. “Whoever idea?” asks.An equally increase caregivers, shoulder burden day-to-day disproportionately immigrants. “Paying minimum wage suggests real indifference towards adults them,” problems we’re today.”One say, allow savings generate occur transferred “Why facilities?” asks.Finally, advocates federal regulators aggressively eliminating bad actors performers industry. added advantage freeing limited beds allowed states’ certificates used homes.“States worst state, year,” “And close, mean, keys, put business. That’s turnover.”‘A Family Atmosphere’Doris Lurline Waller final Monroe Place. Before pandemic maintained rich life, Linda Mullins, Fami