Green House Project

Skilled Nursing News reported a discussion between reporter Alex Spanko and Susan Ryan. Ryan worked at nursing homes for years as a director of nursing. Now she works on initiatives designed to keep the elderly out of institutional care settings at all costs. Ryan is the senior director of the non-profit Green House Project. The project pushes “small-home”-style nursing home campuses, which place a premium on resident autonomy and quality of life.

The model has generated national interest amidst the ongoing COVID-19 pandemic. While tens of thousands of nursing home residents have died from COVID-19, 95% of Green House homes were completely free of the coronavirus with just 32 cases and one death.

Ryan joined “Rethink” podcast to discuss the challenges of turning Green House dreams into reality. She issued a warning that the nursing home industry cannot waste the opportunity to reshape the industry. “If we can’t get honest about why we’re here, and what we need to do to impact the next generation that you’re talking about, shame on us,” Ryan said.

Tell me how you came to work with the Green House model.

Just to give you a little bit of context of who I am, and why I do feel so passionately about the model: I am a nurse, and I was a former director of nursing eons ago, and had what I called my call-to-action moment in a nursing home — where we were, at that time, tying people up to keep them from falling. And that was considered best practice. Somehow in my heart, I thought: This was not right. I was young and just felt there’s no way this can be a good thing.

In 2001, I went back into long-term care with [the mindset that] we’ve got to reform it, because …it can be cost-prohibitive or socially isolating. So I’m working with a community in Maryland and hear about this thing called the Green House model. “Oh my God, this is home care and long-term care coming together. It’s like my worlds have just merged.”

I went to work initially with Green House as a project guide, and worked with providers who had decided to become part of Green House and do the new construction to build Green House homes. I really got immersed into Green House through working with providers to bring it to fruition — working with architects, working with regulators to go through the regulatory process, and then supporting them through the education with leadership and team development.

How can governments and advocates encourage investment in models like this?

I have scratched my head: If this is so good, why hasn’t everybody just jumped on board? You reference the underfunding, you reference the challenges around Medicaid, and absolutely, positively — yes, that’s all true. And yet the people who have done it, the leaders who have embraced it, these are the forward-thinking providers.

That is going to give me a competitive advantage. It’s doing the right thing for elders and their family members, and the right thing for staff, and I’m going to figure out how to make it happen.

I have a for-profit provider in Arkansas with a large percentage of Medicaid. He has 34 homes over four campuses, and he will open another 10 homes in October on a different community. It tells me he has figured out a way to make it happen, and he’s worked through whatever regulatory challenges — and I can tell you that, yes, he is mission-minded, but he’s also margin-oriented, and he has figured out how to make it happen.

What, to me, is rather compelling is that when we were talking about occupancy, he says his occupancy, in fact, [has] gained over the pandemic. As people were looking for places to move their loved ones, and they heard we had a room open, we were able to take the admission.

I just think that we have to shift our thinking. [Instead of saying] here are the reasons we can’t, say: Let’s figure out how we can make it happen. Let’s embrace the concept that this makes sense, and then let’s figure out how to do it.

I have heard that regulatory approval can be a challenge, especially in areas where the Green House hasn’t been developed — it doesn’t fit the general concept of a nursing home, so working with health departments can be difficult. Do you think the pandemic will change that?

I think in every state that we have Green House homes — and I’ve been a part of many of those conversations at the state department level — once they understand how the Green House model meets or exceeds the intent of that regulation, they will embrace it.

I’ll never forget talking to an engineer, and I had presented on Green House and he was so concerned about fire safety. I was pushing for a gas fireplace and open kitchen and all those things that just send terror down an engineer’s spine. We went through the design, and at the end of the conversation, as he and I were talking — and I was showing how I believed we met or exceeded the intent, and the context of the quality of life for those that would live there — he started talking about where his grandmother lives. He said, “This would be really good for my grandmother,” and then it’s just like a lightbulb went off and he realized: “Wow, this would be really good for somebody that I love and I care for.”

It’s really building the relationship, building the trust, and really building an understanding of what we’re trying to accomplish. Regulations were not written with a Green House in mind. They were written for an institution in mind, and so until there’s regulatory reform that would contemplate something like this, we will have to tackle it one state at a time.

The fireplace discussion reminds me of how I felt when my great-aunt, a surrogate grandmother to me, had to move into an assisted living and nursing campus after she could no longer live alone with her disabilities. I was terrified the first time I went to visit her — I was probably 18 or 19 — and what made me feel better was seeing those little touches that felt like home. In her case, it was things like a chapel so she could continue to attend religious services, which was really important to her, and a dining room that felt like a restaurant.

I so appreciate what you’re saying. I think I call it ageism and ageist stereotypes, stigmas — our beliefs that we have about people as they age, especially if there is cognitive decline.

Even somebody living with dementia, it’s amazing to me — our procedural memory system is so intact. It’s the longest that remains intact. Do we need to be safe? Of course we need to be safe. But we also need to look at our needs as humans. Our humanity does not diminish as we get older, and we don’t become children again. I think it’s some of those beliefs and ageism that really is impacting what we do, and what we will do from a reform perspective.

I’ve really tried to include in our coverage of the pandemic a bigger-picture view — so much of the national discussion around reform is about fines and lawsuits, and those are obviously a part of the solution, but the systemic problems around long-term care run much deeper. Retroactive assignments of blame and justice for those harmed are important, but they won’t protect the future waves of seniors on their own.

One of the national publications that I was interviewed in said: Why the nursing home is a design failure, and not just physically in its design, but philosophically.

Why is it a design failure? If we can’t get honest about why we’re here, and what we need to do to impact the next generation that you’re talking about, shame on us — that we are more worried about the litigation and being exempt from it because of the challenges we faced.

It’s tough, it’s uncomfortable, it’s challenging, but I just think if we don’t come together and try to figure out what we’re going to do going forward, we have wasted a pandemic and wasted a crisis, to really bring change.

That will take me to the next thing, and that’s the protests. I do think racism is a part, it is linked to the conversation you and I are having. As I’ve often said, we’ve got to confront our isms — ageism and racism — and how it impacts what we’re doing with regards to nursing homes and how we need to improve what we’re doing.