In hospitals, good care is paramount. But in nursing homes, offering good care is only half the picture; equally important is providing a good place to live. Despite passage of the Nursing Home Reform Act in 1987, which underscored the importance of quality of life and the preservation of residents' rights, there are still serious concerns about quality at the nation's 16,000 nursing homes. Staff shortages and high turnover rates exacerbate quality problems.

A grassroots movement proposes a radical departure from the traditional nursing home model—in effect a total "culture change"—that aims to improve the lives the frail older adults who live in such facilities. Proponents of culture change believe long-term care residents can and should direct their own lives. They recommend replacing institutional units with households of small groups of residents and staff.

Resident-centered care requires a fundamental shift from thinking of nursing homes as institutions where frail elders must live, to conceiving them as residences that also provide health services. A growing body of evidence is revealing that nursing homes that have undergone culture change—such as those following the Wellspring, Eden Alternative, or Green House models—are not only better for the people who live and work there, but they are also economically viable alternatives to more traditional facilities.⁽¹⁾, ⁽²⁾

With Fund support, Rosalie Kane, Ph.D., of the University of Minnesota evaluated the first operational Green House nursing home in Tupelo, Miss., where the residents are mainly Medicaid beneficiaries. The evaluation offered conclusive evidence that small group homes (for six to 10 residents) operated according to the principles of home care, rather than the acute care practices that have shaped the industry, can have positive outcomes for both residents and staff. In a Green House, each elder enjoys a private room or unit, which they decorate with their own belongings. There is easy access to all areas of the house, and residents are free from the limitations of an institutional schedule—sleeping, eating, and engaging in activities as they choose.

Compared with residents of traditional nursing homes, those living in Green Houses reported a significantly better quality of life. Moreover, rates of turnover among nursing assistants have dropped to nearly zero—a tribute to the team-based approach to decision-making, which empowers frontline staff in Green Houses to manage their responsibilities as they see best. These homes' performance on federal inspections has also been outstanding.