January 10, 2016

How Great is Green?

Nearly twenty years ago, the Pioneer Network launched what came to be called the nursing home culture change movement. The idea was terrific: convert nursing homes from medical institutions that revolved around the needs of the nursing staff to real homes that put the resident at the center of everything. The aim was to allow the frailest of the frail to find satisfaction and meaning in their lives. The core ways of achieving this were supposed to be creating a homelike environment, insisting that care be driven by residents' preferences, and empowering the staff to figure out how to organize their time. The results of this experiment have unfortunately been very mixed. When researchers tried to quantify the effect of whatever cultural changes nursing homes made on resident outcomes—and many nursing homes instituted changes in some but not all three domains—the results were modest at best. In response to the less than impressive results of efforts to institute culture change, a new revised approach, the Green House model, was introduced. Preliminary results of this effort to improve nursing home care are now in and they are, well, only slightly encouraging.

The Green House perspective starts with the assumption that small is good. Except for unusual situations such as college students living in dormitories and families living in refugee camps, most people don’t live with dozens, let alone hundreds, of other people. Similarly, the argument goes, nursing homes should be residences for 8-12 people. They should be run by a team, usually including a certified nursing assistant and a nurse among others, who organize their schedules with input from the home’s residents. Since families don’t usually rigidly divide childcare tasks (though there is often at least some division of labor), but instead everyone does a little of everything, Green House employees are also “universal workers,” who share the cooking, the cleaning, the personal care, and the nursing responsibilities. The effectiveness of the model is being investigated by a group of investigators calling themselves THRIVE (The Research Initiative Valuing Eldercare)  and the January, 2016 issue of Health Services Research reports on the results so far. 

THRIVE studied data from 28 homes and compared them to 15 conventional homes. The first finding is that, much as with the efforts to implement the Pioneer model, virtually all the homes adopting the Green House philosophy conformed to the model structurally, that is they were all small units for 8-12 people, but they differed in the practices they used to support resident choice and resident involvement in decision-making. 

Green Houses are notable for a statistically significant reduction in the rate of hospital readmission (31% lower than the comparison group) and a similar decrease in avoidable hospitalizations (30%). The absolute reduction, however, rather than the relative reduction, was quite modest. Moreover, the difference may just mean that the staff in Green Houses made more of an effort to speak to residents and their families about their wishes, which is a good development but does not mean that the care itself was any different. 

Spending on hospice care was lower than in other nursing homes—which could be seen as good if it indicates that the Green House provided everything that hospice normally offers (so enrolling in Medicare hospice in addition was superfluous) or bad if it means that Green House residents are deprived of useful and important hospice services. In a small number of areas, Green House residents did better in their activities of daily living than those in conventional nursing homes. But nurses in Green House models were less satisfied with their work than those in other facilities, presumably because they were unsure what exactly they were supposed to be doing and felt ill-prepared for their work. In all the other domains the researchers examined, Green Houses performed just like other facilities. On balance, the Green House can be seen as probably no worse than other arrangements and maybe marginally better.

What is going on here? Why haven’t the conceptual breakthroughs embodied by Pioneer and now Green House resulted in unambiguously better nursing homes? I think the answer is that most nursing home residents have dementia: in a recent government survey, 26% of nursing home residents had moderate dementia and 39% had severe dementia. These numbers may well be an under-estimate, given the tendency of clinicians to under-diagnose the disorder. Efforts to involve people with dementia in decision-making, to elicit and respect their preferences, and to give them meaningful activities are destined to fail because people with moderate to severe dementia can rarely do any of these things. The Green House, like Pioneer before it, is a great model for the physically frail older person whose mind is intact, but it’s not the answer for people with dementia. 

My view is that the best we can do for people with dementia is to treat them with dignity. That's a loaded and controversial concept in ethics circles, where some philosophers regard "dignity" as a fuzzy, meaningless term and others see it as a code word for "sanctity of life." I think dignity is something else. It has to do with respect and caring and with honoring what a person once was. The way to create better nursing homes for the majority of people who live in them, individuals with profound and worsening cognitive impairment, is to begin by defining just what dignity entails. Only then will we understand how to build the best possible institutions for care of those with dementia.

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