Home Is Where the Hearth Is: New Models for Nursing Homes Introduction In addition to improving the quality of life and This issue brief describes several nursing home care for residents, providers that have established models that feature significant changes to the these alternative models report an added benefit: traditional physical environment. In these models, It makes good business sense. Those adopting the structural layout and amenities support change reported marked improvements in staff the best in elder care, including maximizing retention, competitive position, occupancy rate, Issue Brief opportunities for socializing, activities, and family and operational costs.2 involvement. They also support more consistent staffing so that residents and caregivers can form Alternatives That Deliver relationships.1 Licensed as skilled nursing facilities, the Green House and small home residences generally While this issue brief highlights the Green House include the following features: model as an example of positive change occurring ◾◾ A series of self-contained residences, similar in nursing home design, providers are also creating to private homes in design, offering each of other types of small homes across the country by the 10 to 12 residents a private bedroom and making both physical and operational changes to bathroom existing facilities. ◾◾ A common space — referred to in the Green House model as the “hearth” — including The History of the Nursing Home a living area, an open kitchen, and a single After its creation in 1964, Medicaid established dining table accommodating both residents a licensing system for nursing facilities and a reimbursement program for residents with and staff for recreation, meetings, and meals limited resources. With an emphasis on ◾◾ Specially trained certified nursing assistants delivering health care efficiently, the look and feel of most facilities mirrored that of hospitals who are empowered to work in self-managed — with nursing stations, double-loaded corridors, teams to provide direct care pre-plated meals served on trays, overhead paging, and medication carts. While that initial ◾◾ A support team of licensed nurses, therapists, focus on health care and efficiency helped bring the medical director, and social services, some structure to an unlicensed and unregulated activities, and dietary specialists working in environment, the trappings of the hospital partnership with the direct care staff structure created dreary models for nursing homes. Unlike most culture change models, the Green While there has been substantial change over the last 50 years in how and where health care House project is implemented all at one time, is delivered, very little has changed about the crafted to support both initial success and long physical environment of the vast majority of term sustainability. nursing homes in this country. A pril 2012 Although the Green House and small home models are Finally, state government agencies oversee licensing for geared to a small structure size, even large nursing homes nursing facilities and contract with CMS to monitor are achieving some of the benefits of more homelike those providing care to Medicare and Medi-Cal recipients. environments by grouping small numbers of residents together in a “household” within the larger facility. Each California’s Procedure for Change household includes a living room, dining room, and a In California, applicants must secure approvals for both kitchen serving a variety of food and meals upon request. major renovations and new construction of nursing facilities from three different agencies: Proponents of the household model share a core set of 1. he Office of Statewide Health Planning and T principles: Development (OSHPD), one of 12 departments ◾◾ Cross-functioning staff working in teams who report within the California Health and Human Services to the household instead of up a departmental chain Agency, is responsible for approving and overseeing of command all aspects of general acute care hospital, psychiatric hospital, skilled nursing home, and intermediate care ◾◾ Resident-directed care, where the rhythm of each facility construction in California. individual’s life is dictated by personal desires 2. he Department of Public Health Licensing and T ◾◾ A sense of community shaped and designed by those Certification Program (L&C) licenses, regulates, living there inspects, and certifies health care facilities in the state. Responsible for ensuring that health care facilities A Look at the Legal Controls comply with state laws and regulations, L&C works in Local, state, and federal laws and regulations dictate the tandem with CMS to confirm that facilities accepting physical environment of a nursing facility. Nursing home Medicare and Medi-Cal payments meet federal culture change innovators report that regulations at each requirements.5 of these levels can hamper the physical changes necessary to create more homelike environments. 3. California’s Office of the State Fire Marshal proposes fire and panic safety requirements for skilled The legal structure of nursing homes begins at the nursing facilities. federal level with regulations enforced by the Centers for Medicare and Medicaid Services (CMS).3 CMS has OSHPD preempts the local building department in created a minimum set of health and safety standards, enforcing building codes and also alerts L&C in writing but states may pass and enforce regulations that are more once it begins working on a project. restrictive. Both agencies enforce provisions of the California Code In addition, CMS requires new and existing nursing of Regulations, but there are disconnects in the code facility structures to comply with the Life Safety Code, provisions. Instituting new nursing home models in some a standard established by the National Fire Protection states has required securing changes to the controlling Association. Important vehicles for creating change at the regulations — and the amendment processes these two state level, waivers are granted by CMS to code provisions enforcement agencies follow are quite different. that would result in “unreasonable hardship” to the facility, as long as the residents’ health and safety would not be adversely affected.4 2  |  California HealthCare Foundation OSHPD is able to alter Title 24, which concentrates on Supply, Demand — and Money Troubles safety and construction, in approximately 18 months The majority of nursing homes in California are 30 to 40 — allowing it to keep current with changes in the field, years old, built according to the traditional institutional as evidenced by the recent code revisions creating a model. Many are in need of some level of renovation, while others are hopelessly outdated. household model for skilled nursing facilities.6 Many plans for renovation and building are hampered by the state’s high construction costs. California’s nursing Title 22 of the L&C Code, which focuses on services, homes also suffer from the current budget shortfalls, staffing, and care, commonly takes more than a decade including: to change. While Title 22 has not been updated in • A recent 10% reduction in Medi-Cal payment rates for years, staff members at L&C have made efforts to both nursing homes understand and embrace culture change and new models, • A significant reduction in funding for home- and including the Green House. The code gives L&C the community-based services likely to increase the option of allowing flexibility, which specifically includes number of Medi-Cal recipients and add to the shortfall of Medi-Cal funding of $3.34 per nursing home “alternate concepts, methods, procedures, techniques, resident per day 9 equipment, personnel qualifications, or the conducting of At the same time, demand for long term care services is pilot projects.” 7 slated to reach unprecedented levels in California in the coming decades as the state’s population ages. As noted, the Office of the State Fire Marshal also proposes fire and panic safety requirements, though it California’s Aging Population, 2000 – 2050 tends to be guided by OSHPD enforcement decisions. PROJECTED* NUMBER OF RESIDENTS, BY AGE GROUP (IN THOUSANDS) Local fire inspectors are also given a great deal of ■ 65 to 74 ■ 75 to 84 ■ 85+ autonomy in their decisionmaking, which can be 2000 challenging for applicants. 2010 Finally, California has an additional regulatory layer not found in other states: The Department of Public Health, 2020 Department of Environmental Health must approve the design and construction of the kitchen. While small home 2030 and Green House kitchens are designed to be residential, they fall under the regulations for retail food facilities.8 2040 2050 0 2,000 4,000 6,000 8,000 10,000 12,000 *Data for 2010 to 2050 are projections. Chart Source: State Population Projections and Population Projections Program. Population Division: State of California, Department of Finance, Race/Ethnic Population with Age and Sex Detail, 2000 – 2050. Sacramento, CA, 2007. Home Is Where the Hearth Is: New Models for Nursing Homes  |  3 Salient Features for Change into the kitchen, and locked cabinets and drawers keep Common physical features in Green House, small home, chemicals and sharp utensils out of reach.11 To meet the and household models present both challenges and evolving interpretation of current codes, Green House opportunities to providers during the regulatory approval homes are built with fire shutters or similar devices to process. Following are examples. fully separate the open plan kitchen from the rest of the home. And all new homes include a commercial hood Kitchens above the stove with full fire suppression systems. In states in which culture change models have been adopted or contemplated, the kitchen has been the The National Fire Protection Association recently primary source of many of the regulatory challenges. approved amendments to regulations allowing kitchens to Most state licensing agencies view kitchens as potential be open to other spaces and the corridor as long as they fire hazards — in addition to raising operational issues adhere to other specific guidelines: of ensuring food safety, controlling infections, and ◾◾ Serve no more than 30 residents protecting residents from harm. ◾◾ Are within a smoke compartment and serve only In contrast to institutional nursing homes, small home residents in that compartment kitchens resemble the kitchens in a residence. Elders who ◾◾ Have fully sprinkled smoke compartments can see and smell food being prepared generally have ◾◾ Contain range hoods with a fire suppression system, better appetites and increased interest in this important grease clean-out capability, and a 500 CFM fan that aspect of living. And some residents are able to help staff vents to the exterior or recirculates prepare food, adding to their quality of life.10 ◾◾ Provide local smoke alarms that need not be tied into Historically, nursing homes have been allowed to have the fire alarm system12 “warming kitchens” with noncommercial appliances that allow for heating of prepared food and limited cooking. Access to Corridors The fire marshal refers to this type of cooking as an The Green House model strives to remove institutional “activity” and refers to the space as an “activity center” corridors. But this structural change can also raise rather than a true kitchen. the issue about bedrooms having direct access to exit corridors, as mandated by CMS regulations.13 The licensing challenges have been directed at facilities in which kitchens are used to prepare daily meals. Such The regulations were based on the traditional style of fully functional kitchens are essential in the Green House nursing home construction requiring passage from one model in particular, since all meals are prepared on-site. room into another to reach the corridor. States have gotten around this concern in existing structures by A number of solutions have been shown to reduce risks in defining a corridor as any passageway having a wall on Green House kitchens — including installing induction one side. cooktops that transfer heat from the element directly to a pot or pan and gas shut-off valves when appliances are In a Green House home, resident rooms open onto an not being used. In addition, safety devices can be placed eight-foot-wide corridor surrounding the hearth area — on stovetops if staff members need to leave the kitchen an open space much larger than what would normally be while food is cooking. Retractable gates prevent entry designed for a residential home. 4  |  California HealthCare Foundation The Hearth Signs of Progress Many states, including California, prohibit fireplaces In most states, nursing home culture change began with that are open to resident rooms in the common areas. providers that were willing to seek waivers or amendments However, the National Fire Protection Association within the state regulatory structure to implement a more recently approved a regulatory amendment allowing gas resident-centered physical environment. or electric fireplaces to be used in smoke compartments that contain sleeping rooms, but not within individual In California, some recent regulatory changes have helped sleeping rooms. Controls must be locked, and a sealed ease the way to establishing Green House, small home, glass front provided to block outside objects from the and household models: flames.14 These modified fireplaces achieve the same effect ◾◾ OSHPD approved regulations aimed at creating as a hearth, a central feature of the Green House model. household models within an existing facility or building new units in that format.15 These regulations Staff Space Needs encompass many of the culture change principles In traditional nursing homes with more than 60 beds, espoused by Green House and other small home regulations often require bathrooms designated as developers. female and male for the public and separate bathrooms for staff. While a unisex bathroom may be allowed by ◾◾ The California Department of Public Health codes depending on staff size, separate facilities for staff Licensing and Certification held educational sessions members are necessary for infection control. for its senior management focused on the Green House model and the implications for operations. State regulations often call for defined office space for ◾◾ The Green House Replication Initiative targeted dietary and administrative staff to be located within the California as a key state for replication. dietary service space. In the Green House model, staff members are housed outside of the home, so no such ◾◾ The California State Senate Select Committee on space is required within the home itself. Aging held hearings to clarify the barriers to creating Green House homes in the state. In traditional nursing homes, the nurses’ station serves as ◾◾ The Care Delivery and Design Improvement the control center, but its physical structure can create a Committee, which provides a forum for clarifying barrier that separates staff from residents. Green House California’s regulations, created a subcommittee to homes and many small home models do not include examine the issues around changing the physical nurses’ stations. Staff members sit at the dining room structure of nursing homes, make recommendations table or in the living room while charting and interact for changes, and provide technical guidance to with residents while monitoring their conditions. providers seeking to make changes. Since there are no federal guidelines for nurses’ stations, ◾◾ An all-day conference, “Changing the Physical these requirements fall under state regulations. While Environment of Nursing Homes: Addressing many states do not require nurses’ stations in nursing State Regulatory Hurdles,” coordinated by Chi homes, some states require a specific desk for caregivers, Partners and funded by the California HealthCare and some require a room designated for file storage and Foundation, brought together providers, regulators, private meetings with family members and residents. and other interested parties to seek collaborative solutions for bringing about change in California. Home Is Where the Hearth Is: New Models for Nursing Homes  |  5 Lessons Learned from Other States Dedicated controls. States that created a small Arkansas, Michigan, and Tennessee have successfully home section within the regulatory structure were implemented Green House and other small home models. well-positioned to encourage the growth of that model. While each state took a different path, much can be Some providers were not comfortable using waivers due learned from their challenges — and especially, their to the uncertainty of their longevity. successes. Motivated providers. States did not create change Common Themes without the encouragement of committed providers. A number of similar factors emerged that were pivotal in Advocacy efforts by industry trade associations, skilled instituting change in these states. nursing facility providers, and state culture change coalitions were also crucial to encouraging states to Advocates for change. The Green House model has embrace change. struggled in states that lacked an advocate and flourished in states with a committed advocate at the director level Small beginnings. In many states, incremental change within the state regulatory structure. Many of these preceded full implementation of models such as Green advocates began their culture change journey with the House. Operational changes originally promulgated by Eden Alternative, a philosophy introduced in the early the Eden Alternative led to more substantial changes that 1990s aiming to deinstitutionalize long term care.16 opened the door to small home models. Seeing became believing. Once providers and regulators Arkansas saw a Green House model in action, talked with staff, ◾◾A committed individual within the Office of Long and interacted with residents, they grew to understand Term Care served as an advocate and facilitator. the process and appreciate the outcome. Regulators and ◾◾ Rather than change existing regulations, the state providers from these three states visited Green House simply added new sections to the regulatory structure homes prior to making any changes. that acknowledged Green House and small home models. Experience with the Eden Alternative. Just as regulatory advocates were committed to the Eden Alternative, ◾◾ There was ample support at the legislative level to providers and regulators who were active in the create statutory change. movement to deinstitutionalize long term care were also ◾◾ Civil Money Penalty (CMP) funds were used to offset early proponents of the Green House model. development costs to create new facilities. Flexible regulations. States with a dynamic regulatory ◾◾ Enhanced Medicaid reimbursement provided process — one that is updated regularly to keep pace incentives for providers to engage in culture change with changes in long term care — were in the strongest and new models such as Green House. positions to adopt small home models and implement elements of resident-centered care. 6  |  California HealthCare Foundation Michigan California Works in Progress The director of the Bureau of Health Systems at the ◾◾ While most providers in California have been hesitant to Michigan Department of Community Health took take on the challenge of implementing these new models, an Eden Alternative training and was also an advocate two nursing home renovation projects are currently of the Green House model. making their way through the state regulatory process: Mount San Antonio Gardens in Pomona and Mercy ◾◾ Michigan was one of the key leaders in the nursing Retirement and Care Center in Oakland. home culture change movement in the 1990s. Mount San Antonio Gardens ◾◾ There is a vibrant Eden Alternative movement in Mount San Antonio Gardens is a continuing care the state. Grants were available to providers pursuing retirement community owned and operated by quality of care and culture change through the Eden Congregational Homes Inc., a nonprofit corporation.17 Alternative. The Gardens, located on a 30-acre campus spanning the ◾◾ A number of providers embraced the small home border of Pomona and Claremont, has been operating movement and were willing to make the transition. since 1961 and currently has more than 470 residents in independent living, assisted living, memory care, and ◾◾ Implementing a Green House model did not require skilled nursing. statutory changes, only regulatory changes. ◾◾ There was some level of involvement by the The Gardens began working on a group of Green Houses legislature in encouraging the model’s adoption. in 2009. While the Green Houses were intended to fit into a residential neighborhood, there were significant Tennessee challenges for the Gardens and its residential architect. ◾◾Though not the driving force for change, there was OSHPD viewed this as a new model of care without an advocate within the state long term care hierarchy. corresponding code language, and the complicated project site spanned two local fire jurisdictions. Additionally, ◾◾ The state was very involved in the Eden Alternative, the project presented a new open kitchen concept, and forging strong partnerships within the industry there were significant communication difficulties between associations. CMP funds had been used for nursing OSHPD and the sponsor. homes that sought education about the Eden Alternative. One major issue was the distance of more than 780 ◾◾ Waivers from the Board for Licensing Health Care feet between the proposed Green House homes and the Facilities were relatively easy to obtain, and board existing nursing facility, raising a question of whether the members were amenable to change. new Green House homes would fall under the existing nursing home license. If a separate license was required, ◾◾ An early Green House review of the state building then the project would not be viable. Having a separate standards revealed only minor challenges around the license with only 20 units (two houses) would not be kitchen and a few other areas. possible given the staffing requirements for nursing ◾◾ Implementing the Green House model required only facilities. Title 22 states that facilities acting under one regulatory changes, not statutory changes. license must be on the same grounds. While the Gardens would be on the same campus, that campus is divided in two by the city limits of Claremont and Pomona; the Green House homes would be in one city, while the Home Is Where the Hearth Is: New Models for Nursing Homes  |  7 traditional facility would be in the other. L&C granted a As the final kitchen drawings have not yet been approved, waiver for this issue tailored to these circumstances. it is anticipated that there will be issues raised about the open kitchen. Code does not allow and OSHPD will not While small homes and Green House homes are designed approve any type of heat-producing hearth, so the hearth to be residential, their kitchens are classified under the will be an artificial fireplace. regulations as “retail food facilities.” Health department codes require a “full partition separating the kitchen Mercy Retirement and Care Center from living and sleeping areas with no doors or openings The Mercy Retirement and Care Center, established in (windows).” In this scenario, food must be carried 1872 by the Sisters of Mercy in Oakland, offers assisted outside the building and then back into the dining area living, memory care, and skilled nursing.18 The Center to be served. This rule was intended to stem the flood includes 59 skilled nursing beds, two dining rooms, and of homes in Los Angeles that were being converted into a therapy room. Since 1997, Mercy has been a part of small eateries, but has no real relevance to skilled nursing the Elder Care Alliance (ECA), a regional organization facilities. Environmental Health granted a waiver to operating two skilled nursing and four assisted living resolve this issue. facilities. Some challenges have required an application for an In contrast to the Gardens, which is building only two alternative method of compliance, including: houses, Mercy hopes to completely replace their existing skilled nursing facility with six Green House homes built ◾◾ Reducing the size of the clean and soiled utility, in a high-rise style in keeping with the neighborhood. which serves only 10 residents ◾◾ Arranging for the dietician to share a desk area in the Mercy has taken a very conservative approach to its nurses’ station rather than the kitchen due to space relationships with both OSHPD and L&C. It hired an constraints architect experienced in working with health care facilities and brought together all regulatory participants for an ◾◾ One unisex staff locker and general dressing room for early review of the project. both dietetic staff and general employees ◾◾ Administrative and staff work areas in the main This project may not be challenged in the kitchen area skilled nursing facility rather than in the Green as it will have a full commercial kitchen dietary service House home in the building in addition to the kitchens in each of the Green House homes. ◾◾ Wheelchair storage limited to two wheelchairs ◾◾ Changing the linen storage and laundry services so that soiled linens are kept in each resident’s bathroom, and clean linens in each resident’s room 8  |  California HealthCare Foundation Conclusion About the F o u n d at i o n Homelike alternatives to traditional nursing facilities The California HealthCare Foundation works as a catalyst to — Green House, small home, and household models — fulfill the promise of better health care for all Californians. have been shown to improve residents’ quality of care We support ideas and innovations that improve quality, increase efficiency, and lower the costs of care. For more and satisfaction, and offer the added boon of reducing information, visit us online at www.chcf.org. providers’ operational costs. A b o u t C h i P a rt n e r s Recent regulatory changes, including a comprehensive Chi Partners is a health care consulting firm focused on new code section on household models as well as focused innovation in long term care and service-enriched housing attention from local legislators, have created a more for seniors. It works with state units of government and the accepting environment in California for these alternative private sector on public policy, market research, and strategic nursing home models. But many state providers are still and business planning. Visit them at www.chipartners.net. leery about forging ahead with changes in these relatively untested waters. Author David Nolan, principal, Chi Partners The experiences of early adopters in other states — particularly Arkansas, Michigan, and Tennessee — offer A c k n ow l e d g m e n t s blueprints for overcoming roadblocks and regulatory The author would like to thank the following individuals for challenges to alternative models. Ready advocates within their assistance in writing this document: the system, especially those familiar with the Eden Carmen Bowman, author of The Environmental Side of the Alternative, which sets out culture change specifics, are Culture Change Movement: Identifying Barriers and Potential key to motivating providers to embrace the changes. Solutions to Furthering Innovation in Nursing Homes, provided context and significant background for this issue brief. California nursing facilities can also learn from two Carol Shockley, director of the Arkansas Office of Long Term state pioneers: Mount San Antonio Gardens, which Care, and Walter Wheeler, former director of the Bureau is constructing a Green House model, and Mercy of Health Systems, Michigan Department of Community Retirement and Care Center, which is planning Health, provided background on their states’ work with small construction. homes and presented their “lessons learned” to providers in California. The hope is that these alternative models will encourage Dan Kotyk, chief of the Licensing and Certification Division the spread of culture change within the nursing home of the California Department of Public Health, and Glenn community, enhance the physical environment of nursing Gall, regional supervisor, Office of Statewide Health Planning homes, and facilitate improved qualities of life and care and Development, provided assistance in understanding the for residents. complexities of California’s regulatory system. Barbara Kate Repa, editor, was instrumental in the writing of this issue brief. Home Is Where the Hearth Is: New Models for Nursing Homes  |  9 Endnotes 1.Rosalie A. Kane, Terry Y. Lum, and Lois J. Cutler, 1 5.Code of Federal Regulations, Title 24, Part 2, Volume 1, “Resident Outcomes in Small Nursing Homes: A 1225.5.2 Household Model. Longitudinal Evaluation of the Initial Green House 1 6. William H. Thomas, The Eden Alternative: Nature, Program,” Journal of the American Geriatrics Society 55, Hope and Nursing Homes (Columbia, MO: University of no. 6 (June 2007):83239 and Terry Y. Lum, Rosalie A. Missouri Press, 1994). Kane, Lois J. Cutler, and Tzy-Chyi Yu, “Effects of Green House Nursing Homes on Residents’ Families,” Health 1 7.Mount San Antonio Gardens is described and rated at Care Financing Review 30, no. 2 (Winter 2008): 35–51. www.calqualitycare.org. 2.Michelle M. Doty, Mary Jane Koren, and Elizabeth Sturla, 1 8.Mercy Retirement and Care Center is described and rated “Culture Change in Nursing Homes: How Far Have We at www.calqualitycare.org. Come? Findings from the Commonwealth Fund 2007 National Survey of Nursing Homes” (The Commonwealth Fund, May 2008). 3.Code of Federal Regulations, Title 42, Part 483, Subpart B. 4.Code of Federal Regulations, Title 42, Part 483.70(a)(2). 5.Code of Federal Regulations, Title 42, Part 483.1– 483.75. 6.Code of Federal Regulations, Title 24, Part 2, Volume 1, 1225.5.2 Household Model. 7.California Health & Safety Code §1750. 8.California Health & Safety Code §113789 defines a retail food facility as: “a place where food is stored, prepared, packaged, transported, salvaged or otherwise handled for dispensing.” 9.A Report on Shortfalls in Medicaid Funding for Nursing Home Care (BDO Seidman LLP and Eljay LLC, 2007). 1 0.Pioneer Network, National Long Term Care Safety Task Force: www.pioneernetwork.net. 1 1. The Green House Project Guide Book (Arlington, VA: NCB Capital Impact, 2007). 1 2.National Fire Protection Association, Life Safety Code (2012). 1 3.Code of Federal Regulations, Title 42, Part 483.70(d)(1) (iv). 1 4.National Fire Protection Association, Life Safety Code (2012). 10  |  California HealthCare Foundation