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The Small House Model of Long-Term Care: Association With Older Adult Functioning

Published:November 28, 2018DOI:https://doi.org/10.1016/j.jamda.2018.10.003
      Culture change (CC) initiatives, focused on improving life quality for older adults and supporting empowerment for direct care staff, have become increasingly normative in long-term care, and include key components of providing a home environment: individualized, person directed care; consistent staffing; and meaningful relationships.
      • Saliba D.
      • Schnelle J.F.
      Indicators of the quality of nursing home residential care.
      Although some nursing homes undertake individual CC components, there are comprehensive models that can be adopted. For example, the small house (SH) model in a skilled nursing home is a small intentional community of older adults who need nursing care and help with daily activities.
      • Rabig J.
      Small house nursing homes. Some are trademarked as green houses.
      SHs with staff trained in person directed care have been created in nursing homes and assisted living. SH implementation can be loosely or tightly defined, with key design features including short walking distances, open kitchens, family-style meals, and private bedrooms.
      • Rabig J.
      Small house nursing homes. Some are trademarked as green houses.
      One example of a SH is the trademarked Green House (GH) model.
      • Thomas W.H.
      What are old people for? How elders will save the world.
      The Green House Project
      Core values and practices.
      Most existing research on SH has focused on the GH model, including 1 study that showed less decline in late loss activities of daily living functions (eg, bed mobility) in GH homes compared with traditional homes.
      • Kane R.A.
      • Lum T.Y.
      • Cutler L.J.
      • et al.
      Resident outcomes in small house nursing homes: A longitudinal evaluation of the initial greenhouse program.
      A large, longitudinal study of the GH model has produced further evidence of positive outcomes.
      • Fishman N.W.
      • Lowe J.I.
      • Ryan S.F.
      Promoting an alternative to traditional nursing home care: Evaluating the Green House small home model. An introduction from the funders and the Green House project.
      Consistent elements of GH homes included open kitchens and self-managed work teams with universal workers (direct care staff with additional duties of light housekeeping, cooking).
      • Cohen L.W.
      • Zimmerman S.
      • Reed D.
      • et al.
      for THRIVE Research Collaborative.
      Findings also showed that GH older adults had better scores on 3 care quality measures (bedfast, catheter use, pressure ulcers) compared with traditional homes.
      • Afendulis C.C.
      • Caudry D.J.
      O’Malley et al for THRIVE Research Collaborative
      Green House adoption and nursing home quality.
      Living in a GH may also improve older adult functioning and performance on a wider variety of daily tasks including dressing, walking, and getting around the home. Consistent, empowered, direct care staff, who spend more time with older adults and know them well, may have greater ability to support their functional abilities and interests. Within a home environment, older adults and staff may be more comfortable striving for and supporting a higher level of independence than within a traditional nursing home. The current study extends prior work with a SH model that uses GH values and training with a liberalized physical design (13 older adults per community, some shared rooms) reflective of capital costs and the realities of access to land in the New York area. We examined the association of this SH model on change in more varied areas of function and level of care needed over time. We conducted a retrospective comparison between 50 older adults living in SH communities and 50 older adults in traditional (legacy) communities over a 6-month period in the same nursing home, matched on acuity (care intensity), cognitive status,
      • Thomas K.S.
      • Dosa D.
      • Wysocki A.
      • Mor V.
      The Minimum data Set 3.0 cognitive function scale.
      and sex. Minimum Data Set 3.0 data from the electronic medical record was used at 2 time points (admission to SH; 6 months later) to match participants, compare change in function (acuity, overall functional ability, ability to perform individual functional tasks) between the 2 groups, and examine clinical outcomes over time within each group (pressure ulcers, incontinence, bedfast status, hospitalization, depression, behavioral agitation, rejection of care). The 2 groups did not differ in educational status, but they differed by race/ethnicity with more white older adults in the SH (94%) than the legacy group (75%). Results (Table 1) showed that acuity at 6 months was significantly associated with group status. SH vs legacy older adults had a higher proportion with low acuity and a smaller proportion with medium acuity at 6 months. Comparing change in overall functional ability, results showed a trend for a greater proportion of SH vs legacy older adults to experience improved functional status. In terms of individual functional tasks, a higher proportion of SH compared with legacy older adults had improved mobility within their community. Results showed no significant differences over time for any clinical outcomes in either group. Findings provide some evidence that a SH model can improve aspects of functioning over time compared with a traditional, legacy setting. We posit that study findings in the domain of function may be due to the support of SH older adults to move around freely within their environment, the latter having no long corridors to navigate, with close proximity of bedrooms, living, and dining areas. We did not replicate prior findings showing better clinical outcomes for the SH compared with the legacy model,
      • Kane R.A.
      • Lum T.Y.
      • Cutler L.J.
      • et al.
      Resident outcomes in small house nursing homes: A longitudinal evaluation of the initial greenhouse program.
      • Afendulis C.C.
      • Caudry D.J.
      O’Malley et al for THRIVE Research Collaborative
      Green House adoption and nursing home quality.
      yet few older adults in our study experienced these issues (eg, rejection of care, pressure ulcers) at either time point, a potential floor effect. Generalizability of study findings is limited due to lack of diversity of race/ethnicity of participants. Future research may benefit by broadening the focus of this work to examine how additional aspects of staff/older adult relationships impact life quality.
      Table 1χ2 Analyses for Functioning Outcome Variables
      Functioning Outcome Variables Small House n = 50 Legacy n = 50 χ2 df
      n (%) n (%)
      Acuity (care intensity) at 6 mo 6.25
      P < .05.
      2
       High acuity 4 (8) 8 (16)
       Medium acuity 8 (16) 16 (32)
       Low acuity 38 (76) 26 (52)
      Change in ADL status 5.50
      P < .10.
      2
       Improved 9 (18) 2 (4)
       Same 35 (70) 41 (82)
       Worse 6 (12) 7 (14)
      Change in locomotion on unit 6.55
      P < .05.
      2
       Improved 11 (22) 3 (6)
       Same 31 (63) 42 (84)
       Worse 7 (14) 5 (10)
      P < .05.
      P < .10.
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