OLR Research Report

September 26, 2005




By: Helga Niesz, Principal Analyst

You asked for information on nursing home “Green Houses.”


A “Green House” is a new way of providing nursing home level care, developed by Dr. William Thomas, that attempts to “reinvent” the nursing home. Instead of providing care in large institutional, medical-style buildings, the Green House Project provides it in smaller, more home-like residential-looking buildings that serve around eight to 10 people, give each of them a private room and bath, and arrange the rooms around a central family-style kitchen, dining, and living area.

A cluster of Green Houses together form a nursing home. Each house has two nurse's aides on site. They receive extra training, which includes household management. Registered nurses, doctors, and other medical staff serve a number of such homes, visit when needed, and are on call for emergencies. A nursing home administrator has overall responsibility for a number of Green Houses. The emphasis is on more autonomy for both the residents and staff and keeping the atmosphere as home-like and nonmedical as possible. The project makes use of unobtrusive technology to help residents be more independent and help the staff in their work. The first such homes were built in Tupelo, Mississippi and preliminary findings from an ongoing research study compare them favorably to regular nursing homes. Efforts to replicate them in other states are under way.


The Green House is a new concept for providing nursing home care recently developed by Dr. William Thomas, a geriatrician who was also a physician at a New York nursing home. He is also the inventor of the earlier “Eden Alternative” concept, which tried to make standard nursing homes less institutional and more supportive and interesting for residents by providing more choice and introducing animals, plants and children.

The new concept takes this approach several steps further. The name “Green House” comes from the presence of sunlight, green plants, and access to outdoor spaces. It would replace large institutions with smaller homes that will eventually be integrated into residential communities, although initially they are being built mostly on retirement community campuses. The plan is that they should be indistinguishable on the outside from other area homes and serve only about eight to 12 people in a homelike setting. The homes are built with single rooms with a bath for each resident surrounding a central family style dining room and a living area, with easy access that eliminates the need to negotiate long institutional corridors. However, they still have to follow existing state and federal nursing home regulatory requirements.

Two certified nurse's aides (called “Shahbazim” or elder assistants) are on duty at each home most of the day. At the Tupelo site they work in three shifts: 7 AM to 3 PM, 3 PM to 11 PM, and 11 PM to 7 AM (the overnight shift has only one aide). They also have specialized training and are responsible for running the home, including cooking meals and doing household chores. There is less specific division of labor among the staff and more opportunity for input and participation from the residents themselves. The aides are a self-managed work team coached by an administrator (called a “guide”) and advised by a volunteer resident (called a “sage”).

Registered nurses, doctors, and other medical staff serve a number of such homes, visit when needed, and are available on call. There are no nurses' stations and the nurses' aides function more like homemaker-home health aides serving people in a private home. The Green Houses are designed to take advantage of various hi-tech and assistive devices to facilitate the staff's work and make residents as independent as possible.

The pilot in Tupelo, Mississippi will ultimately include 10 such ranch-style cottages, built on the campus of the Traceway retirement community, owned and operated by the nonprofit coprporation, Mississippi Methodist Senior Services. Traceway also contains independent living units, assisted living, and a nursing home, The Cedars Health Care Center. Four of the new cottages, containing 10 residents each, began operating in 2003, followed by two more with 12 residents each in 2004. The remaining four, with 12 residents each, will begin operating by the end of 2005. At that point, Traceway intends to put the current Cedars nursing home building to other uses.

The Green House Project has committed to helping develop more such programs in Alabama, Arizona, Florida, Georgia, Kansas, Michigan, Nebraska, New York, Ohio, and Pennsylvania. One of them will be in an apartment building in Manhattan. In some locations, the Green Houses are being planned as replacements for small nursing homes that have been part of continuing retirement communities. Others function at the level of assisted living facilities rather than actual nursing homes. In fact, advocates recommend that blending the assisted living and nursing home levels in such smaller environments could allow more elders to “age in place,” rather than having to move to a different facility as their health care needs change.


The total cost for building the first four homes in Tupelo was around $3.4 million. Each building cost over $700,000. Mississippi Methodist Senior Services, a nonprofit corporation associated with the Methodist Church, built them on its Traceway campus with funding from private contributions. When the full complement of 10 buildings is completed at the end of 2005, the building costs are expected to total $9.2 million for 112 residents. Green Houses are not necessarily cheaper than regular nursing homes, but they aim at a better quality of life for the residents at the same cost. They also conduct their operations using current Medicaid payments, so people receiving Medicaid are equally as able to live there as residents paying privately. In Tupelo, the Green Houses receive an average of $145 a day for Medicaid recipients (which are the majority) and $155 a day for private pay residents.

The Green House Project has developed a feasibility tool for organizations interested in replicating the concept. Whether it is feasible depends on a number of factors: state regulations, reimbursement, financial goals, and project scope. More details are available at the project's website:


Rosalie A. Kane, a professor in the Institute for Health Services at the University of Minnesota School of Public Health, is leading a research project comparing residents' quality of life in the Tupelo Green House pilot to life in two regular nursing homes. Specifically, the study, which began in 2003 and released preliminary results in 2004, compared responses from residents, family, and staff in the original four Green Houses to responses from a sample of people remaining in The Cedars nursing home from which Green House residents came and with a sample from Trinity Care, a nursing home in another nearby town. The Green House residents reported a better quality of life compared to the two control settings and showed less decline in activities of daily living, less incontinence, less depression, and less use of antipsychotics. Family members of Green House residents were also more satisfied. Staff knew residents better and expressed greater job satisfaction.

More information on the study is available in a slide presentation at: and


Advocates point out a number of advantages of the Green Houses, which:

1. give people an additional, more “deinstitutionalized” choice for how they receive their long-term nursing care;

2. provide care in a more humane way in a smaller, more homelike setting;

3. create a closer sense of community and empowerment among staff and residents;

4. result in lower staff turnover – less than 10% in two years in Tupelo since 2003 compared to between 80 and 90% nationally for traditional nursing homes, according to Kane's study;

5. potentially could help the nursing home industry compete with other less institutional models, such as assisted living;

6. could appeal more to baby boomers than traditional nursing homes;

Disadvantages include:

1. programs that want to replicate the Green Houses may find it challenging to keep the costs down - potentially higher costs could make them less competitive with other models or with assisted living;

2. obstacles to replication of the model include expenses of rebuilding, regulatory hurdles, liability insurance cost, and bureaucratic barriers;

3. while it appears promising, this model is so new that there have been no other objective studies of it besides the Kane study and

4. making Green Houses available nationwide could require a culture change in the nursing home industry itself.


Testimony by Judith Rabe, director of the Green House Project:

April 23, 2005 New York Times Article, “The New Nursing Home, Emphasis on Home”:

National Public Radio, June 22, 2005 article, “Reformers Seeking to Reinvent Nursing Homes” :

A Dallas Morning News article, “Close to Home “Green Houses” are an Alternative to Nursing Facilities,” August 8, 2005

A Newsweek article: “Aging: Small is Beautiful, August 1, 2005: