Creating the nursing home of the future: interview with Michael Follett, administrator, St. John's Lutheran Home, Billings, Montana.

What if the traditional "nursing home"--that (average) 120-bed structure designed to look like a mini-hospital--disappeared from the national landscape? What if people gave up on trying to make such structures "homelike" and decided to walk away from the institutional model altogether? What would come next?

How about residents living in cottages--say about 12 per cottage, with common dining and living areas, each with a dedicated, specially trained staff? Although it sounds like the famous Green House model conceptualized by long-term care pioneer Bill Thomas, MD, a set of small structures in Billings, Montana, has grown independently from the Green House movement and is on a fast track to replace a 120-bed nursing home by next year.

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These are the cottages of St. John's Lutheran Home, two of which opened about a year ago on this 40-plus-year-old multilevel campus, with another five scheduled for construction starting this summer. The initial cottages--named Langemo and Moorberg after former St. John's board chairpersons--are designed to accommodate persons with mild-to-moderate Alzheimer's disease. The next ones are aimed at broadening the resident populations served in these intimate settings to encompass all 120 of the existing nursing home's residents, skilled and otherwise. The cottages, costing $2.9 million for the two, are approximately 8,000 square feet each, with all-private rooms with baths, large open kitchen/dining area, living room with fireplace, den, and outdoor patio. Monthly rates are $3,780 for a private room and $4,110 for a deluxe. All together, 23 of the nursing home's staff have received 257 hours of training to function in this setting. Needless to say, adapting to this has involved extreme staffing and logistic challenges for St. John's management. Recently, Administrator Michael Follett, who is the spearhead bringing this to fruition, discussed the whys and hows in a recent interview with Nursing Homes/Long Term Care Management Editor-in-Chief Richard L. Peck.

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Peck: Why are you replacing your nursing home with cottages?

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Follett: I think it's because we've found that the nursing home care model is fundamentally broken. Virtually no one in the country would choose to live in a nursing home; in fact, people usually feel that they're "sentenced" to this by their physical condition and their kids. One way the traditional model is broken is in the way we staff these institutions--they're so departmentalized, with the wrong idea that "bigger is better" when it comes to efficiency. We have department upon department in our organizations: nursing, nutrition, laundry, housekeeping, maintenance, and more. No one's actual home is like this and, as it turns out, the "bigger is better" approach doesn't work the way it's supposed to.

Peck: But how did you come up with the cottage idea as an alternative?

Follett: First, a little bit of history. St. John's Lutheran started in 1963 as the first HUD-financed retirement home in Montana, and that was followed four years later with construction of the nursing home. We added on to that structure in the mid-1970s, as mental hospitals in the area started emptying out their geriatric populations. By the 1990s it had been obvious for years that we had an aging plant and that, no matter how much carpeting and paint we applied to it, it was still pretty much semiprivate rooms and less than nurturing bathing facilities. We began looking at alternatives in the 1990s, such as "pod" design, but it was still institutional. Then, in the fall of 2002, I received a phone call.

My grandmother, the matriarch of the family, had suffered a stroke. She had made us promise never to put her in a nursing home, but life doesn't work that way, and we placed her in an institution. However, in spring 2003 my parents invited me to see her new accommodations in an assisted living facility in Washington State. It was located at the end of a cherry orchard, and it was a Thomas Kinkade-looking cottage with private rooms for the residents. I videotaped this and showed it to our management, and everyone was quite interested. Then, in early 2004, I heard about the Green House conference in Tupelo, and found the Thomas Kinkade cottage all over again. The people managing that faith-based organization are in many ways similar to us and were happy to share their insights. I later took three architects and a construction manager to see it and live it firsthand.

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By this time we knew we had a shortfall in our organization. Although we take pride in our continuum, which encompasses skilled nursing, assisted living, independent housing, and adult day care, we were lacking in accommodations for people with moderate Alzheimer's who weren't in need of skilled care. We were losing them to other assisted living organizations in the area. We decided to fill this niche by building two prototype assisted living cottages designed to skilled nursing standards. We opened them last August; they're full, and they're meeting and exceeding our dreams and expectations.

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Peck: You have 23 dedicated staff for these cottages, and you've provided them with 257 hours of training each. And you call them Elder Sharaths, which sounds a good deal like the Green Houses' "Shabazzim." Would you elaborate?

Follett: [laughs] We wonder if maybe they got it from us! We started this concept about seven years ago when, in an attempt to get high school and college students connected with what we do, we began the "Elder Chabar" program. "Chabar" is Hebrew for fellowship. The word "Sharath" is Hebrew for "serving, attending to, or ministering unto" someone. Our youthful Elder Chabars made $5.50 an hour, plus $1 an hour for every hour worked that went toward a scholarship for them, and worked a 3:30 p.m. to 7:30 p.m. shift. Several of these kids came back as CNAs in the summers and one of them now works here as a nurse. In preparing for the new cottages, we provided 169 hours of special training as universal workers, plus another 88 hours if they weren't a CNA already.

Peck: What sort of training did you provide, and how did you organize it?

Follett: We train them as universal workers. (Elder Sharaths) in various areas, such as medication administration, CPR and first aid, self-managed team care, conflict resolution, and culinary skills. Five other senior managers and I--they called us the Six-Pack--sat through every hour of their training. Now I know that we have to figure out how to do this in fewer hours for more people, and we're working on that. The logistics of doing this are close to overwhelming, what with sequencing staff into the cottages and bringing in temps to cover for them during training periods. It's a pretty significant cost altogether, but we feel it's worth it in terms of staff recruitment and retention.

Peck: Why do you say that?

Follett: Because 95% of the decision making flows down to frontline staff; they respond to that with enthusiasm, and they hold each other accountable. Just recently, we had our first call-in in months, and staff confronted that person to the point that a doctor's note was brought in confirming strep throat. Staff is taking ownership of its roles and responsibilities.

Peck: What implications do you see in this arrangement for your role as administrator?

Follett: I would expect that ten years from now, my position won't even be needed. I see the Elder Sharaths "making plays," sort of like the University of Texas football team that won the national championship in January, with the administrator acting as coach.

Peck: What impact do you see this having on overall staffing?

Follett: I think we will require fewer total staff. Take, for example, our nutrition services department, which today has 65.14 FTEs serving 1,300 meals a day. In the cottages, the Sharaths are the ones preparing the meals, with our nutrition department serving as a kind of Costco wholesaler--for example, a 25-pound roast comes in and nutrition services divides it up and distributes it among the Sharaths for cooking. In essence, this operational structure will cut our FTEs in half.

Is this a bad message to pass on to existing staff? It could be seen that way. But you have to make it clear from the start that we will always have a need for staff whose hearts and efforts are in the right place in this sort of care. But peoples' jobs are going to change, including my own. Some don't want to hear that, and some can't handle it. We recently had a 24-year nurse resign, saying that while she understood and admired the concept, she just couldn't live it. She had been in an institutional situation her whole career and didn't want to deal with change like this.

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Peck: As an administrator, how do you deal with this rather unsettling situation?

Follett: Right now I feel that I'm living in two cultures. The cottages are functioning pretty independently, but other parts of our organization are institutionally entrenched. It takes every ounce of energy to cope with these two cultures, and there are times when it feels like the tension never ends. But, in fact, these two worlds are colliding across the United States. I think that, in the end, the institutional world will explode as the other world overcomes it. But it's an inevitability: The model has got to change.

For further information, call [phone] or visit www.sjlm.org. To send your comments to the editors, e-mail [e-mail].

RELATED ARTICLE: Cohousing: The next senior housing option

Interview with Zev Paiss, Cofounder, Elder Cohousing Network

Imagine a group of seniors getting together, deciding they want to start a little community of their own, raising the money, working with professionals to develop the structures and plan, and then running it as a consensus group. "Far out!" comes the distant cry of 1960s commune dwellers. But this isn't "out there" at all. It builds on a Denmark-inspired, 30-year-old community-planning model called "cohousing"--developed typically for intergenerational populations--and the past two years have seen a new focus on the over-55 side of the age continuum. At least three senior cohousing communities are in various stages of development in Davis, California; Abingdon, Virginia, and Boulder, Colorado, and more are on the drawing boards. They comprise some of the most active--and activist--older citizens in our midst, and they're offering yet another independent housing option that long-term care providers might do well to study and learn how to live with. Recently, Zev Paiss, cofounder of the nationwide Elder Cohousing Network, described the concept, its implementation, and its implications for long-term care in an interview with Nursing Homes/Long Term Care Management Editor-in-Chief Richard L. Peck.

Peck: Is this what we children of the 1960s used to call a "commune movement"?

Paiss: No, it's really more in the nature of a group of seniors coming together; coalescing into the idea of developing a small neighborhood of people who like living and doing things together; financing it conventionally with bank loans, usually as a limited liability partnership; and working with professionals to develop the housing and amenities. There's really a balance between privacy and community-mindedness. It's similar to a town house or condominium development run by a homeowners association, but with residents doing more things together.

Peck: Just how involved are residents in actually planning and developing the property?

Paiss: The future residents provide input every step of the way--site plan, floor plans, ongoing focus groups for prospective residents, and so on. They meet on a regular basis to learn the skills of running an association via consensus.

Peck: How would communities like these be operated day to day? Is there someone--an executive director, say--who is "more equal" than others?

Paiss: They have typical boards of directors and officers. My community has 11 households, all of which are represented on the board, including four officers. We meet monthly, with a much higher level of participation than in the typical multihundred homeowners association. Daily problems or situations that arise become the responsibility of individual committees to deal with. But this is not a "faceless" form of government; most of the people have known each other for years before going into this, and it's pretty easy to get people together to address issues, do budgets and the like, and develop consensus.

Peck: What would be the "typical" population of a community like this?

Paiss: They range in age from 55 to 75; are usually well-educated, with lots of professionals both retired and working; and are definitely socially and politically involved. Specifically, they tend to be entrepreneurs, people in the helping professions, civic activists, writers, and artists. They're of the population group that has recently been called the "Cultural Creatives" (and there's even a Web site called www.culturalcreatives.org). It's been estimated that this group consists of some 50 million "self-starters" who are interested in alternative approaches to life. There is also a growing interest among religious communities in this approach.

Peck: What implications might this movement have for long-term care providers?

Paiss: That is a key question. In fact, many actively involved in developing senior cohousing are discussing this issue right now. This all began with the assumption that residents would start off generally fit and active, but there's realization that this won't always be the case. More and more, these places are being designed for aging in place, with universal design elements and an emphasis on home care. But Alzheimer's disease is another matter, and more thought is being given to how to handle this. The basic model, though, is bringing as much supportive service and care to the resident as possible, along with providing space in common houses for treatment and rehabilitation and on-site professional caregivers. One interesting model that many readers will no doubt be familiar with is the PACE (Programs of All-inclusive Care for the Elderly) model, which many are studying. It's conceivable that cohousing could someday replace today's models for CCRC-based independent living and assisted living, with separate provisions for skilled care added. This movement, though, is just springing out of the ground and has a long way to go.

For further information, contact the Elder Cohousing Network at [e-mail] or visit www.eldercohousing.org.