Welcome to the Green House.

First it was the Eden Alternative--now long-term care visionary Dr. William Thomas has come up with a new idea for nursing homes

In its eight years, the Eden Alternative has become arguably the most famous of the "alternative" methods of organizing care and staff management in the nation's nursing homes. However, frustrated by the movement's slow pace at changing the field from within, its visionary leader now pledges to move long-term care from its current institutional bias to something very different.

"We have 16,000 nursing homes. We [the Eden Alternative] are in a few hundred," Dr. William Thomas, president and founder of the Eden Alternative, told a Senate Special Committee on Aging briefing in September. "Man, there's a long way to go.

"The time has come to reinvent the long-term care environment for the 21st century. We must abolish the widespread practice of institutionalizing frail, chronically ill and elderly people. It's a system we've evolved through a thousand choices over decades of experience [but] what comes next?"

The answer for Dr. Thomas and other panelists at the briefing is the Green House.

Here is how the Green House concept has evolved so far. The Faxton-St. Luke's Healthcare System of Utica, New York, chose to close an existing skilled nursing facility and not replace it with another bricks-and-mortar building. Instead, the current residents of the Allen-Calder Home in Utica will move into the first four of seven planned Green Houses starting in the spring of 2001, pending certificate-of-need (CON) approvals and the completion of financing arrangements.

These first Green Houses will be small community homes for six to eight residents, purposely located within a 15-minute radius of the healthcare system's central campus. The 3,500- to 4,000-square-foot homes will be built from scratch, be designed to integrate into the surrounding community, and contain four or five private and semiprivate (for couples) bedrooms.

"The cost of constructing these Green Houses is actually less than constructing a brick-and-mortar standard institution," Dr. Thomas said, estimating the savings to be 25%.

According to Dr. Thomas, the Green Houses are founded on the idea that the physical and social environments in which long-term care is delivered should be "warm, smart and green," a concept that derives itself from the Eden Alternative method of empowering staff by making the resident the center of the community and enlivening the nursing home environment with plants, animals and children.

In the Green Houses, warmth will be created through innovative floor plans, furnishings and decor, and intensive use of a small number of caregivers. The plan is to allow the development of more intimate relationships between residents and caregivers through providing a minimum of 36 hours of staffing, or six hours per resident, per day.

In terms of "smart," each of the houses will make extensive use of technology. For example, there will be Web cams inside the homes serving two purposes: First, to allow physicians and family members to observe care or to visit anytime via the Internet. Second, each of the houses will be connected through telecommunications and the Internet to Faxton-St. Luke's information system, which is relatively large and sophisticated.

By "green," Dr. Thomas means "green all the way through," whether in natural construction materials or in "bringing living things into the lives of the people who are living and working there.

"The ultimate idea," said Dr. Thomas, "is to create a place that is full of hope and life and vitality."

Bruce Gendron, vice-president for continuing care at Faxton-St. Luke's Healthcare, said that the project has already received endorsement from the New York State Department of Health, and the facility does not expect problems with CON or other approvals. The project hopes to break ground in the spring of 2001. The funding of resident services at the Green Houses will come from traditional sources (Medicare, Medicaid and private pay) but, unlike many nursing homes and assisted living facilities, the Green Houses will be targeted at meeting the needs of Medicaid-eligible residents from the beginning.

"Eighty percent of the people in our first project will be on Medicaid," explained Dr. Thomas. "We're not asking for a single dollar more [from New York State] to do this."

In its discussions with the state Department of Health, Faxton-St. Luke's has asked for $150 a day-no more in reimbursement than it currently receives for the Medicaid residents it already serves. Although, said Gendron, "anyone can do better for twice the money, we wanted to say to the state that we can do it better for the same amount."

Gendron noted that only ventilator-dependent residents will not be admitted to the Green Houses in the initial phase; all other nursing-home-eligible residents will be accepted. Dr. Thomas added that the Green Houses would adhere to current regulatory requirements, seeking waivers only for those rules that might conflict with the goals of the project.

Another innovation of the Green House is to do away with staff departmentalization by creating a transdisciplinary, or universal, worker. The aim is to staff the houses with people who do not simply provide nursing home care, housekeeping, nutritional services and other services in a specialized manner, but who provide all those services on a holistic basis. "It will take special people in the first phase to do all that," said Gendron, "but at the same time, we think it will be much more rewarding for staff, reduce turnover and enhance work experience.

Robyn Stone, executive director of the Institute for the Future of Aging Services (affiliated with the American Association of Homes and Services for the Aging), told the briefing, "The Green House Project provides the kind of working environment that is conducive to developing and sustaining a qualified and committed work force. The model's small scale and focus on community help to nurture the kinds of caring relations between the workers and residents that are essential for quality services and good quality of life."

There are no further Green Houses on the horizon beyond the Faxton-St.Luke's initiative, but Dr. Thomas is looking for ways of replicating the idea nationally through raising the interest of Congress, foundations and those in the field. For now, Gendron added, "New York is a good place to start" because of that state's tough regulatory environment. "If it can be done in New York, we feel the concept can be replicated in many other places."

The initial or planning phase of the project has been supported by the Fan Fox and Leslie Samuels Foundation of New York City, which also helped to fund the creation of an "open source Web site." Through the Web site (www.thegreenhouseproject.com), Dr. Thomas hopes to engage hundreds of consumers, academics, providers and others in the creation of the best practices designs and ideas that will be used at the Utica site and in future Green Houses.

As Stone put it at the briefing, "We must begin to support the development of such innovative models and to invest--and I would underline that, invest, not just with goodwill but with good money--in well-designed evaluations so that we can identify what works and what doesn't work."

Scott Parkin is a writer and consultant with AgeComm, Reston, Virginia.