Building Better Nursing Homes

After plenty of isolated successes, the question isn't what good nursing homes look like, but how to transform existing facilities into places that look like them.


CHELSEA, Ma.—The woman Barry Berman saw sitting in the dining room of the nursing home was not his mother.

Or, at least, she was his mother, but didn’t look anything like her. His mother was vivacious, or she had been until she was felled by a massive stroke and then pneumonia, so he’d moved her into a nursing home so she could recuperate. He knew he could trust the nursing home, since he ran it, and knew it was lauded for the efficiency with which it served residents. But when he went to look for his mother a day or two after he moved her in, he barely recognized her.

“I’ll never forget the feeling as long as I live,” he told me. “I said, ‘Oh my God, there’s my mother, this old woman, in a wheelchair, lifeless. Look what my own nursing home did to my own mother in a matter of days.”

Berman had run assisted living and nursing complexes for 23 years before this moment, but it completely changed the way he thought about how to care for the elderly. He moved his mother home immediately, arranged for home-care aides to come to her, and then set about to completely upending the way his organization, Chelsea Jewish Foundation, cared for its aging patients.

“It was the kick I needed, to say there has to be something else for the elderly that we can do,” Berman told me.

Barry Berman, president of the Chelsea Jewish Foundation, in one of the residences at the Leonard Florence Center for Living (Alana Semuels)

What followed was a multi-year project to build, from the ground up, a nursing home that would look totally different from the traditional model. It would be based on innovative experiments from elsewhere, and it would accept people of all different incomes, as well as non-elderly people with debilitating diseases such as ALS and MS. It would be a home, not a hospital, no matter how sick residents were, and it would allow them to make their own choices and live their own lives.

That facility—The Leonard Florence Center for Living—opened in 2010, and since then Berman has remained devoted to his work of reimagining what life can be for the elderly in America. He’s now embarking on what may be his most ambitious project yet—an effort to transform the nursing home where he'd first put his mother into a place that looks more like the Leonard Florence Center. It may not work. Nursing homes have been run the same way for decades, in part to meet government regulations and to qualify for government payments such as Medicare and Medicaid. And it's harder to turn an existing place around than it is to build a better one from scratch. But Berman thinks that if he can do this, he can help change the entire nursing-home industry.

* * *

America is aging, and still hasn’t come to terms with it. By 2050, one-third of the population of the U.S. will be 65 or older, according to the Congressional Budget Office. About 4 percent of the population will be 85 or older, and more than half of them have difficulty performing one or two “activities of daily living,” which include bathing, dressing, eating, walking, transferring out of a bed or chair, and using the toilet, the CBO says.

Long-term care is expensive, and many people don’t want to go into the type of nursing home they can afford, which often feature shared rooms, industrial cafeterias, and overworked staff. Nor can many people afford to live at home, especially if they require 24-hour care.

The recession made decisions for elders even more difficult. Many lost significant savings in the stock-market collapse. Others who might have relied on baby-boomer children to help care for them as they aged were faced with the reality that their children were going to have to work much later in life than they had.

So elderly people move into assisted living, and then when they get sicker, they move into nursing homes, where they get round-the-clock care but where their freedom is often limited. Happiness is often curtailed there: Studies have shown significant rates of depression among nursing-home patients, and anticipation of being placed in a nursing home can lead to patient suicide.

“Our elderly are left with a controlled and supervised institutional existence, a medically designed answer to unfixable problems, a life designed to be safe but empty of anything they care about,” wrote Atul Gawande in his powerful book, Being Mortal, about aging and the problems inherent in long-term care.

Winnie Murphy, a 105-year-old resident of the Leonard Florence Center for Living (Alana Semuels)

When Barry Berman was looking for an alternative to the traditional nursing home, he stumbled across a concept called the Green House Project that seemed promising. It was created by Bill Thomas, a doctor who started working at a nursing home in upstate New York in 1991, and wanted to make residents less lonely. As Gawande recounts in his book, Thomas brought in dogs, cats, and 100 parakeets; and created an after-school program, which brought the residents into contact with kids, with extremely positive results.

In 2000, Thomas decided to build a nursing home from the ground up, taking into account the lessons he had learned in upstate New York. He wanted it to be affordable, so it could accept Medicaid patients, but he didn’t want it to look like a place that was built with only economic efficiency in mind. Most of all, he wanted it to look like a home, not a hospital.

Thomas persuaded an organization in Tupelo, Mississippi to build the first "Green Houses." Each home consisted of 10 to 12 private bedrooms, each with its own private bath, arranged around a communal living area and kitchen. In each home, there are primary caregivers called Shahbazim, certified nurse assistants who also handle some food preparation, light housekeeping duties, and plan activities for residents. They work as a team with other Shahbazim, which gives them the ability to manage their own work schedules and make decisions collaboratively.

Studies showed that Green House residents experience a better quality of life than people in traditional nursing homes, that their families were happier with the setting, and that the staff were happier with their jobs and more likely to remain in their positions.

With funding from the Robert Wood Johnson Foundation, Thomas then created what’s now called the Green House Project, which sought to help non-profits and businesses build Green Houses around the country. Green Houses are all very different, but share a few commonalities—each is designed for just 10 to 12 residents, and are built around a common living room and dining room. Each resident has his or her own bedroom and bathroom, and has a say in the residence’s menu. But Green Houses are not just about architecture, according to Scott Brown, who works for the Green House Project (not to be confused with Scott Brown, the former U.S. Senator from Massachusetts).

“The other two parts of it are cultural change, which is focused on person-centered care, and organizational change—we use a very progressive organizational model that focuses on empowered teams and a coaching approach to leadership,” he said.

There are currently 173 Green Houses operating in 27 states, and more than half of the residents are on Medicaid, Brown said. Some Green Houses are in single-family homes in the suburbs, others are in more rural settings. In Loveland, Colorado, the public-housing authority built a Green House. Most are around 7,000 square feet.

Seniors around the communal table at a Green House (Credit: THE GREEN HOUSE (r) PROJECT)

People are healthier and happier in Green Houses than they are in traditional nursing homes, Brown said, and research appears to support this claim. One study found that Green House residents reported higher quality of life than seniors in traditional nursing homes in subjects such as privacy, dignity, autonomy and food enjoyment. The rate of hospitalization per resident over 12 months was seven percentage points higher in a traditional nursing home than in a Green House, another study found.

Staff are also happier in Green Houses, studies have shown. That's an important metric in an industry with high turnover and a reputation for elder abuse (happier staff means lower turnover, which means less hiring, which in turn means less risk of hiring people who may be abusive). Shahbazim say they feel less rushed and are able to spend more time with the elders in their care, and also feel less stress and guilt around their jobs.

The Green House Project was able to achieve these outcomes without adding on a lot more expenses. Seniors in Green Houses cost Medicare and Medicaid about $1,300 to $2,300 less than those in traditional nursing homes, according to studies in Minnesota and Washington.

Still, the Green House model is expensive to build, and difficult to scale. Only 2,000 of the 16,000 nursing homes in the country have fewer than 50 beds, and most have more than 100, according to the Kaiser Family Foundation. To change these places to 10-bed facilities doesn’t seem feasible to many administrators. To date, there are about 1,700 Green House beds in the nation. There are 1.5 million beds in traditional nursing homes. So the question at this point isn't so much what do good nursing homes look like, but how do you transform the existing institutions into places that look like them?

* * *

The land Barry Berman had to build on could not accommodate a sprawling Green House. It was a small lot in an urban setting, and Berman wanted to house dozens of people, not just 10. His organization ran a large assisted-living home, and he didn’t want to have to turn his existing residents away from moving to a nice nursing home because he only had 10 slots.

So he came up with an idea. He would build the first urban Green House in the country. It would still have 10 units per Green House, and those units would each have a separate entrance and be built around a common living room, but he’d stack them on top of each other in an apartment-building-like complex.

“We loved the idea of the 7,000 square foot residence but we were in Chelsea,” he told me. (Chelsea is a dense inner suburb, population 35,000, just outside of Boston. Large, undeveloped tracts of land are not in abundance.)

He went to the Green House Project with the proposal and they liked the idea. Then he realized he had to find the money to build it. The Green House he wanted to build would cost about $380,000 per bed, whereas the cost per bed in a traditional nursing home is about $200,000. The total cost would be around $38 million.

He got commitments from a few donors, including Sheldon Adelson and the Harry and Jeanette Weinberg Foundation. He raised $7.5 million in a six-week period. But it still wasn’t enough.

So he applied for and received a new-market tax-credit program from the Treasury Department, which would help fund the construction.

Steve Saling's room at the Leonard Florence Center for Living (Alana Semuels)

Berman also had to get waivers from the state of Massachusetts, because the state had a moratorium on new nursing-home beds. Berman’s state Senator introduced legislation that passed the Massachusetts House and Senate, but it still had to get by then-Governor Romney.

“We figured, no way is a Republican governor not going to veto more nursing home beds,” Berman told me.

But right before he left office, as Romney went through the line item veto process, an aide told him about the Green House proposal. He didn’t veto the law.

Now, Berman had his tax credits, his state waiver, and his philanthropy. He could start building his Green House.

* * *

Steve Saling wasn’t who Berman would have normally turned to for help designing a bunch of small residences for the elderly. For one thing, Saling isn’t elderly. He doesn’t work with the elderly. But Saling, a landscape architect, knew exactly what Berman needed.

That’s because Saling was diagnosed with ALS at age 38. He was losing some of his abilities and looking for a place he’d be able to live once he could no longer live on his own. He’d visited other single guys with ALS, and was disappointed to see they often lived in a nursing home or hospital and shared a room with a 90-year-old roommate. Many of them were left lying in bed staring at the ceiling.

“Our society treats prisoners with more dignity and respect than the chronically disabled kept alive,” he told me (Saling now speaks through a computer). “I knew I had to work quickly to avoid their fate.”

Steve Saling in his room at the Leonard Florence Center for Living (Alana Semuels)

Saling and Berman met at a conference and decided to work together. Berman wanted to create Green Houses for people with ALS and MS, and Saling wanted to help him make those places feel like home.

Saling took me on a tour of the Green House Berman built, called the Leonard Florence Center for Living. It is set atop a hillside next to luxury condo buildings in Chelsea’s Admiral Hill neighborhood. It has a wide, bright lobby with a coffee shop and deli, a chapel, and a spa where residents can get their hair and nails done. An elevator brings visitors to each Green House. There are 10 in total, two on each floor, and each has an entrance that looks very much like a home, with yellow siding, a mailbox, a door that opens and closes, and a light.

The first thing you see upon entering the 7,000-square-foot Green House where Saling lives is a living room with a couch and fireplace, a fish tank in the corner and artwork on the walls. Around the corner is a pristine kitchen and a large dining room table, where aides and residents sit, some eating, some reading, some just relaxing. There’s a patio and light streamed in from the outside, even though it was a cloudy day.

The Leonard Florence Center for Living (THE GREEN HOUSE (r) PROJECT)

“This is not a nursing home with residential trappings,” Saling told me. “It is my home that happens to provide skilled nursing services.”

Saling’s room is spacious, with walls painted red, a warm yellow, green, and red bedspread and a flat-screen TV. Pictures of him from his old life—skydiving, rock climbing, posing with his young son—are mounted on the walls, alongside bottles of alcohol from around the world. The only thing that distinguishes this room from a spacious college dormitory is the track that runs along the ceiling from his bed to the bathroom, which allows aides to help him shower.

Perhaps most important, to Saling it feels like home. He is able to shut his door and have some privacy. When I visited, the room was quiet, and the smell of lunch cooking wafted over from the kitchen. It looked nothing like a hospital, or even like an assisted-living facility.

“Living in a Green House is the only reason I continue to live a vital and productive life,” he told me. “It doesn't matter if you are elderly or disabled people want to live with dignity and respect, make their own decisions and direct their own care.”

An aide puts away dishes at the Leonard Florence Center for Living (Alana Semuels)

Though he can barely move, Saling designed a system that allows him to control the elevator, open the doors to the home, turn on the lights, raise and lower the blinds, turn on the TV and radio, and send and receive emails through a computer he keeps on his wheelchair, which he controls with a tiny computer mouse mounted on his glasses. He worked with Berman to enable others in the Green House to use the same system, and is now trying to replicate it in other residences for ALS patients around the country.

Stephen Hawking, who also has ALS, left Saling a voicemail when the center opened to congratulate him. Saling played it for me in the warm lobby of the Leonard Florence Center, where a bright display of Passover-friendly baked goods were arranged on china plates.

"I have always been interested in the role of technology in empowering the lives of those who would otherwise depend entirely on the care of others," Hawking says, on the voicemail. "I look forward to living centers such as this becoming a standard for the world."

The residences built for seniors look very similar to the one where Saling lives. I went into one where an 105-year-old woman sat at a table, eating pie. Two workers, dressed in bright colors, bustled about in the kitchen, while a few of the other residents looked out the window in silence. There was no central nursing station piled high with paperwork, no long hallways, no fluorescent lights or linoleum, just a bunch of people eating lunch at a long-table in a well-lit room next to a state-of-the-art kitchen.

It may sound more expensive to have private rooms and so many kitchens, but the expenses mainly come in the form of construction costs. There are efficiencies that make Green Houses, in some ways, less expensive to run, Berman told me. Everyone has their own private bathroom, so there’s no infection-control department, for example, and staff help plan and prepare meals, so there’s no dietary department.

Many nursing homes have 123 beds because accountants have found this an efficient formula to keep staffing and other costs low. Thomas threw this out the window, and to Berman, that’s what makes a difference. Green Houses don’t consider just the economics of care, but also what can make a person’s life better.

Most people with ALS on a ventilator would receive sponge baths, for instance, but patients at Leonard Florence still take showers in their own bathrooms. It’s just common sense, Berman says.

“I would question anyone to answer—what is so innovative about having warm water cascading over your body?” he asked me. “Isn’t that just a basic human right people should have access to?”

Steve Saling in a Green House kitchen (Alana Semuels)

Families say the home-like atmosphere makes life much more pleasant for them when they visit their loved ones.

Bob Kelley’s wife of 43 years, Ann, had a stroke 10 years ago that left her able to move only part of one arm. He tried to tend to her at home, but, he said, “ I admit I wasn’t up to it.” He put her in a nursing home that she seemed to like, but then he learned through a friend about the Leonard Florence Center. Ann moved in three years ago.

“It’s head and shoulders more appealing than the other place,” Kelley told me. He goes and visits her every day and takes her to get her hair done at the hairdressers, and sometimes they’ll sit in the bakery, or in her room. The previous nursing home wasn’t a very pleasant place to sit together, he said.

The Green House “has made the process very, very manageable,” he told me. “I see her every day, and I’m not sure I’d be able to do that without Leonard Florence.”

* * *

Barry Berman may have built a Green House. But he also runs a traditional nursing home a mile or two from Leonard Florence, Chelsea Jewish Nursing Home, which was the place where he'd put his mother. I visited it immediately after seeing the Green House, and was struck by the differences.

The nursing home lobby was a little shabby, and crowded with families talking to their loved ones, often huddled around circular tables. In an atrium below, more than a dozen residents were ushered out into a bus for a field trip. There was nowhere to really hang out in the nursing home—the elevator on each floor opened up to a hallway lit by fluorescent lights that reminded me of a hospital, with residents’ names posted outside the doors.

Each room had two people in it, and some had three, and walking down the hallways, I could hear TVs turned up to full volume, announcers jabbering about the trial of the Boston Marathon bomber. Aides huddled around a desk at a nurses station piled high with folders, and elderly people seemed scattered about, sitting in wheelchairs, sometimes gazing at the wall. The sound of the TVs was only interrupted by the occasional sound of coughing. Though some residents were working on arts and crafts project in a common room, others just sat alone, looking like they had been parked there. It felt, in a word, institutional.

This was not a bad nursing home: The staff seemed friendly and competent, and the elders were well-cared for. Chelsea Jewish received five out of five stars from U.S. News and World Report, which rates nursing homes. But after seeing a Green House, it was hard to wish a traditional nursing home on anyone.

Barry Berman feels that way, too. That’s why he’s embarking on an ambitious project to change Chelsea Jewish Nursing Home into something that more closely resembles a Green House. It won’t be a Green House, exactly, but it will be close, he says.

There will be 20 people to each “house,” which is double the number in a typical Green House, but a far better ratio than 40 to a floor, Berman says. Each house will be built around a central kitchen. There will be self-managed work teams, and residents will have more input on what they’re eating—if the building is having chicken, one house could have grilled chicken with lemons, while other could have chicken cooked a different way.

There will still be two people per room—Berman says he can’t get the economics to work any other way—but “I would rather do what we’re doing than nothing at all,” he told me.

Architectural renderings of the renovated Chelsea Jewish Nursing Home (DiMella Shaffer Architects)

Edward J. Stewart, the executive director of Chelsea Jewish, laid out the changes to me on the tour. The walls to the long, hospital-like hallway will be knocked out to allow in more light. When the renovations are done and you step off the elevator, there will be a living room with a fireplace and better lighting, he said. The whole area will smell like home-cooked food, Steward told me. The nurses’ station will be moved to the back of the residence, and the industrial kitchen that currently prepares meals for the whole nursing home will be scrapped.

The staff of Chelsea Jewish will go through training to understand the philosophy of the Green House, and the renovated facility will also have Shahbazim.

The $14 million project begins this month, and construction will happen while residents still live there. HUD helped guarantee some of the loans.

Berman was excited about the Green House he built, but he’s even more excited about turning this nursing home into something better, inspired by the Green House. Most nursing homes don’t have the financial capacity to build a new Green House from the ground up, but many have acknowledged there must be a better way to treat the elderly who need full-time care. His project could be a model that could be replicated, he says.

“This is probably going to be the most exciting program that we’ve ever built because it is going to change the face of nursing homes throughout the country,” Berman told me. “We understand not everyone can build a Leonard Florence Center—we get that. But every organization, if they want to, can do what we're doing at Chelsea Jewish."

Still, it’s unclear if Berman’s new project will really change the way nursing homes work. It will be a test for the Green House Replication Initiative too, which is struggling with how to adapt its core principles to bigger institutions.

After all, there are thousands of nursing homes around the country that still run on the traditional model. But many of them have started to feel like “the ugly stepchildren” of the industry, called out as undesirable but with little ability to do anything about it, said Susan Frazier, the chief operating officer of the Green House Project. The Project wants to figure out how it can maintain its ideals but still help change the thinking in more institutional, traditional settings. It's calling the initiative "Pathway to Green House."

“While the idea would be for them all to be Green House homes, you are capital constrained to be able to do all Green House homes,” Frazier told me. “So we really have been thinking—what does a Green House look like when it meets a legacy building?”

The initiative has come up with a list of important aspects of Green Houses that legacy buildings should try to consider. It recommends nursing homes try to keep the scale of the home small, that they have a hearth area with a dining room, living room and kitchen, that they have private rooms for residents, a front door to each residence, and that they allow patients to function as autonomously as possible.

The Green House Project will be training the staff at Chelsea Jewish to implement the Green House culture, Frazier said. Already, Berman and his staff have decided that a lot of the most exciting parts of a Green House are centered around the kitchen, the hearth and the communal table, and that adding those aspects to a traditional nursing home could make a big difference.

The Project isn’t working with any legacy nursing homes that don’t have a traditional Green House as well, Frazier said. Any nursing home trying to transition into something resembling a Green House needs to experience how skilled nursing and elder care can be provided differently, she said, in order to change their own facility.

“I don’t want people to spend money just to put wallpaper in, or fancy this or that—it’s just spit and shine,” Frazier said. “If it doesn’t get you to really more fully honoring and implementing the core values of a Green House, it’s a waste of money.”

But Berman says he’s mindful of the need to implement the values of the Green House, in addition to the architectural changes. The whole purpose of doing the renovations is to make the nursing home into a place that people want to spend time, rather than a place that mostly focuses on meeting regulations and controlling costs.

The accountants are no longer designing the nursing homes,” he told me.

Steve Saling approaches the entrance to his home in Chelsea (Alana Semuels)

The values of the Green House Project, if taught correctly, can be seen even outside of the nursing home setting, he told me. That's how he knows architecture is less important than the concept of putting the patient first.

He saw this in action this past week, when Patrick O'Brien, one of the other residents of the ALS house at Leonard Florence, had a movie accepted into the Tribeca Film Festival. O'Brien, who was diagnosed in 2005, is on a ventilator, which makes it extremely difficult for him to travel or even to live outside of a hospital setting. But staff were determined to help him get to the premiere. So eight of them traveled with Patrick, Steve Saling, and Barry Berman to Manhattan to attend the premiere.

"You do not have to have the structural changes to have a good nursing home," Berman told me. "More than any architectural design would be the caring, competent, compassionate staff."