Evaluating THE GREEN HOUSE® Model

The Green House approach is a radically new, non-institutional model that reinvents the experience of long-term care for elders. Elders receive needed assistance and care in small homes that meet all required state and federal regulatory and reimbursement criteria for licensure as skilled nursing facilities.

The National Green House Replication Initiative is active in 33 states, with 185 homes open including our Green Houses in Westchester at Sarah Neuman, and many more in development, including our landmark Living Center of Manhattan. Evaluations conducted between 2003 and 2014, including those cited in the 2016 THRIVE Report from the Robert Wood Johnson Foundation and THRIVE Research Collaborative, examined numerous measures of care, satisfaction, and financial performance:

Green House elders relative to comparison group of nursing home residents1,2

• Improved quality of life: Green House elders reported improvement in seven domains of quality of life (privacy, dignity, meaningful activity, relationship, autonomy, food enjoyment and individuality) and emotional well-being.

• Improved quality of care: Residents whose units adopted the Green House model showed lower levels of hospital readmission, as well as lower levels of being bedfast, needing catheters, and having pressure ulcers.8

• Improved family satisfaction: Green House families were more satisfied with general amenities, meals, housekeeping, physical environment, privacy, autonomy and health care.

Green House homes relative to nursing home comparison sites3

• Higher direct care time: 23–31 minutes more per resident per day in staff time spent on direct care activities in Green House homes without increasing overall staff time.

• Increased engagement with elders: More than a four-fold increase in staff time spent engaging with elders (outside of direct care activities) in Green House settings.

• More stable staff: Direct caregivers in a Green House setting had lower staff turnover than CNAs at traditional nursing homes.6

• Improved care outcome: Fewer in-house acquired pressure ulcers in Green House homes. Green House homes versus traditional and other culture change nursing home costs.4

• Savings for Medicare: When a traditional nursing home transformed some of its units into the Green House model, Medicare Part A spending was reduced in those Green House units.7

• Cost neutral operations: Green House homes operate at the same median cost as the national nursing home median cost.

• Lower capital costs: Green House homes provide private bedrooms and baths and enhanced common space while building the same or fewer square feet than other current culture-change nursing home models. Lower square foot costs lead to lower capital costs.

Role of direct-care workers5

• Comparable quality: Removal of formal nurse supervision of direct care workers did not compromise care quality.

• Timely intervention: High level of direct care worker familiarity with elders led to very early identification of changes in condition, facilitating timely intervention.


1 Kane R, Cutler L, et al. “Resident Outcomes in Small-House Nursing Homes: A Longitudinal Evaluation of the Initial Green House Program,” Journal of the American Geriatric Society, 55(6):832-839, June 2007.

2 Kane R, Cutler L, et al. “Effects of Green House® Nursing Homes on Residents’ Families,” Health Care Financing Review, 30(2):35-51, Winter 2008-2009.

3 Sharkey S, Hudak S, et al. “Frontline Caregiver Daily Practices: A Comparison Study of Traditional Nursing Homes and The Green House Project Sites,” Journal of the American Geriatrics Society, 59(1):126-131, January 2011.

4 Jenkens R, Sult, T, et al. “Financial Implications of THE GREEN HOUSE® Model,” Senior Housing & Care Journal, 18 (1): 3-21, September 2011.

5 Bowers B, Nolet K. “Exploring the Role of the Nurse in Implementing THE GREEN HOUSE® Model” University of Wisconsin Unpublished 2009.

6 Brown P et al for the THRIVE Research Collaborative. “Workforce Characteristics, Perceptions, Stress, and Satisfaction among Staff in Green House and Other Nursing Homes.” Health Services Research, February 2016.

7 Grabowski D et al for the THRIVE Research Collaborative. “The Impact of Green House Adoption on Medicare Spending and Utilization.” Health Services Research, February 2016.

8 Afendulis C et al for the THRIVE Research Collaborative. “Green House Adoption and Nursing Home Quality.” Health Services Research, February 2016.