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Fixing the Institutional Model of Nursing Home Care

The COVID-19 pandemic laid bare the problems that have long been baked into America’s institutional nursing home model – one that can be characterized as “large, impersonal, hospital” instead of “small, personal, home.”


Covid-related deaths in nursing homes caught the attention of some in Congress who have introduced the Nursing Home Improvement and Accountability Act which would, among other government-driven reform measures, create a $1.3 billion pilot program to convert traditional nursing facilities to small-home campuses with private rooms and baths, more collaborative care teams, and an emphasis on resident-centered programming.


However, private industry has been light years ahead of government, with The Green House Project leading the way.


The Green House Project since 2003 has acted to transform the institutional nursing home model into one of real home with:

  • Social relationship with intimate care

  • A life style in which small numbers of elders per home live in private bedrooms with private bathrooms

  • Tight-knit caregiving teams cooking and serving meals in communal kitchens

  • A setting where residents are encouraged to make meaningful connections to each other and enjoy unfettered access to the outdoors



The concept has grown into Green House communities around the country, including the Green House Community at Vernon Homes now in the works.


This type of elder living is something we at Vernon Homes have long envisioned. The benefits of this style of care vs. institutional care only became clearer when comparing the two during the height of the Covid-19 pandemic:


The Green House model and culture led to substantially fewer COVID-19 infections and deaths compared to traditional facilities.


Of course, seniors and their families prefer small-home nursing campuses and in-home services to the traditional nursing home – but the small-home option must first be available to them!


The “institutional” status quo took decades to harden, and entrenched interests have been slow to change. The Green House Project, while already leading the movement for change with actual “bricks and mortar,” offers additional advice for government regulators and the senior care industry that will help fix things:


  • Update regulations to encourage new development. Traditional nursing homes persist because rules at the state and federal levels often, intentionally or not, preserve them. In 35 states, certificate of need (CON) laws restrict the total number of licensed nursing home beds. This stifles innovation. Developers of new facilities must wait for older properties to close or downsize before they can build. The solution: exempt small-home developments from bed-count caps and prevent the transfer of bed licenses to operators of traditional facilities.

  • Regulators should be more open-minded about building designs that promote elder autonomy and empowerment – such as real fireplaces, or free access to secure outdoor areas.

  • Offer permanent development and reimbursement incentives for small-home models. For example, The Green House Project argues that higher Medicaid reimbursements (which pays for more than 60% of the residents who live in nursing facilities) should be increased.

  • Simply throwing more money at a broken system will not magically transform it into one that provides the “real home” experience. The Green House Project sees benefit in the proposed Nursing Home Improvement and Accountability Act which would provide monetary incentives for operators to develop, build, and operate small-home campuses – and enable homes with quality care, private rooms and well-paid staff.

  • Expand home health options that enable seniors to receive care in the setting of their choice. However, instead of eliminating congregate care communities for an exclusively home-based approach (which does not address loneliness and isolation), home health providers and congregate living centers should work in harmony to provide a full continuum of care.



Creating positive change is never easy, but the Covid-19 experience provided a widely heard wake-up call. The small-home, personal-care benefits demonstrated since 2003 by The Green House Project offer a practical vision of what can be.


“What’s the real test of the worth of a Green House community? When a family member understands the true home environment that we are building and says, ‘Wow, this would be really good for my mom or dad! I didn’t think that this kind of senior care existed.’”


- Brad Ellis, Vernon Homes Executive Director



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