A green house movement
As long-term care facilities implement culture change, some locations are turning to the Green House model to bring person-centric care to residents.
During the past couple of years, most long-term care communities have undergone a shift in culture to move away from an institutional approach to senior care to a more personal approach. This transformation is known in the senior living industry as culture change. One strong example of this shift in senior living is known as the Green House.
A Green House is a home designed for a small number of residents, called elders. The term Green House was selected to suggest a home where people can continue to grow and thrive. Each elder has his or her own separate living area and bathroom. But the heart of the Green House is the kitchen, hearth and dining area. The Green House employs a universal worker, called Shahbazim, who provide all care for the elders, from nursing and laundry to cooking. The Shahbazim are certified nursing assistants (CNA) who undergo an additional 120 hours of training, during which they learn how to fulfill their foodservice duties. (Shahbazim is an ancient Persian word meaning royal falcon. According to Robert Jenkens, director of the Green House Project, the term was chosen because it has no negative connotations that he says are often associated with CNAs.)
Dr. Bill Thomas developed the Green House model. Thomas worked as a medical director in a nursing home in upstate New York, when “he realized that there was really good care and there were really good people, but the [residents] were really struggling with loneliness, boredom and a sense of helplessness,” Jenkens says.
Thomas developed the Eden Alternative in 1991 as a way to work within the confines of a nursing home to provide better care to help alleviate the residents’ struggles. “A lot of nursing homes adopted the Eden philosophy and then some of those realized that they had a very old physical building and that they were going to need to replace that,” Jenkens says. “Bill really started to think about what it would look like if we totally redesigned nursing homes to fit what we were trying to accomplish. That was the birth of the Green House Project.”
The first four Green Houses opened in May 2004 in Tupelo, Miss., as part of the Mississippi Methodist Senior Services’ Traceway campus. There are now 10 Green Houses at the Traceway Retirement Community. To date, almost 70 Green Houses have opened across the country. Green Houses can be found on any type of senior living campus.
Because there are no traditional foodservice employees in a Green House, meal service is dramatically different. The Shahbazim prepare all meals, and depending on the location the Shahbazim may plan the menus and do ordering as well. In most locations, the Shahbazim coordinate with the community’s foodservice director.
“For Bill, one of the key elements he identified for a Green House was that the kitchen and the hearth have to be key because that’s what makes it a home and not an institution,” Jenkens says. “Cooking in the house came about for two reasons: One was that food is obviously very important to people’s enjoyment of their life, but it is also the key element in a traditional nursing home that drives the schedule. It is one of the reasons why people get up at 6 o’clock in the morning so that they can be made ready to be taken down to a centralized dining room. So cooking food in the house also allows elders and staff to really control their schedules a lot more effectively and be able to be very responsive.”
Traceway at Tupelo: The foodservice at the first Green Houses at Traceway was managed in-house. But shortly after the first four houses were opened, Morrison Management Specialists was hired to oversee foodservice.
“Morrison provides the clinical support the Green Houses need on the dietary side,” says Monty Fletcher, director of dining for Morrison at Traceway. “We have a dietitian who sets the basic menus and then we put together an always available menu. We find the common thread between the 10 or 12 elders who are in the house and then the Shahbazim always have those menu items available so staff can do substitutions at mealtime and still meet all the daily requirements. We also make sure that the menus meet all of the state and federal guidelines. There is no lax in regulations just because it’s a Green House.”
Because the Shahbazim have nursing backgrounds, training in foodservice is necessary. Morrison created a Green House Dining Experience training module, which comprises five days of ServSafe and culinary education. “We have to train the Shahbazim the same as we would dietary personnel who are in our normal kitchen,” he says. “They have to understand all the diets. We teach them about the nutritional needs of the elderly. We have to train them how to read, prepare, serve and monitor diet orders.”
Fletcher says as the Shahbazim become more confident in their culinary workload, they take over additional tasks. For example, Fletcher says he does the ordering for a house until the Shahbazim complete the second training module, where they learn more about recipe and menu production. Orders for the Green Houses are delivered in bulk to the main campus. The items are then resized into smaller portions and delivered to the houses.
St. John’s Lutheran Ministries: Gary Morgan, general manager of nutrition services at this facility in Billings, Mont., visited Traceway six years ago when St. John’s was contemplating opening Green Houses on its campus. “My job for the trip was to play devil’s advocate,” Morgan says. “I’ve been in this industry for 30 years and I was supposed to ask a bunch of questions to find out what was working and what wasn’t.”
Morgan admits that at first he was skeptical about how smoothly a Green House model could run, but he says dining with the elders quickly changed his mind. “The thing that absolutely blew my mind was having lunch,” he says. “To watch the elders light up and have control over things in their own homes was amazing. There was one woman I had lunch with who had lived in the main home for a long time. She stopped feeding herself and stopped talking, and her daughter said within a couple of hours of being in the Green House she started feeding herself and talking again. It was awesome that they were able to get some of those things back that get lost in nursing homes.”
Eight Green House cottages have opened at St. John’s. Twelve elders live in each cottage. The universal workers at St. John’s are called Sharaths.
Morgan says one of the biggest hurdles to opening the Green Houses is training the Sharaths. Morgan and his executive chef developed a training program where each Sharath is taught ServSafe and culinary skills. “We had teams come through the training together,” he says. “They had three and a half weeks of training, and culinary was the tail end of it, so by then they had really bonded. We taught them everything. Every person had to cook two or three things and then we’d all walk around and coach them and show them how to do things correctly. We had some nineteen-year-old girls who had never cooked anything and all of the sudden they are cooking omelets. It was really successful.”
Each cottage has its own food coordinator, who does most of the documentation and ordering for the cottage. One of St. John’s original Sharaths is Bill Groll. Because of Groll’s background running a restaurant, he was named a food coordinator for Liggett Cottage.
“In the beginning it was difficult because we had training, but we had never done any of this so it took us a couple of months to get all the systems up and running and refined,” Groll says about the opening of the Green Houses. “It’s a lot of on-the-job training.
“We have a cooking schedule so the same person doesn’t cook every day.
I do the ordering and I do the documentation for all the temperature logs for the dishwasher, the freezer, refrigerators and the food when it comes off the stove. The food preparation is a huge part of someone’s day.”
Groll says the main meal at Liggett Cottage is at noon, but he says that varies at the other cottages depending on the elders’ wishes. He says currently there aren’t any elders who can help with food preparation at the cottage, but he says in the past several residents would always ask to help by doing tasks like peeling potatoes.
Because the cottages are run separately from the main campus, Morgan says he was concerned about the financial aspect. “I could see this nightmare trying to do the accounting and costing all this food out to all these various cottages,” he says. Through a computerized ordering system developed by the campus’s vendor, each cottage’s food coordinator places his food order, which is sent to Morgan. He then combines the cottages’ orders with the main campus orders.
The food is sent in bulk and Morgan repacks items into smaller portions for the cottages. “We are almost an on-campus vendor for these cottages.”
Each cottage is a separate cost center. Morgan says that, on average, the cottages’ price per meal is less than at the main campus. The average cost per meal for all eight cottages is $1.50. In September, the average cost per meal for the main campus was $1.72.
Morgan says some houses are better at managing costs and waste. “One of the first audits I did, I went down and emptied out two or three two-gallon trash bags of frozen leftovers that were in their freezers and were worthless. They were producing 18 servings
for everything instead of 13, so they were winding up with four or five extra servings.” Morgan says making sure the Sharaths understand foodservice basics like production is paramount to running a financially sound Green House.
Morgan says some operators are afraid of the Green House model because of job security. “The fear when a lot of people hear about Green Houses is that, ‘my job is going to be gone,’” he says. “My job is going to be secure as long as I want it to be because of the complexity of this whole operation and my knowledge of how all this stuff works. There is always going to be something that we have to problem solve or go in and re-teach people. You can’t have a big truck come in and drop huge amounts of food for a 12-person cottage. There is no place for storage, so somebody is going to have to break all that stuff down into smaller amounts.”
One of the lessons Morgan learned was about order size. “We went to a lot more custom-size packaging,” he says. “We were slicing and repackaging turkey deli meat and stuff and I finally realized that was stupid because we were wasting time. Why don’t we just get the retail package of those meats and repack it and just sell that to them directly? We get steaks in smaller cuts. You aren’t going to have everything in a #10 can.”
Legacy Village in Bentonville, Ark.: Not all Green Houses are located on a campus with a nursing home or other assisted living quarters. At Legacy Village, the community consists entirely of six Green Houses. Each Green House houses 10 elders.
Karen Reeder is the dietary manager at Legacy. Because the Green Houses stand alone, Reeder only needs to work part time. She helps develop the menus and does the ordering. She orders food items twice a week through a prime vendor and when she can’t get items in small enough quantities, she shops at a local grocery store.
Reeder says breakfast is à la carte and that salads and fresh fruit are available every day. Each house has the same set menu, but the Shahbazim know the likes and dislikes of the elders so they can make substations as needed.
Before coming to Legacy Village, which opened in January 2009, Reeder worked as a dietitian at several hospitals and nursing homes. She says the main difference between Green Houses and traditional nursing homes is the environment. “The Green Houses are more family oriented,” she says. “The elders do all of their activities in the dining room. It’s more like cooking for a family rather than cooking a large amount and just putting food out for residents to take.”
Adapting the Green House model
Implementing the Green House model isn't feasible for every location. FSD talked with three operators to find out how they employ some Green House concepts in a non-Green House facility.
Cura Hospitality: A couple of months ago, the Orefield, Pa.-based management company developed a culture change guide to help its clients and on-site staff move away from the institutional way of serving seniors to an individualized approach. “It’s a journey,” says Deb Santoro, director of staff development for Cura. “It’s not like you can flip the light switch and change your environments and programs. The roots are very deep and it takes a lot of educating, training and hands-on experience for our communities to transition.” To help with the change, Cura developed a step-by-step guide for culture change. The guide includes a self-assessment tool so a facility can see where it is in the culture change journey. From there, the guide has an action plan for staff to implement, as well as a list of resources for help.
“The manual includes lessons learned and do’s and dont’s,” Santoro says. “The journey is unique in every environment so the experience has taught us a lot of lessons. There is no reason to make the same mistakes twice.” Some of those lessons include learning to work within your client’s vision, allowing for ample time and being flexible to plan changes.
One of Cura’s locations to undergo significant culture change was 450-resident Phoebe Berks in Wernersville, Pa. Three months ago, Village Garden, a 24-bed memory care support unit, opened on the Berks campus. Because of Village Garden’s small size, the staff is able to focus more on the residents, according to Tracy Bozik, director of corporate marketing for Cura. Much like a Green House, the heart of Village Gardens is its open kitchen. The kitchen has food and beverage selections available at all times, but the interaction between staff and residents is another benefit, Bozik says. “There’s a little counter area where the residents can sit and watch their food being prepared and have conversations with the staff and perhaps assist with the preparation of the meal,” she says.
Maria Burdette, district manager for Cura, also sees the benefits of the smaller units in assisting with resident-staff interaction. “Prior to this we delivered meals on food carts from the main kitchen. This is a huge change in really improving the quality of life for the residents because they participate. We have a resident who does not like to get up early in the morning and if he wants bacon and eggs for lunchtime we can do that.”
Burdette says the residents aren’t the only ones undergoing a culture change. “It’s a tremendous shift in the way staff has traditionally thought about their roles,” she says. “We’re seeing this shift in attitude and pride. They take ownership in what they do because they now have a personal relationship with those few residents.”
ACTS Retirement-Life Communities: Open kitchens are a theme in four of ACTS’ 19 communities. ACTS Signature Experience is the company’s culture change model. “We are doing person-centered care and trying to teach staff to think ‘task’ last and making relationships first with our residents,” says Theresa Perry, director of culinary nutrition services for ACTS. To achieve this, four communities opened country kitchens. Similar to the open kitchens in Cura’s communities, the country kitchens have a breakfast bar where residents can interact with the foodservice staff. The residents also have access to certain food and beverage items at all times.
Each country kitchen has a stove, refrigerator and coffee machine. “If there is something the residents want, we will put it in the refrigerator for snacks,” Perry says. “The country kitchens are like what you would find in any new home. During the day there might be an activity in the kitchens where the residents might help prepare [something like] the dessert of the day.”
Perry says education is key to the success of the Signature Experience. Perry is one of three coaches who teach the communities about making the transition to person-centered care. “One of the first things we did was make a list of all the things that were institutional and all the things that were like a home,” she says. “Then we worked on ways to move toward the home things.”
Some of the changes toward a home-like environment have been minor, such as making coffee and tea service available earlier in the morning for those early risers who want a cup of coffee while they read the newspaper. “We might bring soup over at lunchtime so when the residents come into the dining room there is always soup and crackers to consume before they have the whole meal, or dessert could be a dessert cart versus dessert coming on the tray.”
Rice Home: Culture change isn’t only about changing service. Good food is still the heart of dining services. At this 95-bed CCRC in Columbia, S.C., the menus were revamped several years ago as part of the community’s culture change. Rick Schmitt, culinary and hospitality director, runs a five-week menu cycle. In addition to the day’s menu selections, there is an alternative menu with seven entrées, five salads, two soups and three desserts to select from. Schmitt says increasing choices was important in the facility’s culture change.
“Before the menu change, we had a standard cycle menu and the alternates were very hit or miss,” Schmitt says. “We surveyed our customers to find out what they liked and wanted to see on their daily menus. We rearranged our dietary department to where it is more of restaurant dining instead of institutional-style dining.”
The department has moved to that restaurant style of dining by doing simple things like using tablecloths and linen napkins.