Inside the National Academies’ Nursing Home Report — and How Green House Can Help

Published On: April 26th, 2022By Categories: Blog

The National Academies of Sciences, Engineering, and Medicine (NASEM) announced seven goals this month via its report The National Imperative to Improve Nursing Home Quality. The recommendations to achieve those goals are thorough. They are clear. And they involve everyone.

A quick glance at the recommendations may leave a provider confused. What can I do to effect change in the survey process or the nursing home financing system? While not all recommendations require provider involvement, there are many that do.

The Green House Project (GHP) is proud to note how its model of care already answers some of the recommendations of NASEM, and GHP is here to help organizations as they respond to the National Academies’ call to action.

The Green House Project’s work falls most specifically under the first two goals stated in the report:

  1. Deliver comprehensive, person-centered, equitable care that ensures the health, quality of life, and safety of nursing home residents; promotes resident autonomy; and manages risk
  2. Ensure a well-prepared, empowered, and appropriately compensated workforce

Goal One highlights the need for culture change and operationalized person-centered care within the nursing home setting. For almost 20 years, this has been the number-one goal of GHP.

We at GHP work with sites to transform their culture – putting the elders’ needs and preferences at the forefront. Instead of saying, “That’s how we’ve always done it,” or “Well, that works best for our staff,” cultural transformation asks: “What’s best for the elder? What is most dignified?”

GHP already provides a suite of trainings such as Person-Directed Care, The Role of the Nurse and Communicating for Success along with our more comprehensive cultural transformation site-by-site consulting that help nursing homes move to shared decision-making processes, elevate resident care preferences, and develop a balanced approach to resident autonomy  versus safety.

Within Goal One, the imperative to move to single rooms and smaller nursing homes is also raised. The report specifies some design elements of this new type of nursing home.

The design of these nursing homes should include consideration for the following characteristics: unit size, activity and dining space by unit, a readily accessible therapeutic outdoor area, an open kitchen, a staff work area, and entrances and exits. Smaller units should be designed to have the flexibility to address a range of resident care and rehabilitation needs. New designs should prioritize private bedrooms and bathrooms.

Since 2003, when the first Green House home opened, all trademarked Green House homes have had private bedrooms and bathrooms, 12 or fewer elders per home, a communal living room and dining room, an open kitchen, a staff work area, and access to the outdoors.

Moreover, the report states how smaller units assist with infection control. Green House homes are living proof of this. For example, in 2020, Green House homes had a COVID-19 infection rate per 1,000 elders that was only 48% (less than half) of the national nursing home infection rate. In 2021, the COVID-19 infection rate in Green House homes was even lower – this time 40% of the national nursing home infection rate. Additionally, Green House homes lost fewer elders to COVID-19, with death rates per 1,000 elders roughly one-third of the rate for nursing homes nationally in both 2020 and 2021.

And now for Goal Two.

Throughout the report, staff empowerment is raised both as a way to improve the workforce and to improve quality of care. Empowered Staff is one of the three values that all Green House homes are built on (the others are Real Home and Meaningful Life). And without an empowered team, the Green House model of care doesn’t work.

This empowerment is built on granting more autonomy to the frontline caregivers in daily decision-making, consistent staff assignments, and a coaching model of management.

Through several classes offered – including role/level-specific coaching classes – sites that work with GHP learn to restructure the traditional nursing home hierarchy into an alternative that creates better collaboration,  improves communication, and better utilizes caregivers’ skillsets.

But will this help address the workforce shortage? While it may not help a site immediately attract new employees, the Green House Project would argue yes, because staff empowerment improves retention. Turnover in Green House homes – especially at the CNA level – is significantly lower than the national average: 33% compared to well over 100% nationally. Staff appreciate the increased autonomy and respect afforded under the universal caregiver model.

Finally, there has been much discussion about the need to advance the role of the CNA – including the need to include the CNA as a member of the interdisciplinary care team. The Green House model of staffing is built upon a collaborative care team and respects the CNA as a vital part of that team. After all, who spends the most time with the elders? Who knows them best? Within the Green House homes, CNAs’ voices are valued and central to the care decision-making process.

The wide-ranging goals of the National Academies’ report puts responsibility on all of us – state agencies, CMS, payors, providers, health systems, and more – to make major changes to improve a nursing home system that does not provide the quality of care that it should. These recommendations are interconnected and need all parties to work together. It’s a call on all of us to do our part now, not tomorrow.

There are immediate steps everyone can take – within their respective industry/discipline/organization – to improve care.  For providers, this can begin with a move towards cultural transformation and staff empowerment. The Green House Project offers ready-to-use solutions and is eager to help.

Want more information on how The Green House Project can help your site undergo cultural transformation? Interested in further exploring staff empowerment? Please reach out to