Culture Change in Nursing Homes Improved Quality of Life During COVID

August 30, 2022 – Nursing homes that embraced culture change principles prior to COVID-19 largely maintained or expanded their efforts to focus on resident quality of life and person-centered care principles, a new study from a group of leading culture-change organizations has found.

Nearly three-quarters, or 71%, of key culture-change metrics were maintained or expanded within at least 60% of surveyed nursing homes, the non-profit Altarum found in a recently fielded survey. Other key findings from the group of 62 nursing homes in 30 states include:

  • 77% maintained or expanded efforts to learn and support residents’ interests
  • 87% had no restrictions on visitation as of March 2022, and 81% reconfigured or updated indoor space to better facilitate COVID-safe gatherings
  • 61% expanded support for virtual communication, such as assistance with video calls and e-mail

The surveyed homes consisted of communities affiliated with The Green House Project, Pioneer Network, the Eden Alternative, and the Live Oak Project – organizations dedicated to overhauling the institutional nursing home culture that far too often prioritizes operator convenience, efficiency, and profit over resident quality of life.

Despite the positive trends, culture change sites still faced challenges during the pandemic, with many reporting having to scale back group outings, intergenerational programming, resident input into mealtimes and menu selection, and other vital principles of nursing home culture change.

These results emphasize the real need to incorporate culture-change principles both more widely within nursing homes and more broadly in long-term care policy and regulations, particularly during current and future public health emergencies.

Altarum’s report and recommendations also build on other recent work that calls for both physical transformation of nursing homes – including conversions to all private rooms and bathrooms – and comprehensive culture change that puts residents, not finances or efficiency, at the center of all decisions.


“There is no one-size-fits all solution to the challenges facing long-term care in America, but we cannot go wrong when we put elders’ needs and wants ahead of all other considerations,” Green House Project senior director Susan Ryan said. “We must work together to ensure that these vital culture-change principles are incorporated into any and all post-COVID nursing home reforms.”

“Altarum is very pleased to learn that the creativity and flexibility inherent in person-centered care enabled these nursing home leaders to continue, and even expand, practices like resident choice in daily routines and supporting visits from people important to residents, during the pandemic,” Sarah Slocum, program director for delivery system transformation at Altarum, said. “We believe that person-centered care is key to resident quality of life and to nursing home quality improvement overall.”

“Enough already! The system of services and supports for elders and people with disabilities has failed. The time is NOW to reimagine, redesign, and transform the entire system, including reimbursement, regulation, architecture, staffing, and person-centered care, with a culture that works for the well-being of each person,” Live Oak Project co-founders Barry Barkan, Rose Marie Fagan, and Jeff Jerebker said.

“We are pleased to see the results of the Altarum research, and at the same time, not surprised that elder-directed care resulted in such positive outcomes – even in the midst of a pandemic,” Patrick Bultema, president and CEO of the Eden Alternative, said. “After all, it only makes sense that empowering elders to live the lives they want – recognizing changing abilities and circumstances – leads to greater wellbeing.  Furthermore, the research illustrates how this partnering approach to care is also better for staff.”

“This report shows us all what’s possible,” Pioneer Network CEO Penny Cook said. “If person-directed practices and principles can survive during a history-making pandemic, they can be implemented and practiced everywhere in the United States. It will take all of us to make that happen.”

Media Contact
Alex Spanko
Director of Communications
The Green House Project

Press Releases

  • Provider to operate first Green House community outside of the U.S. Linthicum, Md. and Elizabeth, South Australia, April 18, 2023 – The Center for Innovation (CFI) and ACH Group today announce that the Green House model of empowered eldercare will soon be implemented in Australia, marking the first formal expansion of the model outside of the United States. ACH Group, a provider based in South Australia, will implement the Green House model into its newest residential care home, Healthia, scheduled to open in Elizabeth in August 2023. “Introducing the Green House model of care outside of the U.S. is such a significant milestone for our organization, and we’re so pleased that ACH Group is the local operating partner that will make it happen,” CFI CEO Susan Ryan said. Since 2003, the Green House model has provided a vital alternative to traditional nursing homes and assisted living communities. With private rooms and bathrooms, ample outdoor space, and an elder-directed care philosophy, these small homes of no more than 10 to 12 elders have redefined the standard for empowering and high-quality eldercare. Operating partners across the U.S. have built and maintained nearly 400 Green House homes over the last 20 years. While several international organizations have adapted the Green House principles to their operations, Healthia marks the first community outside of the country to implement the model in its entirety. “Residents living at Healthia will feel an increased sense of control, have an improved quality of life, and a fulfilling and positive experience,” ACH Group CEO Frank Weits said. “There is an increasing urgency and growing expectation for change in Australia– driven by residents, customers, workers, and regulators alike – to move to a model of care where the priority is the older person’s preferences and staff skills are developed and nurtured. The Green House Project delivers this.” Leaders from CFI – the non-profit parent organization of both The Green House Project and Pioneer Network – will travel to Australia over the coming months to provide training and operational support ahead of the August opening. “ACH Group’s commitment to reimagining care services was clear from my very first conversations with leadership, and we can’t wait to partner with ACH Group,” Ryan said. “Together, we can create the empowering services and supports that older people in Australia, and everywhere else around the world, truly deserve.” About the Center for Innovation The Center for Innovation is the parent organization of The Green House Project and Pioneer Network, two non-profit groups dedicated to building the next generation of high-quality, empowering services and supports for elders. Whether we’re helping providers build small-home alternatives to traditional communal care settings, changing the operational culture of existing communities, or providing workforce training, CFI is the catalyst for person-directed living and empowered cultures in the community of one’s choice. About ACH Group ACH Group is a non-profit organization that has been offering services to support older people in living good lives since 1952. As well as accommodation options across Adelaide and the Fleurieu Peninsula, ACH Group offers a range of health, wellbeing, respite and support services, help at home, and social experiences. ACH Group’s 1,900 specialist staff and hundreds of volunteers share the belief that older people should be valued and respected, connected to their communities, and in control of their lives. Media Contact Alex Spanko, Director of Communications 516-587-2097

  • Former Pioneer board members to bring national, international perspective LINTHICUM, Md., January 19, 2023 – The Center for Innovation, Inc. (CFI) today announces the addition of Jessica Luh Kim and Thomas Gilmartin to the non-profit’s board of directors as the integration of The Green House Project and Pioneer Network teams continues. Kim and Gilmartin had previously served as executive members of Pioneer Network’s board, holding the respective roles of secretary and treasurer. “CFI is the new hub for changemakers and innovators, and we’re both honored and excited for Jessica and Tom to bring their unique experience, expertise, and perspective to our work in the years ahead,” CFI board chair Michele Holleran said. “Pioneer’s legacy of infusing person-directed care practices into all types of communal care settings – particularly through building grassroots coalitions of elders, caregivers, and those who care about them – is a cornerstone of CFI’s mission. Jessica and Tom are vital custodians and champions of that legacy.” Kim currently works as an independent consultant to senior living providers in Canada and the United States, drawing on her extensive experience in the field with the Ontario Retirement Communities Association, Schlegel Villages, and the Murray Alzheimer Research and Education Program at the University of Waterloo. “I’m excited to serve on the CFI board and support the coming together of two amazing organizations,” Kim said. “I look forward to what the future holds and grateful to be part of this new beginning.” Gilmartin is the chief financial officer for National Health Care Associates, Inc., an organization focused on providing short-term rehabilitation, skilled nursing, and post-acute care in six states within the Northeast. He has spent the majority of his career in the senior care sector, including senior housing and home- and community-based services (HCBS). “I am grateful for this tremendous opportunity to work collaboratively with other exceptional leaders from our industry as CFI advocates for systemic change,” Gilmartin said. “I look forward to working with like-minded leaders and organizations as they migrate from an institutional model of care to a more meaningful and rewarding home-based model of care.” The Green House Project and Pioneer Network formally combined under the CFI banner in 2022. “Together we will go farther than we ever could have separately, and the addition of Jessica and Tom to our board is proof of how this combination makes us stronger,” CFI CEO Susan Ryan said. “They bring years of experience in both the theory and practice of elder-directed care to the CFI board, and I’m eager to call on their counsel and vision for the work ahead of us.” About The Center for Innovation To learn more about the Green House-Pioneer alliance under CFI, visit Media Contact Alex Spanko, Director of Communications 516-587-2097

  • Green House, Pioneer Merge Executive Teams to Oversee Future Growth LINTHICUM, Md., November 28, 2022 – The Center for Innovation, Inc. (CFI) today announced a combined leadership structure for the newly allied Green House Project (GHP) and Pioneer Network, with executives from both organizations taking on new roles to oversee the continued growth of the long-term care reform groups. Susan Ryan will serve as the Center for Innovation’s first CEO, bringing her 35 years of experience in eldercare reform – with more than a decade at The Green House Project – to the top position. Ryan was most recently GHP’s senior director. Penny Cook is now the chief culture officer for CFI, with direct oversight of external relationships – including Pioneer’s nationwide network of state-level leaders and volunteers, as well as the LinkedUp peer network of Green House adopter organizations. Cook had previously served as president and CEO of Pioneer Network. Marla DeVries is the new chief learning officer for CFI, spearheading the non-profit’s internal and external education programming – including workforce development training, person-directed living certification, and leadership coaching classes. DeVries previously held the same position at GHP. Colleen Kammar will serve as the CFI’s chief financial officer, continuing a role she previously held at GHP. “CFI is the new home for eldercare transformation in all settings and for all elders, regardless of where they call home,” CFI board chair Michele Holleran said. “This new leadership structure will strengthen the existing power of the Green House and Pioneer brands while also expanding our reach – and deepening our impact – as we look to create new solutions for the entire continuum. Whether it’s nursing homes, assisted living communities, home- and community-based services, or anything in between, CFI will be at the forefront of person-directed living.” Taken together, the moves kick off a new era in the movement to bring true cultural and physical change to the eldercare system in the United States and around the world. “Seeing GHP grow to include more than 370 homes across 32 states has been a high point of my career, and I can’t wait to see where this team will take our mission into the future,” Ryan said. “This leadership team will honor the legacies of Green House and Pioneer while building on our experience, knowledge, and passion to blaze new trails in eldercare improvement and reform.” “GHP and Pioneer are all about culture – both in terms of transforming the culture of long-term care and harnessing the spirit of the individuals who have come together to demand better services and supports for elders and their families,” Cook said. “It’s my honor to serve as the custodian of that culture. I look forward to strengthening the GHP and Pioneer networks while welcoming new leaders, providers, advocates, and volunteers into our movement.” GHP and Pioneer announced a formal alliance earlier in 2022, with CFI serving as the parent organization of both groups. The new leadership structure was approved by CFI’s board of directors earlier this month and takes effect immediately. To celebrate the alliance and kick off this new era in eldercare transformation, CFI will host its first annual conference in Pittsburgh from July 23-26, 2023. For more information, visit Media ContactAlex SpankoDirector of

  • LINTHICUM, Md., October 17, 2022 – The GREEN HOUSE® Project (GHP) and Pioneer Network today announce the expansion of the Green House trademark to bring their flagship model of small-home care to more elders in more communities across the country. GHP granted approval to The New Jewish Home of New York City to use the Green House trademark on a new care community currently under development in Manhattan, becoming the first eldercare operator to undergo the updated trademark approval process. “For many years, providers have expressed a desire to adapt the Green House model to their communities’ unique needs, from land-use challenges to capital constraints to local regulatory issues,” Green House Project senior director Susan Ryan said. “This new approval process is the result of intensive work by our model integrity experts to ensure the correct balance between adaptability and adherence to the principles that set Green House homes apart from traditional hospital-style facilities.” The move comes as Green House and Pioneer officially reorganize under the banner of the Center for Innovation (CFI), a non-profit that will serve as the new central address for eldercare solutions. The Center for Innovation now provides a host of services for eldercare providers of all types, including: Workforce education and development support Green House home development Cultural transformation for traditional nursing homes and assisted living communities Memory care consultation The 174-year-old non-profit The New Jewish Home will use the Green House trademark on a new Rehabilitation and Community Healthcare Center, applying the small-home concept to a unique post-acute care community in Manhattan. Once opened, the community will be the first purpose-built Green House community exclusively designed for post-acute care, providing the latest equipment and technology, advanced infection control, and beautiful outdoor green spaces. “We are excited to partner with The Green House Project to enhance the clinical care we will provide at our state-of-the-art Rehabilitation and Community Healthcare Center,” said Dr. Jeffrey Farber, president and CEO of The New Jewish Home. “As we begin planning for what will be a tremendous resource for older adults looking to get well and go home, this collaboration means a commitment to revolutionizing the standard of care not only for our organization, but for others across the country.” CFI has compiled a list of frequently asked questions on the new trademark process and will be exhibiting at booth 1429 at the LeadingAge Annual Meeting + Expo in Denver from October 17-19. “We’re so pleased to welcome this new addition into Green House network, and we will continue to work with The New Jewish Home to help them provide top-quality care in these innovative Green House homes,” Ryan said. Media ContactAlex SpankoDirector of

  • LINTHICUM, Md. and ROCHESTER, N.Y., September 6, 2022 – The Green House Project (GHP) and Pioneer Network applaud the introduction of the IMPROVE Nursing Homes Act (H.R. 8677), legislation that would overhaul the nation’s outdated nursing home infrastructure and bring small-home care to 250,000 more Americans before the end of this decade. Introduced last month by Rep. Jan Schakowsky of Illinois, the bill would create a federal grant program to fund the development of small-home nursing communities with private rooms and bathrooms, easily accessible outdoor space, and fully elder-directed programming. “We are humbled and honored to see Green House and Pioneer principles take center stage in this proposed federal grant program,” Green House Project senior director Susan Ryan said. “The future of eldercare is small and elder-directed, and we want to work with advocates, policymakers, and officials across the country to make that a reality.” Crucially, the proposed grant program would also include strong oversight to ensure that operators use the grant funding for its intended purposes and provide elder-directed care services for years to come. “Creating a real home for elders, no matter their abilities, isn’t just about bricks and mortar,” Pioneer Network CEO Penny Cook said. “It’s about responding to their needs and giving them continued autonomy, making elder-directed principles a crucial part of any reform effort.” Research has shown that the Green House model – in which elders live in small homes of no more than 12 residents – provides superior quality of life, health care outcomes, and infection control for elders when compared to traditional nursing facilities. “America’s elders deserve high-quality care in the setting of their choice,” Ryan said. “For those who prefer or require care in a communal setting, the Green House small-home model is the gold standard.” Green House and Pioneer also thank the diverse group of reform and resident advocacy organizations – the Center for Medicare Advocacy, Justice in Aging, the Long-Term Care Community Coalition, and the National Consumer Voice for Quality Long-Term Care – for endorsing the legislation. Media Contact Alex Spanko Director of Communications 516-587-2097