THE GREEN HOUSE® Frequently Asked Questions
BECOMING A GREEN HOUSE® PROJECT!
1) I understand that you have received a grant of several million dollars to create Green House® homes in all 50 states. Can you clarify this and describe how it impacts a group establishing a Green House® project?
The Robert Wood Johnson Foundation awarded a grant to NCB Capital Impact's Community Solutions Group to support the development of fifty projects across the United States through THE GREEN HOUSE® Replication initiative. Under the grant, The Green House Project:
- Provides 30 months of direct technical assistance (from the design stage through six months’ post-occupancy) to organizations accepted into the program through an application process
- Develops tools and resources for adopters to support development and implementation of the model
- Provides orientations and specialized on-site training for project staff, including the caregivers, clinical support team, and organizational leadership
- Offers subsidized fees for the first 50 projects
- Provides predevelopment loans to accepted nonprofit groups
- Conducts ongoing research to improve the model
Projects are governed by The Green House principles and only accepted projects are authorized to provide long-term care services under the licensed service mark: THE GREEN HOUSE®. Review the steps to becoming a Green House® project.
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2) My company is interested in The Green House project. How do I get started?
There are several steps to becoming a Green House Project. Please see Information & Workshops for details. Major steps are summarized below.
- Review The Green House Project Guide Book, which provides an overview of the model and several resources that will help organizations understand the philosophy and organizational requirements of The Green House model.
- Attend an 8-hour orientation workshop at a Green House® training center.
- Apply to The Green House Replication Initiative after attending an orientation workshop.
- Demonstrate capacity and willingness to comply with The Green House principles (through an online readiness survey). For more information, contact Marilyn Ellis at (703) 647-2313.
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3) If my organization does not have experience in long-term care, do we need to partner with another entity in order to be successful?
As a start-up, organizations may need to seek help from successful developers and/or long-term care operators. Consider partnering with a development consultant or an organization with experience operating long-term care in residential settings; or partner with someone who already has a Certificate of Need, which is required in most states for a Green House® to be licensed as a nursing home. Service providers may include home health agencies, local health care providers, or an existing nursing home.
In addition to their having a commitment to providing quality care for elders, organizations or individuals planning to become early Green House® adopters are evaluated on the basis of their experience and ability to obtain funding. Groups should have a h4 management team in place. The Green House team can provide some guidance on fundraising options.
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4) Is there a fee to participate in The Green House Replication Initiative?
The Green House Project offers subsidized fees to early adopters through the Robert Wood Johnson Foundation grant. Fees are based on the size of the project and the number of phases required to complete the project.
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5) Does The Green House Project offer individual grants to organizations?
While individual grants are not available to Green House® adopters, technical assistance fees for the first 50 Green House® projects are heavily subsidized by The Robert Wood Johnson Foundation. Learn more about The Green House Replication Initiative.
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6) Is The Green House model a franchise?
The Green House Project is not a franchise, but it shares some similarities with franchise models: First, The Green House Project licenses THE GREEN HOUSE® service mark to adopting organizations. Second, The Green House Project provides tools and technical assistance to help groups start up and manage their Green House® Projects.
The difference between The Green House Project and a conventional franchise model is that a typical franchisor takes a percentage of franchisee revenues and generally makes decisions in order to maximize franchisor profits. Although The Green House Project will charge a nominal annual fee to support The Green House network of providers, it does not charge a percentage of revenues.
In addition, The Green House Project is part of a nonprofit organization. The Green House Project makes decisions first and foremost to promote residents’ quality of life and to further The Green House model of high-quality long-term care.
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GREEN HOUSE® SPONSORS
7) What is a Green House® sponsor?
A sponsoring organization supplies or arranges the delivery of health care to the elders in a Green House® home and organizes and/or manages the personnel, fiscal, administrative and office management functions.
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8) Can a private individual own a Green House and contract with a health care organization to provide the clinical services and office management functions?
Yes. The entity would be considered for-profit.
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9) Does The Green House Project require that the Guide, or administrator, be a Licensed Nursing Home Administrator (LNHA) or does it depend on the state’s regulations?
The Guide can be a Licensed Nursing Home Administrator, but it depends on the state's regulations. If the state requires a LNHA in a skilled nursing facility, the required LNHA may serve as the Guide, although this is not required by The Green House Project. The person serving as a Green House® Guide should be the most qualified person for the position. If this is not the LNHA, the organization determines the appropriate relationship between the Guide and the LNHA to meet state requirements.
The Guide serves as coach and supervisor to the Shahbazim or direct care workers, and is responsible for the overall operations and quality of services in the home. The Guide should be a person who supports The Green House mission, and who has the experience, willingness, and time to manage a self-directed work team in one or more Green House® homes, depending on the size of the community.
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10) I represent a for-profit organization. Can I participate in The Green House project?
Green House® homes may be developed by individuals and organizations (nonprofit and for-profit) that can provide a high level of services and care to elders under the licensing structure of their state.
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11) Can I donate equipment (e.g., computers, golf carts for visiting other homes) to The Green House homes?
Each Green House® project is run independently. You can contact a specific Green House® sponsoring organization to discuss your donation. See a list of Green House projects.
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LICENSING A GREEN HOUSE® PROJECT
12) What type of license is required to run a Green House® home?
Green House® homes may be licensed as nursing homes (which will most often require a Certificate of Need from the state) or assisted living, depending on your state’s licensing guidelines.
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13) What are my options if there is a moratorium on nursing home beds in my state?
Some options to explore include purchasing/transferring licensed beds from an existing nursing care provider in the state or partnering with an organization that has licensed beds that might be interested in transitioning them to Green House® homes.
In some circumstances, a Green House® project may be licensed as Assisted Living (or the state equivalent category for this level of care). Assisted Living licensure is an option for Green House® homes only in states where the regulatory requirements support aging in place in Assisted Living and the provider organization is willing to make a commitment to supporting elders in The Green House homes with needed services to enable them to live out the remainder of their lives in the setting. This includes having provisions in place both for service delivery (directly or through an outside service provider) to meet a high level of medical need/acuity as well as sufficient financial capacity/reserves to cover the cost of care for individuals living in a Green House® home who deplete their assets and no longer have an ability to pay.
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14) I want to develop a project similar to a Green House® project. Can I use The Green House name?
Only projects accepted through the initiative’s application process and developed in cooperation with The Green House Project team are authorized to provide long-term care services under the licensed service mark: THE GREEN HOUSE®. These projects are governed by a specific set of Green House® Quality Standards, which are described in The Green House Project Guide Book. Please see Information & Workshops for details.
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CULTURE CHANGE
15) What is the difference between Culture Change, the Eden Alternative and The Green House Project?
- Culture Change: Is the broad generic term (umbrella) that may range from small modifications such as introducing plants and animals in a traditional nursing home environment to very significant changes in organizational structure and operating principles.
- Eden Alternative: Is a specific culture change model for improving the physical environment and altering the organizational structure to improve residents’ care, with the goal of providing a home like environment with control in the hands of the residents, all within the current nursing home environment.
- The Green House Project: Is a specific approach to changing the nursing home culture and environment. The Green House model focuses on deinstitutionalizing elders, moving to a small house setting, changing the organizational structure, and providing sustainable skilled nursing care in a truly home like environment and with a philosophy that supports continued growth, engagement and meaning for elders.
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16) What role do families play in a Green House® home?
Family participation is encouraged and welcomed in The Green House home, from sharing meals with loved ones and participating in activities, to volunteering time and services or helping the elder to decorate his or her personal space. Well-behaved family pets also are welcome to visit if elders in the house have no medical restrictions.
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17) Does The Green House Project want to partner with community organizations like churches, schools, civic groups etc?
Several faith-based groups are already Green House® adopters and others provide in-home services or have arranged transportation to places of worship in the community. Schools also have partnered with Green House® communities to provide entertainment for elders on holidays and special occasions. See a list of current Green House projects.
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STAFFING
18) The Green House calls for staffing homes with a very different model of trained employees rather than “aides”. Is there specific training available for these positions that are a relatively new concept?
The direct care workers in a Green House® project are universal workers, called Shahbazim, with core training as Certified Nursing Assistants. They typically receive about 120 additional hours of specialized training in preparation to take on their new roles. The curriculum covers The Green House philosophy of care, policies and procedures for their specific project, communications skills, culinary training and safe food handling, and certification in first aid and CPR.
The Shahbazim in each house form a self-managed work team that provides 24-hour care to 7-10 elders at a staffing ratio of four hours per elder per day. They are responsible for a variety of tasks, including: menu planning and daily meal preparation, laundry and light housekeeping, personal care, and communications with the clinical team, families, and the community.
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19) How does the staffing in a Green House® home compare to a traditional nursing home?
Under The Green House model, some positions may be eliminated or reduced, with funds typically shifted away from some administrative and ancillary departments toward the elders’ direct care. The clinical team, which includes nurses, therapists, social services, activities and dietary professionals, works in partnership with the Shahbazim to develop and implement individualized care plans for the elders.
See The Green House Project Guide Book for an illustration of how staffing shifts under The Green House model as compared to a traditional nursing home model. See Information & Workshops for instructions on how to request a free Guide Book.
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20) If there is no nurses’ station in The Green House home, who cares for the elders?
- A Clinical Team will provide skilled care for the residents as required in the care plan. The Shahbazim, by developing close relationships with elders, will provide the Clinical Team with valuable information to assist in the development of the care plan.
- The Clinical Team is comprised of a Medical Director, Director of Nursing, nurses, therapists, social workers, dietician, and activities coordinator.
- Typically, one nurse will support two to three Green House® homes (20-30 residents) depending on the elders’ needs and time of day.
- Licensed nurses are available to and responsible for clinical care in Green House® homes on a 24-hour basis. At any time, if a nurse is not in a home and is needed, he or she is available to Shahbazim and elders via emergency pager and other communications technologies.
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21) Is there a physician directly related to The Green House home or do elders keep their own physicians?
As in any nursing home, elders may choose to retain their personal physician or to use the project’s medical director as their primary care physician.
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22) What are the average Green House® home staffing costs?
The salaries for the direct care workers in The Green House homes will vary, depending on the area. Because the Shahbazim, with core training as Certified Nursing Assistants (CNAs), assume more responsibilities under The Green House model, we recommend that they receive a salary increase that is at least 10% above what CNAs currently are paid to work in the traditional nursing home. To prepare them for their new responsibilities, CNAs receive approximately 120 additional hours of training, ranging from safe food handling and culinary training to communications skills and household operations.
23) The Green House Project uses different terminology to describe the staff, such as: Shahbaz, Guide and Sage. Who are they and what are their roles?
- The Shahbaz is a universal worker who provides personal care, meal planning and preparation, light housekeeping, and laundry for 7-10 elders. The plural form of the word is Shahbazim. Read about the origins of the first Shahbaz (PDF, 59 KB).*
- The Guide serves as coach and supervisor to the Shahbazim, and is responsible for the overall operations and quality of services in the home. The Guide may be responsible for one or more Green House® homes, depending on the size of the community.
- The Sage is a local elder who acts as a coach or mentor, assisting to facilitate the development and continued growth of the self-managed work team and to serve as a trusted advisor to the Shahbazim. This is a volunteer position.
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ARCHITECTURE
24) In the U.S., there are some religious denominations that provide a blue print for the construction of their churches. They all have the same design. Are Green House® homes like that?
There are elements of a Green House® home that are common throughout the model to achieve desired outcomes, but the homes will look different in each community: single family homes in the suburbs, apartments in urban areas. Architects should design a home that fits into the surrounding community, but retains the core elements: 10-person home, private bath and bedroom for each elder with locked medicine cabinet, hearth area with open living room, dining room and kitchen, dining table that seats all elders and caregivers, ceiling lifts, fenced outdoor space, and lots of windows. Sizes range from 6,000 – 7,000 square feet.
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25) If I have an existing house, can I convert it to a Green House® home?
In most cases, new construction is necessary to meet the model’s specific design and quality standards. The Green House Team will work with your architect to develop a floor plan that meets these requirements and must review and approve the architectural plans. View a typical floor plan (PDF). You will find examples of other floor plans in The Green House Project Guide Book. See Information & Workshops for instructions on how to request a free Guide Book.
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26) What is the square footage of a Green House® home?
A typical one-story Green House® home averages 6,400 square feet, but may be as large as 7,400 square feet, depending on the size of the bedrooms. A Green House® home designed for a high-rise building may include two or more Green House® homes per floor.
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27) In a high-rise Green House® home, is it possible to add a staircase between the homes on each floor?
Green House® homes can share an elevator and emergency exit stairway, but must have separate entrances and do not share other spaces or services between the homes.
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28) What is the lot size for a Green House® home?
While there is no standard lot size, homes may be situated on lots ranging from one-quarter acre to one acre, as long as there is ample space for front and back yards, a porch (or balconies, if a high-rise), public access to services (which will be governed by local guidelines) and access for emergency vehicles. The project should also consider family/visitor parking areas.
If the houses are located within the community, two Green House® homes should be built on adjacent lots at each location to allow the nurse to move quickly between the homes. According to the current staffing plan, one nurse is assigned to every two Green House® homes.
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29) What is the square footage of the bedrooms in The Green House home?
Bedrooms typically are approximately 210 net square feet.
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30) The Green House model provides a private bedroom and bath for each resident. What happens when a spouse also wants to live in the same home?
Couples may share a bedroom in the same home, occupy separate bedrooms in the same home, or live in a separate house in the same Green House® home community. Because regulations will prevent a Green House® home from exceeding the licensed capacity, a couple who choose to share a bedroom will typically occupy two rooms with a door opened between them. The second room can then serve as a sitting area or other living space.
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FINANCIAL FEASIBILITY
31) My organization wants to start a Green House® project, but we don’t know if it is feasible. Can you help?
The Green House Team will:
- Provide a financial feasibility analysis tool to assist organizations in developing an estimated operating budget, based on their individual project requirements,
- Review and assess the project’s development budget and the organization’s audited financial statements,
- Provide guidance around the organization’s market and feasibility studies, and
- Assist with identifying potential capital funding sources and fundraising options.
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CONSTRUCTION COSTS
32) What is the projected cost for a Green House® project?
Average construction costs for a typical one-story Green House® home range from $1,200,000 - $1,500,000, though can be substantially higher depending on local costs and project-specific decisions about design, finishes, etc. Generally, costs for a one-story, 10-bedroom Green House® home fall roughly in the middle of the range between multi-family residential and institutional construction costs, and will vary depending on the location. For a Green House® home developed in a multi-story building, the costs are closer to institutional construction costs. Please contact an architect in your area for more information on typical local construction costs.
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GREEN HOUSE® FORUM
33) What is The Green House Forum?
The purpose of the forum is to provide networking capabilities for Green House® homes nationwide. It is a web-based collaboration workspace where adopters can share experiences and best practices or post a question and receive feedback from The Green House team and colleagues who are Green House® pioneers.
34) Can anyone participate in The Green House Forum?
The Green House Replication Initiative invites only projects that have been accepted into the program through an application process to join the forum. Learn more about the steps to becoming a Green House® project.
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GREEN HOUSE® PAYOR SOURCES
35) What costs does a resident incur living in a Green House® home?
- Medicaid: The costs are equivalent to the traditional Medicaid costs for nursing homes. If the income level is above the Medicaid minimum, there may be a co-pay.
- Private Pay: Each facility determines its own private pay cost structure based on their local market.
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36) Are Green House® homes eligible for Medicaid and Medicare reimbursement along the same lines that a traditional long-term care facility would be?
Yes, for nursing homes. If licensed as assisted living, Medicaid reimbursement depends on the state's assisted living provisions.
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37) Can Green House® homes deny residence to individuals based on income status?
- Individual Green House providers may determine accepted payment sources for new admissions. It is an expectation of The Green House Project, however, that a participating project must agree to maintain elders who spend down their funds in their Green House® homes. This can be done through Medicaid or other resources provided by the sponsoring organization (e.g., a charitable foundation).
- The resident's care may be covered by Medicaid, private pay and under limited circumstances, Medicare.
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38) What does it cost to live in a Green House® home?
Medicaid, private pay and limited Medicare, may cover the elder’s care. The cost per elder per day depends on the cost structure in your area. Green House® homes that are licensed as traditional nursing homes are eligible for Medicaid and Medicare reimbursements along the same lines as a traditional nursing home. If licensed as assisted living, Medicaid reimbursement depends on the state’s assisted living provisions.
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FINANCING A GREEN HOUSE® PROJECT
39) I would like to apply for a Green House® grant. What is the grant process?
The Green House Replication Initiative, funded by the Robert Wood Johnson Foundation, does not award grants to individual organizations. Organizations are accepted into The Green House Project through an application process. The Foundation’s grant to NCB Capital Impact’s Community Solutions Group subsidizes the technical assistance fees paid by early Green House® adopters. Review the steps to becoming a Green House® project.
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40) Does The Green House Replication Initiative offer loan financing?
The Green House Project does not finance construction loans. However, nonprofit organizations are eligible for predevelopment loan (PDL) financing to secure an architect, engineer, site, feasibility and/or market studies, and other non-construction-related costs. The PDL Fund is available only to projects that have been accepted as participants in The Green House Replication Initiative. Learn more about the PDL loan fund.
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41) Do you know of Bricks and Mortar Funding sources?
Organizations first should explore local lenders. The Green House team can provide information on potential funding sources. Learn more about the PDL loan fund.
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42) Describe the typical operational funding that is being used?
Many projects use bond financing to develop their Green House® residences. Some also access conventional bank financing, tax credits and other financial vehicles. Many also conduct a capital campaign to raise charitable funds and reduce the debt required finance the project.
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43) What are some sources for making grants for such a project?
Most organizations are doing fundraising campaigns (high-volume donors—most groups know who they are and how to approach them because of previous contributions). The Green House team works with organizations and local fundraising consultants to develop a fundraising strategy.
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REGULATION AND LEGISLATION
44) What are the hurdles (political, legislative, regulatory, waivers, financial, etc.) we have to address to get approval to move forward with building a Green House® project?
- Political: The state may have too many nursing home beds currently in service and be trying to reduce overall capacity. It is difficult to obtain a Certificate of Need (CON) for new nursing home beds and even, in some cases, to transfer existing beds from one location to another.
- Legislative: Organizations can introduce a bill requesting approval to start a pilot Green House® project. Two projects (in MA and NY) successfully used the legislative process to get CONs. Learn more about Regulation & Legislation.
- Regulatory: After obtaining a CON, there should be no regulatory obstacles at the federal level. The project has buy-in from the Centers for Medicare and Medicaid Services (CMS). CMS has provided opportunities for The Green House team to educate national and regional staff, as well as state survey agency leadership about the model. They have also provided written confirmation that The Green House model is not in conflict with any federal nursing home requirements. Download the CMS letter on our Regulation & Legislation page.
- Financial: Inexperienced groups need someone with experience in the financial, regulatory approval and licensing process and should find a partner who can remain with the group for the life of the project. The Green House Team will work with organizations on a case-by-case basis on financial feasibility assessments. Keep in mind that the nursing home business is tough.
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RESEARCH
45) What research has been conducted on The Green House model?
The initial Green House® pilot project, located in Tupelo, MS, was the subject of a two-year study funded by the Commonwealth Fund and conducted by Dr. Rosalie Kane and a team from the University of Minnesota. The research team collected information from residents, primary family caregivers, and staff in four Green House® homes and two nursing homes. The results of the study were published in the Journal of the American Geriatrics Society in June 2007: “Resident Outcomes in Small-House Nursing Homes: A Longitudinal Evaluation of the Initial Green House Program” (Vol. 55, Issue 6, Pages 832-839). Visit Research & Resources to download the study.
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46) What impact does The Green House model have on the health and well-being of the elders?
In the findings comparing The Green House homes to the traditional nursing care settings, The Green House® homes reported:
- Higher satisfaction levels reported by residents, family and staff
- Less decline in late-loss Activities of Daily Living (ADL) [late-loss ADLs include bed mobility, transfer, eating and toileting]
- Less prevalence of depression
- Increased sense of privacy, dignity and individuality for elders
- More meaningful activity, relationships and food enjoyment
For more information, read the study by Dr. Rosalie Kane and researchers from the University of Minnesota on our Research & Resources web page.
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WHERE TO FIND A GREEN HOUSE® PROJECT
47) I would like to move my parent from a nursing home to a Green House® home. Where can I find one?
Currently, there are 11 operating Green House® projects throughout the country. Please contact each Green House® sponsoring organization for more information. See current Green House projects.
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48) When will Green House homes be built in my state?
Green House® projects are planned in over 20 states. See current Green House projects in development.
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GREEN HOUSE® GUIDE BOOK
49) How can I order The Green House Guide Book?
The Guide Book explains key components of the model. See Information & Workshops for instuctions on how to order a copy.
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GREEN HOUSE® VIDEO (DVD)
50) Where can I find a copy of The Green House video?
A new FREE Green House® DVD, "Where Love Matters," was released in November 2008. This 35-minute video highlights the successes, challenges and stories of four operating Green House® projects, as told by elders, staff, and family members. It includes an overview of The Green House model. Order DVD now.
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GREEN HOUSE® ORIENTATION WORKSHOPS
51) Where can I find a list of Green House® orientation workshops?
The workshops are designed to answer many of the questions organizations have about the model. Sessions are held at a Green House® training center and include a visit to The Green House homes. Review the currentworkshop schedule, download anagenda, and register via our Information & Workshops web page.
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52) What topics are covered at The Green House workshop?
Learn the key elements of the model, including the foundational philosophy, the architectural characteristics of Green House® homes, and the organizational redesign. The presentation will include the implementation story of the host Green House® project and the progress of The Green House® Replication Initiative, including tools for adopters and Green House® research outcomes.
The session includes a visit to The Green House homes and discussions with the host Green House® Project team. Review the current workshop schedule, download an agenda, and register via our Information & Workshops web page.
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53)Does The Green House Project offer Continuing Education Credits for its 8-hour introductory workshop?
No. Participants may request a certificate of completion that includes the date, location and total number of training hours.
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54) I would like to learn more about The Green House Project, but I am not a long-term care provider. Is the workshop open to anyone?
Yes. Anyone interested in learning about the model can attend a workshop. The first step is torequest a free copy of The Green House Project Guide Book, which explains the key components of the model. If you are interested in learning more after reading the Guide Book, register for a workshop. For details on how to request a Guide Book and subsequent steps, see our Information & Workshops web page.
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CONTACT US
55) For more information about The Green House Project:
- Visit our website: www.ncbcapitalimpact.org/thegreenhouse. Request a free copy of The Green House Project Guide Book and receive information about the 8-hour orientation workshops.
- Contact Marilyn Ellis, (703) 647-2313
- Mail: The Green House Project, NCB Capital Impact, 2011 Crystal Drive, Suite 800, Arlington, VA 22202
- The Green House Forum (only for Green House® Adopters): Contact Marilyn Ellis,(703) 647-2313
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