This article appeared, in slightly shorter form, in Human Life Review, Spring 2007. Copyright © 2007 by Mary Meehan.
Back to Eden?
Ah, the dread of living in a traditional nursing home! Many people view it as life in a warehouse where residents are fork-lifted like so many boxes, carted around, and then dumped somewhere they don't want to be. Or a long stretch in solitary for inmates who already live in confusion. Or the last, bleak stop on the railroad for passengers who are old and frail.
There is, though, a strong movement to transform nursing homes into modern-day Gardens of Eden. This approach, called the Eden Alternative, dates back to the early 1990s. It offers seniors with disabilities a way to avoid the ultra-medical nursing home with its rigidity, loneliness, and depression. The Eden homes meet the medical needs of their residents--sometimes better than traditional homes do--but they also provide a more natural environment for living. They emphasize the joy and spontaneity of life.
The approximately 255 Eden homes in the United States(1) do not form a chain. Rather, they share a philosophy and many ideas on ways to implement it. Some Eden homes are privately-owned; many are non-profits; and many have religious connections. Recently I visited one Eden home in Maryland and two in Western Pennsylvania, spoke with staff, and observed the residents.(2) The three used to be traditional nursing homes, but have been on the Eden path for five to eight years. They contemplate more change as they continue down that path.
A friendly receptionist greeted me at the Levindale Hebrew Geriatric Center, a non-profit home in Baltimore, Md., in late January. Later a French poodle named Lincoln bounded into the sunny reception area and added his welcome. Other dogs, cats, birds, and fish abound at Levindale. It's part of a large complex of Jewish institutions, including a hospital, an adult day-care center, and a child-care center. There's much interaction between the kids and the older folks. From the nursing home lobby, a gazebo outside, or the adult day-care center, the elders can watch the children at play. The term "elders," which Eden homes prefer for their residents, emphasizes respect for the experience and wisdom of seniors--a respect that is key to the Eden philosophy.
Levindale staff member Heather Allen said a school group visits with elders, "and they break the challah bread." Communications coordinator Helene King remarked that such visits are nice for the children, too, especially since some have no grandparents in the area. One local mother, home-schooling her large family, brings her kids in once a week to visit with the elders. Another brings her baby in to visit. The children, King noted, "definitely brighten up the place."
Freshly-brewed coffee and freshly-baked bread are available to the elders on their halls during the day. The home meets the clinical need for good hydration partly by sending an old-fashioned vendor cart (blue-and-white-striped) up and down the halls with sodas and ice cream. In a late-afternoon happy hour, the elders can sip beer, wine or non-alcoholic drinks while chatting and listening to old-time music.
Levindale has its own synagogue, a large, peaceful room where there are Sabbath and Holy Day services, as well as daily prayers. Its rabbi is the home's full-time chaplain. While Jewish residents predominate, many others are Christians, and another room is available for their regular services.
At Rolling Fields in rural Conneautville, Pa., about 30 miles southwest of Erie, I was greeted by a receptionist and also by Gabby, a lovely cockatoo who lives in a huge cage in the lobby. She was not truly gabby when I was there; but after looking me over for awhile, she did say a few words.
On a tour, I saw dogs in the corridors and cats visiting with residents or staff. Chester, a big dog with soulful eyes, is a special favorite. Some residents have birds in their rooms.
It was a cold day in February, with lots of snow on the ground, so I couldn't really see the gardens outside. But Cindy Godfrey, vice president of Rolling Fields, told me about a vegetable garden in which residents had grown "the most gorgeous vegetables and entered them in the county fair," where the beets won a prize. She said there's also a cut-flower garden, a tranquillity garden, and "an enchanted garden with a couple of Koi ponds." Kimberly Moody, Cindy's sister and the home's administrator, told me about the large catch-and-release fishing pond, where some residents fish every day in good weather.
Rolling Fields, privately-owned, is very much a family enterprise. The sisters' parents started it many years ago in a smaller, home-like building that had to be replaced when it no longer could meet code. One sister explained that their Eden program is a return to the spirit of the original home. It includes afternoon tea in the lobby, as well as a happy hour. And as part of a continuing effort to get away from schedule rigidity, Rolling Fields offers a continental breakfast from 6-7:30 a.m. and a hot breakfast buffet from 7:30-9:30, thus accommodating both early risers and those who prefer to sleep in. A child-care center in the home is a major convenience for staff with small children. It's also a source of joy for the elders, who can talk with the kids or do arts and crafts with them.
Beacon Ridge is a private, non-profit Eden home in Indiana, Pa. A county seat with a population of 15,000, Indiana is surrounded by a rural area with many Christmas-tree farms. It used to be a major coal-mining area, too; so many Beacon Ridge elders come from farming or mining families. While its administrator said the home has "a Christian-based philosophy," it is not affiliated with a specific church.
The elders enjoy regular visits from kids who attend a child-care center next door. There's also a "junior volunteer" program involving children who are 8 or older. Administrator Kelly Pidgeon explained that this started as a summertime convenience for staff with children from 8-13 years old, because "you can't leave 'em at home, but they don't want to be at camp all day." So, she said, staff "just bring their kids to work," and the elders "love having all the kids around." The children help the elders, and elders read to the kids or teach them how to bake, sew, knit, crochet, or work the gardens outside.
Beacon Ridge also has resident pets, including two guinea pigs that have a calming effect on seniors who "are agitated or just completely out of sorts," Pidgeon said. An approach of "Have a pig, not a pill" often works in these cases. Ronald Conrad, the nursing director, noted that his wife's grandmother lives in the home and is greatly helped by a cat who practically "lives above her chair." The varied activities available at Beacon Ridge include a quilting group and a men's club.
Impressive as the three homes' amenities are, they do not fully explain the difference that the Eden approach makes. Michelle Mills, a Levindale staff member, remarked that "a lot of folks think that Eden is the cats and the dogs and the kids." But the "real crux" of it, she says, is providing care that is truly resident-centered, so that "we're doing what a resident would do if they were home." If an elder wants coffee and chocolate-chip cookies at two in the afternoon, for example, the relevant question is, "How do we make that happen?"
Eden planners realize that making it happen requires staff relations very different from those in traditional nursing homes. Old-style homes have what Eden founder Dr. William Thomas calls "a paramilitary command structure." He adds, "Tightly restrict workers' daily routines with rules and regulations, and you can expect the same to be visited on residents. Adopt a punitive stance toward mistakes and shortcomings, and residents will suffer under the same lash."(3)
The Eden philosophy replaces the old style with a team approach in which staff have more responsibility and initiative. Kelly Pidgeon has a three-fold goal for Beacon Ridge: "Not only do we want to make it the best place for residents to live; we want to make it the best place to work, and we want to make it the best place to visit. She likes to throw out challenges to her staff so they can improve the elders' quality of life and clinical outcomes at the same time. One challenge was: "Guys, we need a better hydration." Someone came up with a nifty solution: providing elders with water bottles that rest in holders on their walkers or wheelchairs. Like bikers out on a mountain trail, they now have water right at hand when they need it.
At Levindale, every staff member--including adminstrators, bookkeepers, housekeepers--is supposed to have some hands-on contact with the elders. This could be, Heather Allen explained, taking elders to a birthday party, taking care of plants in one area, feeding someone who needs assistance, or just visiting with an elder. She said that "we like to see every staff member involved about 30 minutes a week at least."
The more relaxed Eden atmosphere appears to make a real difference at all three homes. Staff seem more at ease, less hurried, and more friendly than in traditional homes. Residents, too, seem more contented and secure, and a visitor sees more of their individual personalities. When I dropped by to see the quilting group at Beacon Ridge, most of the ladies were very intent upon their work, each sewing a square from fabric they had selected on a shopping trip. Most spoke little, but one joshed a staff member who was also working on the quilt. The home's oldest resident, a venerable 102, stopped by to check on the quilters' progress. Propelling her wheelchair with the walking motion of her feet, and appearing to be quite alert, she watched and listened for a few minutes and then continued on her rounds. Activities director Deborah Fenner told me the oldest resident is a veteran of knitting, crocheting, and even the old art of "tatting" (a form of lace-making).
Doctor with a Vision
When Bill Thomas attended Harvard Medical School in the 1980s, both medical staff and students there focused on "rare and interesting diseases" instead of "the ordinary burdens of age, disability, and decay." In his four years as a medical student, he writes, "I never set foot inside a nursing home." As a young doctor, he loved to deliver babies and to care for young children; but he tried to avoid nursing home patients. After all, "My medical training had led me to think of myself as a master mechanic who happened to specialize in the human body.... Struggling to keep a worn-out jalopy on the road is drudgery compared with fine-tuning a late-model sports car."(4)
After experience in family practice and emergency-room work, though, Thomas wanted a change. Someone persuaded him to consider becoming medical director of a nursing home. "Three weeks later, still wondering what I had gotten myself into, I was a nursing home doctor." He found that he liked working with older patients, yet he was still bothered by the sterility and rigidity of nursing home life. He felt that loneliness, helplessness, and boredom--rather than physical ailments--caused most of the residents' suffering. And it wasn't just tradition that caused the rigidity; it was also the dependence on Medicare, Medicaid, and other health insurance. "Because these programs have the greatest experience and comfort with hospital-like arrangements," Thomas says, "nursing homes devote considerable time and attention to remaining as much like hospitals as possible.... Reimbursement is based on the variety and number of treatments rendered.... For nursing home residents, life is therapy, and therapy is life."(5)
With admirable energy, Thomas and his colleagues at the 80-bed Chase Memorial Nursing Home, New Berlin, N.Y., set about making Chase a happier place for its residents. The key, he says, was to view it "as a human habitat" and to copy the rich diversity of natural habitats. "Why shouldn't we have pets here?" they wondered. "Why not bring houseplants into our home? Not just a few, but hundreds?.... Why not start a summer camp for children? What about an after-school program?.... Why settle for a lawn when we could replace it with a lush garden of flowers and vegetables? Why not grace our residents' dinner plates with delicious food grown right outside their windows?" With the help of a grant from the New York State Department of Health, they were off and running.(6)
They were able to do everything they planned, and even more. Changing the top-down staff structure to a team approach was essential to their success. Combined with the other changes, this made a major difference at Chase. Restoring the joy of life to the elders was the greatest improvement. But there were also clinical benefits: significant reductions in infections, the use of mind-altering drugs, and the death rate. There was a major drop in staff turnover, which tends to be alarmingly high in traditional homes. As Thomas notes, "reducing staff turnover is one key to improving residents' quality of life."(7)
One might guess that Eden improvements add a great deal to nursing home costs that already are quite high. Thomas, though, says Eden "requires much more change in the heart than in the pocket" and that "costs are minimal compared with the facility's total budget." He adds that "start-up funds and supplies can often be procured from community and philanthropic groups."(8) And he emphasizes the savings from better clinical outcomes and lower staff turnover.
My interviews and research confirmed these points, with one exception. When Eden involves major additions or renovations to promote a more home-like atmosphere, there is no way to avoid high costs. Levindale, for example, began its Eden journey in 1999. Three years later, the Washington Post reported that Levindale had "spent $60,000 on a children's playground, $70,000 on a greenhouse and $500,000 on a cafe-style dining room for residents." But Eden resulted in a much higher occupancy rate, which helped offset the higher costs.(9) Moreover, both a strong Levindale Auxiliary group and private foundations have made substantial contributions toward the home's Eden transformation.
Changing the Mind-Set
What's the hardest part of changing over to the Eden approach? Dealing with regulators and inspectors? Or coping with older buildings that were designed like hospitals? Both present problems; but Kelly Pidgeon, the Beacon Ridge administrator, said the key problem is mind-set. Involved in nursing home work for 18 years, she remarked that "when you're in a particular industry that is very highly governed by rules, it's hard to change. And change, from any perspective, for anyone, is difficult."
One of her staff emphasized the challenge of "trying to get the other employees to buy into the whole concept" and "not think of it as just a job." Deb Fenner, the activities director, believes staff thought the Eden approach "was going to be more work for them." How do they respond now? "They're getting better," Fenner replied, to laughter from other Beacon Ridge leaders. "We'll be honest: They're getting better." Nursing director Ron Conrad sounded more optimistic, suggesting that "we're very close to having a good buy-in throughout the whole facility." The sharp drop in staff turnover suggests he is right. Pidgeon said it used to be around 70 percent a year, then dropped down to 50, and is now in the teens, which "is unheard of." It has taken a lot of training to reach this point. Pidgeon herself does the Eden training at Beacon Ridge. It involves a significant cost, since each staff member is paid during training. But Pidgeon believes she recoups that cost through her low staff turnover.
Over at Rolling Fields, Kim Moody and Cindy Godfrey also see staff training, or retraining, as the hardest part of implementing the Eden approach. The traditional schedule and the use of meal trays in the rooms, they said, tends to drive everything else. Part of the solution is a flexible meal schedule, such as their home's 6-9:30 breakfast, but they also plan to get rid of the tray system altogether. That way, Godfrey said, the staff might realize "that they don't have to get everybody up and ready because the trays are coming. If the trays aren't coming, they don't have to worry." The alternative? The sisters hope to hire both a chef and a short-order cook so that elders can have just what they want, when they want it. While this sounds quite expensive, they believe it will save money in the long run by reducing food wastage.
In its first Eden year, Rolling Fields invested $125,000 in staff education, including use of an outside trainer and paying staff during training. Now the home does its own training, much of it conducted by its "Eden Ambassador," Wendy Vaughn, a young woman who clearly loves her job. Besides her in-house educational work, she spreads the Eden message to outside groups such as schools and Rotary clubs.
Kim Moody and Cindy Godfrey handpicked a leadership team of 15-20 staff in the early days and started the Eden education with them. "I think we've weeded out pretty much all the people who weren't going to get it," Godfrey commented. "And at this point, we have a great leadership team, absolutely great.... But we just need to get the rest aboard." She said they are seeing clinical benefits from the Eden approach: fewer bedsores, fewer falls ("we're not sending people to the hospital with fractures"), and less use of anti-psychotic drugs.
Her sister Kim mentioned a case in which good listening and a snack precluded the need for a pain pill. An elder named Ray approached the nurses' station in the middle of the night and said he needed something for his pain. Responding in a way seldom seen in traditional medical settings, the nurse asked Ray what he thought he needed. He replied that he had "a lot of pain... I really think that I need to have a peanut-butter-and-jelly sandwich." And that was all he needed. Moody described another resident who had been "frequently obsessed with her pain." After they placed birds in the woman's room, she transferred her concerns to the birds' needs--Were they okay? Did they need food or water?--and "quit taking her pain medication." As Godfrey remarked, the elders are "not sitting around, thinking about their aches and pains... They have things to live for, things to get up and do."
How about state regulators? Are they an obstacle to Eden innovations? Moody mentioned a problem that arose over creation of a space where residents could visit casually in a chair and love seat "at the corner of an intersection" in the halls. They love to gather in such places, she said, so they can "see the comings and goings." She said the hallway wasn't blocked, and there "certainly was the ability to move a chair if there was a fire." But regulators had a different view, and "they made us move the furniture... Recognizing it was movable and temporary and all those things, it still needed to go."
Regulators have been more flexible, though, about pets. One home, in fact, received its first pet from a state inspector. "Yes, we did," a top staffer acknowledged, "but we're not gonna mention that." Apparently inspectors realize how much pets help ward off loneliness in the homes. While they may not be able to bless the pets officially, they don't want to shut them down, either. "They watch it all," one staffer remarked, but they don't say anything about it.
Kelly Pidgeon said she understands there will be new regulations on pets. But she added that her activities director, Deb Fenner, "keeps perfect records on all of her animals." Fenner commented, "I even have care plans for the individual cat.... I'm ready when they find me and want to do something."
Rolling Fields is careful about pets, too. "We have our dog committee and cat committee," Cindy Godfrey reported, "and there's all the testing." Key questions include: Do the dogs or other animals "get along with the cats? Do they get along with the kids? And all those things." She said there "really aren't any issues with allergies," since "we're sweeping all the time" and also have air recirculation systems.
The pet situation seems to be well in hand at all three homes. Chester, Lincoln, and Gabby--as well as Patches, Trixi, Tweety, and many others--appear to have a bright future.
Wendy Vaughn of Rolling Fields said that "we're fortunate that we are making Eden happen in a building that was built to be an institution. That's one of the hard parts." She and her colleagues are also fortunate that everything's on one floor in their building and that it presents an attractive and welcoming appearance to visitors as they drive in.
But Kelly Pidgeon and her staff are dealing with a building that used to be a bowling alley and was converted to a nursing home 30 years ago. She said that "we have built on and built on and built on to this building. And no matter how much space we add, we never have enough." She called it "an ugly old building." Yet there are pretty nursing homes that lack the great heart of Beacon Ridge. And its staff add beautiful touches wherever they can: having art students paint murals in the courtyards, for example--
--and showcasing art work by the elders themselves. The quilting elders, especially, are adding beauty as well as comfort to their home.
All three of the Eden homes I visited, though, have the long hallways and nursing stations that remind people of hospitals. But Beacon Ridge has removed one of its nursing stations, putting the record-keeping into a smaller space around the corner. This freed a large area for a gathering space for elders, one where they can see "the comings and goings." Rolling Fields plans to remove its nursing stations. "In fact," Kim Moody remarked, "if you come back in two years, I'm sure they'll be gone."
Adding or changing space, Kelly Pidgeon reported, "is an incredibly tedious, red-tape process, through the regulators, to have your plans approved: perfect submissions, four sets of plans, codes." Putting up a brand-new home that's built around the Eden approach would be financially difficult, if not impossible, in Pennsylvania at present. The state has a virtual moratorium on new building in nursing homes. "You can't build any more beds and have it be paid for by the state--Medicaid beds," Kim Moody remarked. "You can build all the private beds that you want to..." But as Kelly Pidgeon said, this can mean "losing a ton of money." Besides, she explained, there's now a major state push for use of home-based and community-based services instead of nursing home placements. The high cost of nursing homes is driving this, she said. "It's all about the buck."
There are certainly cases where home- or community-based services are more appropriate. And many people need nursing home care only for a short time; then they can return home and get by with help from family, visiting nurses, and/or home health aides. Yet the problem with many seniors is not that they enter a nursing home too soon or stay too long, but rather that they enter later than they should--sometimes after serious accidents at home. The many who have dementia, of course, are at special risk if they live alone. And anyone who has seen seniors pushed out of hospitals too early--only to see them readmitted a short time later, in much worse shape--is likely to question the idea of discouraging access to nursing homes. There is, however, another pressure for a shift to home and community services. It comes largely from younger people with severe disabilities who have had terrible experiences in traditional nursing homes, an issue I'll deal with later.
If Pidgeon had millions of dollars to start over, she would build a new home around the Eden idea. Each elder would have a private room, and the rooms would be arranged "in circles, with common spaces between each one." Similarly, if Kim Moody were starting over, she "would have lots more areas where small, intimate gatherings could occur."
Making Neighborhoods and Families
All three homes encourage small gatherings and projects through their "neighborhoods" (appropriately called kibbutzim at Levindale), which are smaller units within each home. At Rolling Fields, they are based on the corridors, which are called streets and named after trees: Ash, Birch, Cherry, Dogwood, Elm, and Fig. Each street has two "families"; both elders and staff belong to families and make decisions together. Cindy Godfrey said the families "do constant fund-raisers now, because it's fun for them to do." They then spend the money as they want. One family, her sister added, "decided that they really wanted all their elders to have a special blanket for Christmastime, with their family name on it."
A family also makes decisions about pets: whether they want to have one at all and, if so, what kind. Plus, said Moody, "Who's going to feed it? Who's going to take it out? When are they going to let it in? Who's going to go to the vet?" While many elders love pets, some are skittish about them. A Levindale resident told me he likes to look at them, but "I never liked scratching dogs... 'Cause right away, I feel like I gotta wash my hands and everything." A Rolling Fields elder had been bitten by a dog years earlier and initially didn't want anything to do with dogs at the home. Yet now she loves Chester, the dog with soulful eyes, and enjoys his visits.
Neighborhoods over at Beacon Ridge enjoy parties and special meals--a picnic, a Pizza Day. They, too, have fund-raisers and vote on how to spend their money. There's also a fund-raising committee with representation from all the neighborhoods. It runs major events, open to the public, to raise money for Eden programs. It offers a spring flower sale; and it holds raffles of jewelry, a gambling trip to Atlantic City, N.J., a trip to an amusement park in Hershey, Pa.
At Levindale, a kibbutz has a meeting of "residents, family members, staff, whoever wishes to attend," Heather Allen explained. Everyone who shows up can vote on the color of curtains for the neighborhood, the color of the shower room (one neighborhood chose hot pink), or how to rearrange the fish tank. Allen remarked that "every little decision that's made, when it comes to living in the community...we make it as a team." But the meetings, called "circles," are not for decisions only. Helene King noted that the participants "can talk about anything," including weather, their favorite memories, or the current outlook for the Baltimore Orioles.
Activities and Volunteers
While Eden homes emphasize the small joys of everyday life, they also offer activities much like those of traditional nursing homes. Bingo is big at Rolling Fields, which also offers "Music with Frank" and, more intriguingly, an appearance by the "Amish Singers." Any special day is an occasion for a party or competition: a "Senior Prom" for Valentine's Day, a Mardi Gras party, and--this must be a real hoot--a contest for "Best Ground Hog Day Costume." Sometimes there's a more intellectual event, such as a "Tamarack Wild Life Presentation." Rolling Fields has its own bus, which takes elders on shopping and restaurant trips, to festivals and county fairs, and to picnics and parades. There are regular church services on Sundays and Wednesdays, as well as Bible study on Thursdays.
At Beacon Ridge, Kelly Pidgeon remarked, "We would be shot if we didn't have bingo!" The home's bus takes elders out for antiquing, fishing, and picnics as well as visits to state parks and minor-league baseball games. Sometimes they go over to Pittsburgh for a riverboat cruise. Levindale activities include "Jeopardy" as well as bingo, music and dance therapy, pottery, Russian culture. There's a major emphasis on gardening, with a greenhouse, gardening clubs, and raised gardens (on carts) for wheelchair access.(10) The Levindale bus takes elders to destinations including art museums and an aquarium. Occasionally there's a boat trip in the Baltimore harbor. "They are out and about a lot," Helene King commented.
Cindy Godfrey said it's harder for Rolling Fields, compared to a city-based home, to find volunteers, because "we're out in the middle of nowhere." They are working on it, though. "World Makers Wanted!" proclaims their flier seeking volunteers to host afternoon tea or happy hour, deliver mail, escort elders on outings, or help in other ways.
Levindale's volunteers include Keith Orem, who usually comes five days a week. "It beats sitting home," he told me. "There's nice people here. I enjoy coming here. I made a lot of friends here." Pidgeon doubts the Eden approach has brought more volunteers to Beacon Ridge, but said it has made a major difference in participation by elders' own families. On a recent walk through her home's therapy room, she noticed: "It's packed. It's half-family, half-residents." And family members help with therapy.
Women in the United States live, on average, about five years longer than men.(11) Women dominate nursing homes so overwhelmingly that I wondered if men might feel like an endangered species there. Are they lonesome for guy stuff? Apparently some are, for the three homes I visited all have men's clubs. Keith Orem, the super-volunteer at Levindale, hosts the men's club there for an hour every Thursday. They play basketball or toss horseshoes, sometimes "watch old sports movies" or "talk about old times" and "whatever they want to talk about," Orem said. In the Rolling Fields men's club, Wendy Vaughn reported, men are "welcome to come out and share their stories, maybe sit and have a beer or a glass of wine." They like to watch sports together, or a movie about World War II. At Beacon Ridge, men play cards or checkers with one another or garden together. But there was a different slant recently, when activities director Deb Fenner hosted a men's cooking session where, she said, the guys "had to make their own lunch."
How about young residents who have especially severe conditions? Do they find it difficult to be with much older people? "I always dissuade them from coming," replied Kelly Pidgeon of Beacon Ridge. "I hate to say that. But it's really not an age-appropriate setting. It is tough." Beacon Ridge offers them Internet access and a play station, but Pidgeon said it's hard for them to "absorb into daily life" in the home.
Rolling Fields currently has just a couple of younger people. Awhile back, when "we had a small handful of younger folks here," Wendy Vaughn recalled, "they simply wanted to go out and have a drink in a tavern like they used to. So one evening we loaded up the Rolling Fields bus, and we all went to the local tavern. And they shot pool and had a beer or two or three, and then we came back." She also mentioned a man who had Parkinson's disease and wanted to visit a nearby lake so he could "walk down the front of the spillway all by himself.... And we did that. It just depends on what they would like to do."
Many people with severe disabilities are pressing for paid attendants in their own homes, or in independent-living communities, as an alternative to nursing-home placement. The pressure comes especially from young and middle-aged people with disabilities such as cerebral palsy or brain injuries from accidents. Some have suffered neglect or outright abuse in bad nursing homes. Others find the atmosphere of traditional homes oppressive and cannot bear the thought of spending their entire lives there. Dependent on Medicaid and other government programs, many now obtain waivers allowing them to use government money to move to apartments or group homes and hire their own assistants to provide the personal care they need. This is a welcome development in many ways. It has liberated people who can and should live in their own homes or in group homes.
Yet there is reason for caution. The federal government now has a "Money Follows the Person" approach to encourage this process. While partly driven by the campaign of disability-rights activists, this is also--and perhaps mainly--a response to the high cost of nursing home care. Federal and state governments are pressing for a "rebalancing" of long-term care, applying their own pressures for a shift to greater reliance on home and community programs.(12) Family members, other citizens, and legislators should monitor these pressures carefully, because they could lead to denial of nursing-home care to some people who really need it.
Looking Toward the Future
The formidable Dr. Bill Thomas has moved on to promoting "Green Houses"--small buildings that look like everyday homes, but are designed to meet the special needs of elderly people with disabilities. The pilot project for Green Houses opened in Tupelo, Mississippi, in 2003. It's a complex of such homes, each with 7-12 residents and with staff who are "universal workers." This means they are certified nursing assistants who also cook and clean and do nearly anything else the elders need, except medical care. A nurse visits regularly, and doctors make house calls when needed. So do therapists and social workers. Each elder has a private room and bath. Their rooms are clustered around a hearth area, dining area and "country kitchen," where elders able to do so are encouraged to help with cooking. Each house includes a screened porch and a patio.(13)
A New York Times reporter who visited the Green Houses in Tupelo two years ago gave a generally positive report. He noted the smell of "corn bread baking" at one home and quoted a resident who said, "'This is the most wonderful place I've been to yet. The people, the food, everything.'" The reporter added, though, that "the undisputed cheer that a homelike setting seems to provide still leaves the fact that old age is old age." He doubted whether, "for residents who suffer varying degrees of disability and dementia, anything more than dignity can be restored to life."(14)
Writing in The Gerontologist last year, Dr. Thomas and several colleagues described the pilot project and lessons learned thus far. They said the caregivers in each home work "the usual three shifts." Two caregivers are there during each of the first two shifts, but just one on the night shift. They receive extra training and higher pay than they previously received. But professional staff, worried about resident safety and their own "loss of power," were more resistant to Green Houses than expected. Apparently the tensions generally have been resolved, and many health professionals "have come to 'own the model' and be enthusiastic proponents."
The sponsoring agency, Mississippi Methodist Senior Services, operates nursing homes and retirement communities in Tupelo and elsewhere. So it's able to provide key administrative services for the Green Houses: accounting, purchasing, medical records, heavy cleaning, repairs. This seems to give the Green Houses the best of both worlds: small homes, yet economies of scale. Several foundations, especially the Robert Wood Johnson Foundation, financed the pilot project. Thomas and his colleagues wrote that: "Building costs were less than the cost of a new traditional nursing home building and less than comparable renovation costs within the existing building [the Mississippi Methodist nursing home in Tupelo] would have been."
Thomas and his associates did not offer many specifics about effects of the Green Houses on the elders themselves. But it's encouraging to read that many "stopped using wheelchairs because they were able to navigate the short distances in the house." They are happy with their private rooms, where "hospital beds are rare." Also: "Elders are frequently outdoors, and when indoors they tend to cluster in the hearth room, at the kitchen table, or in the recliners in the living area." Their families "take advantage of the many areas for visiting and regularly stay for meals with the elders."(15) Sounds like a real home.
Leaders of the Robert Wood Johnson Foundation, pleased by the pilot project, awarded a grant of $10 million to a development corporation to establish more Green Houses around the country. By October, 2006, Green Houses were operating in three states and were under development or construction in a dozen more. While Thomas and his colleagues acknowledge that the Green House is "not the only way" to go, they suggest it may be ideal in three cases: when a nursing home has an old building that needs replacement; when a retirement community needs to add a nursing facility; and when a group wants "a dementia-specific care unit." (16)
The future may include Eden homes, Green Houses, and other possibilities as well. It's fascinating to see the way the Eden journey leads to so much creative thinking and gives new meaning to the words "can-do." The staff I met are impressive in the way they stretch themselves, using every talent they have and developing new ones along the way. They also find real joy in their work. Henry David Thoreau suggested that making a living should be "not merely honest and honorable, but altogether inviting and glorious."(17) The Eden staff make it so.
Where quotations are not cited to notes, they are from one of the
following interviews by the author (in-person interviews unless otherwise
Beacon Ridge, Indiana, Pa.: Group interview with Administrator Kelly
Pidgeon and staff members Brenda Bezilla, Ronald Conrad, Deborah Fenner,
and Terri Watson, 8 Feb. 2007; and telephone interview with Kelly Pidgeon,
6 March 2007
Levindale Hebrew Geriatric Center, Baltimore, Md.: Interviews with Heather
Allen, Helene King, Frederick Lonesome (resident), Michelle Mills, and Keith
Orem (volunteer), 25 Jan. 2007; and telephone interview with Helene King,
8 March 2007
Rolling Fields, Conneautville, Pa.: Joint interview with Cindy Godfrey and
Kimberly Moody and interview with Wendy Vaughn, 7 Feb. 2007; telephone
interview with Cindy Godfrey, 6 March 2007
My special thanks to all for their time and valuable information.
Additional thanks to Deborah Fenner, Helene King, and Wendy Vaughn for
guiding me on tours, and to Wendy Vaughn for a helpful bibliography.
Most U.S. Eden homes are listed on
www.edenalt.com/findinghomes.htm, which also leads to other information
on Eden homes and the Green House initiative. Many Eden homes have their
own web sites as well.
Beacon Ridge, Indiana, Pa.: Group interview with Administrator Kelly Pidgeon and staff members Brenda Bezilla, Ronald Conrad, Deborah Fenner, and Terri Watson, 8 Feb. 2007; and telephone interview with Kelly Pidgeon, 6 March 2007
Levindale Hebrew Geriatric Center, Baltimore, Md.: Interviews with Heather Allen, Helene King, Frederick Lonesome (resident), Michelle Mills, and Keith Orem (volunteer), 25 Jan. 2007; and telephone interview with Helene King, 8 March 2007
Rolling Fields, Conneautville, Pa.: Joint interview with Cindy Godfrey and Kimberly Moody and interview with Wendy Vaughn, 7 Feb. 2007; telephone interview with Cindy Godfrey, 6 March 2007
My special thanks to all for their time and valuable information. Additional thanks to Deborah Fenner, Helene King, and Wendy Vaughn for guiding me on tours, and to Wendy Vaughn for a helpful bibliography.
Most U.S. Eden homes are listed on www.edenalt.com/findinghomes.htm, which also leads to other information on Eden homes and the Green House initiative. Many Eden homes have their own web sites as well.
1. Carol Ende, interview by the author, 7 March 2007. Ende is one of four staff at the Eden Alternative office in Wimberley, Tex. She said there are also Eden homes in Canada, some European countries, and Australia.
2. While I was able to do in-depth interviews with some staff, I did not speak at length with residents.
3. William H. Thomas, Life Worth Living: How Someone You Love Can Still Enjoy Life in a Nursing Home (Acton, Mass.: VanderWyk & Burnham, 1996), 69-70.
4. Ibid., xi-xiii & 7.
5. Ibid., xiii-xiv, 23-25, & 8-9.
6. Ibid., 2, 30-31, 33-34, & 28.
7. Ibid., 70; center insert, figs. 2-8; 47-53; 56-57; & 71-75.
8. Ibid., 96.
9. Beth Baker, "Costs and Habits are Barriers to Change," Washington Post "Health" section, 16 July 2002, F-6. This accompanied Baker's helpful article on Levindale and similar homes, "Old Age in Brave New Settings," ibid., F-1 & F-6.
10. "Rolling Fields Monthly Activity Calendar - February 2007" (Rolling Fields, Conneautville, Pa.); "It Can Be Different" (Rolling Fields, Conneautville, Pa., n.d., ; and "Eden Alternative," www.lifebridgehealth.org/levindale/levindalebody.cfm?id=2073, accessed 6 March 2007.
11. [U.S.] National Center for Health Statistics, Health, United States, 2006 (Hyattsville, Md., 2006), 176, Table 27, www.cdc.gov/nchs/data/hus/hus06.pdf#027, accessed 7 March 2007.
12. Joseph P. Shapiro, "Up from the Nursing Home," in his No Pity: People with Disabilities Forging a New Civil Rights Movement (Times Books/Random House, 1993), 237-57; www.adapt.org, accessed 7 March 2007; and [U.S.] Centers for Medicare and Medicaid Services, "Rebalancing Long-Term Care," www.cms.hhs.gov/NewFreedomInitiative/035_Rebalancing.asp, accessed 6 March 2007. Also, search for "Money Follows the Person."
13. Judith Rabig, William Thomas, and others, "Radical Redesign of Nursing Homes: Applying the Green House Concept in Tupelo, Mississippi," The Gerontologist 46, no. 4 (2006), 533-39. See Fig. 1, p. 537, for the floor plan.
14. William L. Hamilton, "The New Nursing Home, Emphasis on Home," New York Times, 23 April 2005, A-1 & A-9.
15. Rabig and others (n. 13), 536 & 538.
16. Robert Wood Johnson Foundation, "Developing Small Community Homes as Alternatives to Nursing Homes," press release, 7 Nov. 2005, www.rwjf.org/newsroom/newsreleasesdetail.jsp?id=10375; Michael H. Brown, "'Green Houses' Provide a Small Group Setting Alternative to Nursing Homes -- and a Positive Effect on Residents' Quality of Life," www.rwjf.org/reports/grr/057114.htm, accessed 6 March 2007; and Rabig and others (n. 13), 539.
17. Henry David Thoreau, "Life Without Principle," in Brooks Atkinson, ed.,
Walden and Other Writings of Henry David Thoreau (New York: Modern
Library/Random House, 1937), 716.