Green House Senior Director: If Nursing Homes Can’t Embrace Change Post-COVID, ‘Shame on Us’

After a disheartening experience working in nursing homes, former director of nursing Susan Ryan spent years working on initiatives designed to keep the elderly out of institutional care settings at all costs.

But over time, she came to believe that there would always be a need for skilled nursing facilities to serve a specific portion of the aging population — just not the kind that have existed for decades.

As senior director of the non-profit Green House Project, Ryan has traveled the country spreading the gospel of “small-home”-style nursing home campuses, which place a premium on resident autonomy and quality of life.


The model has generated national interest amidst the ongoing COVID-19 pandemic, bolstered by both a renewed focus on nursing home reform and an impressive track record: While tens of thousands of nursing home residents have died from COVID-19, through the end of May, 95% of the 229 Green House homes that were included in a national survey were completely free of the coronavirus, with just 32 cases and one death, according to Ryan.

Ryan recently joined SNN’s “Rethink” podcast to discuss the challenges of turning Green House dreams into reality, as well as to issue a warning that the nursing home industry at large cannot waste the opportunity to permanently reshape the landscape for a post-COVID world

“If we can’t get honest about why we’re here, and what we need to do to impact the next generation that you’re talking about, shame on us,” Ryan said.


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Tell me how you came to work with the Green House model.

Just to give you a little bit of context of who I am, and why I do feel so passionately about the model: I am a nurse, and I was a former director of nursing eons ago, and had what I called my call-to-action moment in a nursing home — where we were, at that time, tying people up to keep them from falling. And that was considered best practice. Somehow in my heart, I thought: This was not right. I was young and just felt there’s no way this can be a good thing.

I accepted a job with a grant-funded program to prevent the institutionalization of the elderly. And I said I’m going to keep people out of nursing homes, and did that for a really long time — until 2001 — and tried to come up with every program that I could to keep people in their own homes.

In 2001, I went back into long-term care with [the mindset that] we’ve got to reform it, because as good as home care is, it can be cost-prohibitive or socially isolating. I thought home care’s great, and I still love home care, and I’m always happy to see what they’re doing to expand services and get really creative. I’m hoping funding will improve for home care, but we will always, always need, in my opinion, skilled nursing homes.

So I’m working with a community in Maryland and hear about this thing called the Green House model. I went to Tupelo, Miss. in 2005, I saw it, and I’m like: “Oh my God, this is home care and long-term care coming together. It’s like my worlds have just merged.”

We ended up not doing greenhouse, but we did something like it — we did it for assisted living. We weren’t quite sure it would fit within the regulatory environment, so we decided we could do this in assisted living — 16 private rooms with private showers. We did not do the universal worker that Green House [has]. We kind of picked and chose what we thought made sense.

I was working on that with this organization in 2008. Green House was looking for a nurse.

I went to work initially with Green House as a project guide, and worked with providers who had decided to become part of Green House and do the new builds — the new construction to build Green House homes. I really got immersed into Green House through working with providers to bring it to fruition — working with architects, working with regulators to go through the regulatory process, and then supporting them through the education with leadership and team development.

I then became chief operating officer … and then in 2014, I became the senior director.

Now that the pandemic hit, I think if ever there’s a case to be made for going the distance and doing something like this, gosh, this is the time. And I think our data would show that a case could be made for a model made for the moment, if you will.

How can governments and advocates encourage investment in models like this? We don’t really see a lot of momentum for new long-term care buildings; most of the construction happening in the space, if it happens at all, is of specialty post-acute centers, and the system is kind of stuck with a lot of inertia.

I have scratched my head: If this is so good, why hasn’t everybody just jumped on board? As I reflect on it, as I look at this moment in time — you described it as inertia. You reference the underfunding, you reference the challenges around Medicaid, and absolutely, positively — yes, that’s all true. And yet the people who have done it, the leaders who have embraced it, these are the forward-thinking providers.

They are the ones who have said: Here are the reasons you can’t do it, but I’m instead looking at how can I make it happen? And I’m going to make it happen because there’s something in my gut that feels [right] — and I’m seeing other Green House homes doing it. That is going to give me a competitive advantage. It’s doing the right thing for elders and their family members, and the right thing for staff, and I’m going to figure out how to make it happen.

I have a for-profit provider in Arkansas with a large percentage of Medicaid. He has 34 homes over four campuses, and he will open another 10 homes, he said, in October on a different community. It tells me he has figured out a way to make it happen, and he’s worked through whatever regulatory challenges — and I can tell you that, yes, he is mission-minded, but he’s also margin-oriented, and he has figured out how to make it happen.

What, to me, is rather compelling is that when we were talking about occupancy, he says his occupancy, in fact, [has] gained over the pandemic. As people were looking for places to move their loved ones, and they heard we had a room open, we were able to take the admission.

I just think that we have to shift our thinking. [Instead of saying] here are the reasons we can’t, say: Let’s figure out how we can make it happen. Let’s embrace the concept that this makes sense, and then let’s figure out how to do it.

I will say that every state’s a little bit different in terms of Medicaid reimbursement. There are states, arguably, that are easier than others to do. But it’s really determining how you get the right payer mix, and how you have the right financing, how you control your development costs, and your operating costs. But you’ll make it work.

I have heard that regulatory approval can be a challenge, especially in areas where the Green House hasn’t been developed — it doesn’t fit the general concept of a nursing home, so working with health departments can be difficult. Do you think the pandemic will change that?

I don’t know what will happen from a regulatory perspective as they react to COVID. A concern of mine would be that there will be a tendency to just really go in and try to control from a regulatory perspective — and really, I hate to say it, make it more institutional. But let’s put that aside, because I don’t think anyone has a crystal ball to see what might happen.

I think in every state that we have Green House homes — and I’ve been a part of many of those conversations at the state department level — once they understand how the Green House model meets or exceeds the intent of that regulation, they will embrace it.

I’ll use an example in Tennessee. I’ll never forget talking to an engineer, and I had presented on Green House and he was so concerned about fire safety. I was pushing for a gas fireplace and open kitchen and all those things that just send terror down an engineer’s spine. And he said: “There will be no fire on my watch in a nursing home.”

And I said, “Absolutely. Let me show you how Green House homes are built to really ensure there is safety, the four exits.” We went through the design, and at the end of the conversation, as he and I were talking — and I was showing how I believed we met or exceeded the intent, and the context of the quality of life for those that would live there — he started talking about where his grandmother lives. He said, “This would be really good for my grandmother,” and then it’s just like a lightbulb went off and he realized: “Wow, this would be really good for somebody that I love and I care for.”

Then we went back to the drawing board, and he talked about: “Here’s the waiver that we will do. Here’s what you need to do for a gas fireplace in order for me to feel that it’s safe.” And so we’ve got gas fireplaces, as an example, in the state of Tennessee. Other states, we don’t have gas fireplaces — California, we don’t have a fireplace at all. We could not work through the regulatory requirements, but it did not preclude the two homes to be built.

It’s really building the relationship, building the trust, and really building an understanding of what we’re trying to accomplish. Regulations were not written with a Green House in mind. They were written for an institution in mind, and so until there’s regulatory reform that would contemplate something like this, we will have to tackle it one state at a time.

There’s turnover at the state department level, and so you’re really having to do some re-education with new stakeholders that come in. That’s part of the work that we do, and we have the track record of Green House homes all across the country that have opened to help frame that conversation going forward.

The fireplace discussion reminds me of how I felt when my great-aunt, a surrogate grandmother to me, had to move into an assisted living and nursing campus after she could no longer live alone with her disabilities. I was terrified the first time I went to visit her — I was probably 18 or 19 — and what made me feel better was seeing those little touches that felt like home. In her case, it was things like a chapel so she could continue to attend religious services, which was really important to her, and a dining room that felt like a restaurant.

I so appreciate what you’re saying. I think I call it ageism and ageist stereotypes, stigmas — our beliefs that we have about people as they age, especially if there is cognitive decline.

Even somebody living with dementia, it’s amazing to me — our procedural memory system is so intact. It’s the longest that remains intact. Do we need to be safe? Of course we need to be safe. But we also need to look at our needs as humans. Our humanity does not diminish as we get older, and we don’t become children again. I think it’s some of those beliefs and ageism that really is impacting what we do, and what we will do from a reform perspective.

I’ve really tried to include in our coverage of the pandemic a bigger-picture view — so much of the national discussion around reform is about fines and lawsuits, and those are obviously a part of the solution, but the systemic problems around long-term care run much deeper. Retroactive assignments of blame and justice for those harmed are important, but they won’t protect the future waves of seniors on their own.

I have to be really careful because I’m not operating a nursing home. I am a health care professional, if you will; I am a nurse, I’ve been there, done that, but I’m not doing it right now. So I want to certainly make it very clear: I hold in high esteem those that are doing it at such a time as this, especially. I do think they’re real heroes.

That having been said … we have to acknowledge that it wasn’t good enough. One of the national publications that I was interviewed in said: Why the nursing home is a design failure, and not just physically in its design, but philosophically.

Why is it a design failure? If we can’t get honest about why we’re here, and what we need to do to impact the next generation that you’re talking about, shame on us — that we are more worried about the litigation and being exempt from it because of the challenges we faced.

It’s tough, it’s uncomfortable, it’s challenging, but I just think if we don’t come together and try to figure out what we’re going to do going forward, we have wasted a pandemic and wasted a crisis, to really bring change.

That will take me to the next thing, and that’s the protests. I do think racism is a part, it is linked to the conversation you and I are having. As I’ve often said, we’ve got to confront our isms — ageism and racism — and how it impacts what we’re doing with regards to nursing homes and how we need to improve what we’re doing.

This interview has been condensed and edited for clarity.

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