How Otterbein Built a Green House Nursing Home Network — With a $12M Plan to Grow

Like many senior living and care executives, Jill Wilson’s first reaction to the “small home” model of nursing homes was a mixture of curiosity and skepticism.

The year was 2004, and Wilson was the chief financial officer of Otterbein SeniorLife, a Lebanon, Ohio-based non-profit that runs senior living communities and standalone nursing campuses.

The CEO at the time, Don Gilmore, had just returned from a meeting where Bill Thomas had given a presentation on his Green House prototype: a drastically different kind of nursing home that would allow elders to live in small groups with a dedicated staff of caregivers who would cook and clean along with providing traditional nursing services.


Gilmore couldn’t contain his excitement about the model’s potential.

“He scared me, honestly, because he was really intent on it,” Wilson — now Otterbein’s CEO — told SNN last week. “But it made zero sense to me.”

Gilmore was persistent, sending board members to tour the first Green House-style community in Tupelo, Miss. When they returned, the sentiment was unanimous: This is the future that we need to build for our seniors.


“Those folks had real clarity around the fact, back in 2004, that this was necessary, and that we needed to be the ones to stick our necks out,” Wilson said.

Wilson, a CPA by training, had the same concerns that so many executives in the industry bring up when they hear about the Green House model: How can I make this work financially? What do you mean, caregivers also cook, and there are multiple little buildings on a campus?

“Everybody who has done this, I think, has expressed the same thing: Until you see it, it’s hard to believe it,” Wilson said.

At Gilmore’s urging, she did just that, taking the trip down to Mississippi to see the Green House in action for herself — and once she did, the advantages became clear.

“You didn’t have the layers of management — the supervisors, the managers, the department heads,” Wilson said. “All that went away, and you were really putting your money into the frontline staff.”

Wilson drew up a business plan, and Otterbein took the proactive step of securing seven certificates of need (CONs) for potential small-house developments; at the time, there were signs that Ohio lawmakers might place a blanket freeze on new senior housing and care construction, she said, and the operator wanted the flexibility to expand into the future.

Of those seven original CONs, six turned into fully built developments. Nearly two decades after Gilmore first returned from that Bill Thomas presentation, Otterbein now runs nine standalone small-house nursing communities, with a tenth on the same campus as a larger life plan retirement community; the most recent opened in the spring of 2020.

All told, the non-profit has invested $81 million in its small house campuses, with a $12 million expansion under way that will see Otterbein add two rooms to each house across the portfolio.

The evolution of small-home living at Otterbein reached another milestone earlier this year, when all of its facilities received formal designation from the Green House Project, the Linthicum, Md.-based non-profit that supports the development of small-home nursing care neighborhoods.

“We are very excited to have Otterbein SeniorLife join the Green House community,” Susan Ryan, senior director of the Green House Project, said in a statement. “They will bring such deep knowledge of the small house model to our network as we continue to revolutionize care by propelling the small house movement forward.”

Wilson’s story isn’t unique: John Ponthie, managing member of the Arkansas-based Southern Administrative Services, told SNN last summer that for him and his team, seeing was believing.

“We were developing new long-term care projects in Arkansas, and someone mentioned to me Green House. I gathered my partners, and we went and actually saw a Green House — and were stunned. We were absolutely stunned,” Ponthie said.

Though Green House has been winning converts like Wilson and Ponthie for years, the model has received wider media and regulatory attention during the COVID-19 pandemic for its focus on quality of life and its built-in infection control advantages.

Green House communities and other small-home nursing campuses had median COVID-19 infections and deaths of zero per 1,000 resident days, according to a recent study published in the Journal of the American Medical Directors Association; that’s compared to a median death rate of 10 per 1,000 resident days for nursing homes under 50 beds, and 12.5 per 1,000 for facilities with more than 50 beds.

“Although small size is known to limit the proportion of COVID-19 cases, Green House/small NHs are beneficial above and beyond the mere benefit of size, perhaps due to their private bedrooms and bathrooms, limited ancillary staff, and fewer admissions; in fact, traditional NHs <50 beds were not as advantaged in terms of COVID-19 admissions as were Green House/small NHs,” the researchers observed.

That research builds on an earlier probe that found residents of Green House campuses were one-fifth as likely to contract COVID-19 and one-twentieth as likely to die from the virus as their counterparts in traditional nursing homes.

Outside of the clear health, safety, and quality-of-life benefits, adopting Green House principles may be vital for nursing homes to survive in a post-COVID world. At the very least, private rooms are quickly emerging as a must-have, with consulting firm Plante Moran declaring single occupancy to be “non-negotiable” for providers in the future; Zimmet Healthcare Services Group even recommended that operators consider voluntarily relinquishing bed licenses to facilitate the development of private rooms and achieve some cost efficiencies related to lower total capacity.

For Otterbein, the proof is in the census: Even amid the ongoing pandemic, the operator’s small-house facilities remain about 88% full, according to Wilson, only a slight drop from the pre-pandemic peak of 93%. For comparison, national nursing home occupancy sat at 69.7% at the end of February, consulting firm CliftonLarsonAllen determined.

And while the conceptual hurdles of the Green House may continue to generate initial confusion and skepticism among leaders in the sector, Wilson insisted that small houses actually provide a cleaner, more streamlined vision of nursing home care than the traditional institutional model: With self-contained units and close-knit teams instead of large administrative departments, the layers of complexity between management and the front lines melt away.

“There’s simplicity in smallness,” Wilson said.

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