Why the Green House Model

Why the GreenHouse Model

Dr. Bill Thomas is an author, entrepreneur and physician and the founder of the global non-profit (The Eden Alternative) and the creator of The Green House®.  The Green House Model nursing facility is a revolutionary way of providing care and services to elders.

As of 2017, the National Green House Replication Initiative is active in 32 states with 200 homes open. Evaluations conducted between 2003 and 2012 examined numerous measures of care, satisfaction, and financial performance. The following characteristics have been identified by studying the existing GreenHouse buildings in operation:


Green House elders relative to comparison group of nursing home residents:

Improved quality of life: Green House elders reported improvement in seven domains of quality of life (privacy, dignity, meaningful activity, relationship, autonomy, food enjoyment and individuality) and emotional well-being.

Improved quality of care: Green House elders maintained self-care abilities longer with fewer experiencing decline in late-loss Activities of Daily Living. Fewer Green House elders experienced depression, being bedfast and having little or no activity.

Improved family satisfaction: Green House families were more satisfied with general amenities, meals, housekeeping, physical environment, privacy, autonomy and health care.

Improved staff satisfaction: Green House staff reported higher job satisfaction and increased likelihood of remaining in their jobs. Green House homes relative to nursing home comparison sites:

Resident and nurses
GreenHouse Model Residents
  • Higher direct care time: 23–31 minutes more per resident per day in staff time spent on direct care activities in Green House homes without increasing overall staff time.
  • Increased engagement with elders: More than a four-fold increase in staff time spent engaging with elders (outside of direct care activities) in Green House settings.
  • Less stress: Direct care staff in Green House homes reported less job related stress.
  • Improved care outcome: Fewer in-house acquired pressure ulcers in Green House homes.

Green House homes increase revenues:

  • Increased market areas and occupancy rates. “People will travel from near and far to come here,” says Betsy Mullen, executive director of the Leonard Florence Center for Living in Boston. For organizations that have implemented The Green House model, nursing home occupancy rates have increased an average of 6.5 percent overall while private pay days increased 24 percent.
Retirement residents with grandchildren
  • Research shows that 61 percent of caregivers would pay 5 percent to more than 25 percent more to have their family members live in a Green House home, with three-fourths of those caregivers willing to pay 10 to 25 percent more. When family members see a Green House home, the response is very favorable. That is where they want their loved one to live. Green House home adoption is consistently associated with higher occupancy rates and higher proportions of private-pay residents.

Risk mitigation and more flexibility:

  • Green House homes are easily adapted to address changes in complex markets and reimbursement policies. They can be deployed or redeployed for short-stay rehabilitation, long-term care, hospice, and specialized services for older or younger populations, as needed.

Operating costs at or below average level:

  • Operating costs are the same in Green House homes as they are in a traditional nursing home. Direct care staffing hours are higher in Green House homes. These increases and associated costs are more than offset by reductions in supervisory and administrative staffing.

Capital costs at the low end:

  • Green House homes require the same or fewer square feet per elder, compared to other culture change models, minimizing construction costs. In fact, Green House homes have, on average, almost 100 fewer square feet per elder than other small-house models.

Role of direct-care workers:

  • Comparable quality: Removal of formal nurse supervision of direct care workers did not compromise care quality.
  • Timely intervention: High level of direct care worker familiarity with elders led to very early identification of changes in condition, facilitating timely intervention.
  • Higher staff satisfaction In sum, existing studies show that overall, total staffing time is lower in Green Houses (although direct care performed by staff is higher) and that staff view their work more positively than CNAs.