Introduction
About 100 miles west of Philadelphia in the town of Palmyra, PA, a dozen seniors are living out their final years in what you might think of as the “anti-nursing home.”
At Hostetter House, there are no wheelchair-bound residents crowding around a nursing station or patients waiting too long to be attended to in their beds. You won’t see medication carts, laundry carts, housekeeping carts or food carts blocking the halls. You won’t hear a steady flow of intercom announcements or call bell alarms.
Instead you find elders socializing in front of the fireplace, out on the patio or around a common dining table. The warm scent of a home-cooked meal permeates the air. Though elders here require skilled nursing care, they move with freedom and dignity and set their own routines. That is because Hostetter House is, in every sense of the word, their home.
Hostetter House is a certified Green House® home, designed from the ground up to provide the highest quality long-term care in an environment that looks and feels like a real home. Twelve years ago, there were no Green House homes anywhere. Now there are 134 in 21 states around the country, with another 100 homes in development.
The Green House Project is not just a breakthrough in how we care for aging Americans, but is also a model designed to catalyze change in the field of long-term care. It is a signature example of the Robert Wood Johnson Foundation’s (RWJF) efforts to bring game-changing ideas to scale.1
Our Strategy: Bringing Solutions to Scale
Much of the Foundation’s work centers on the fact that the health of all Americans, but particularly the health of the most disadvantaged people in our society, is influenced significantly by factors outside of the healthcare system, such as economic opportunity, cultural barriers, housing and neighborhood conditions, education quality, and exposure to violence in the home and community. Despite the challenges inherent in tackling these issues, it is critical that we address health where people live, learn, work and play if we want to give those at greatest risk their best opportunity to live healthy, productive lives.
We also recognize that we cannot make a meaningful difference through modest, incremental changes to what currently exists. We must find and test innovative models that have the potential to effect fundamental change—visionary solutions that are feasible and sustainable and can be applied on a wide scale.
Our strategy in the Foundation’s Vulnerable Populations program focuses on three stages of grantmaking:
- Identifying compelling issues and supporting early-stage ideas.
- Testing the sustainability and replication of promising programs, practices, and policies that are active in a single site or limited number of sites.
- Preparing select programs and approaches to achieve national impact and visibility.
At each stage, we evaluate the models and approaches to determine: (1) whether they have potential for greater impact; and (2) their readiness to advance to the next stage of development. This is not a linear process; our financial support to a grantee can begin or end at any phase and, depending on its progress and potential, may or may not proceed to the next stage of growth.
Applying Our Strategy: The Green House Project
An Inspiring Idea
In 2001, an idealistic gerontologist from upstate New York named Bill Thomas showed up at RWJF headquarters in Princeton to talk about nursing homes. Though he looked unconventional, clad in jeans, a sweatshirt and Birkenstocks, he had a bold, compelling vision: to replace large, impersonal, institutional nursing facilities with small, community-based group homes.
Soon after, an RWJF team traveled to upstate New York to explore the feasibility of developing and building Green House homes. After this assessment, we decided to take a risk, and funded Thomas’ Center for Growing and Becoming to pilot a cluster of Green House homes with a nonprofit senior-care provider, United Methodist Senior Services, in Tupelo, MS, with the hope that we could replicate any success. An initial study of the pilot concluded that early outcomes were positive and the model appeared feasible.
Expanding a Good Idea
It soon became clear to us that Thomas’ Center lacked the organizational capacity to manage the national replication of the Green House concept. For that, we turned to NCB Capital Impact, which provides financial services and technical assistance to organizations that create quality housing, education and health services for low-income people. Starting in 2005, we awarded NCB $12 million to develop a business plan and recruit and provide technical assistance to help long-term care organizations around the country build Green House homes. NCB retained Bill Thomas as a consultant and licensed the name The Green House Project, which he had trademarked.
The original goal was to build 50 Green House homes. Within five years, NCB had doubled that. Meanwhile, the body of evidence validating the model continued to grow. One study found that there was significantly less staff turnover. Another found that elders received as much as four times more personal care. Last year, Seniors Housing & Care Journal gave its highest research award to a study that found Green House homes cost no more to operate than traditional nursing homes (Jenkens 2011).
Green House Homes Go Mainstream
The Green House Project now has a goal of creating 300 Green House homes by 2013. To help them get there, RWJF has provided other support besides direct funding and research. For example, even though very few Americans actually want to live in a traditional nursing home, the regulatory landscape often still favors large institutions. We have helped NCB encourage policymakers to remove unintentional barriers and consider new incentives for pursuing the Green House approach. We also recently funded a nationwide survey of informal caregivers to help NCB and local providers more effectively market to the people most likely to make decisions about long-term care for a loved one.
What We Have Learned
Through our work with The Green House Project and across the Vulnerable Populations Portfolio, we have learned a number of valuable lessons about what it takes to scale a good idea successfully.
1) A rigid model is hard to grow.
One of the reasons why the Green House model is so consistently effective is that it is consistently implemented. But if the model is too rigid, then it becomes more of a challenge to get larger providers to adopt. That is why we continue to invest in research, not only to measure the impact of Green House model, but to understand what aspects of the model have the biggest impact on its success. That will tell us where we can be flexible without sacrificing quality.
2) One foundation cannot do it alone.
If we want to transform long-term care, our efforts and dollars must attract other partners and local funding. Toward that end, we have added other investment tools, like program-related investments, that have greater potential to bring other partners to the table. In 2011, the Foundation awarded NCB Capital Impact $10 million for a low-interest loan fund to help finance the development of Green House homes in low-income communities. NCB Capital is bringing in other investors to leverage Foundation funding in any one project by a ratio of 4 to 1. Last spring, the first Green House homes built with the aid of this innovative financing opened in Baltimore.
3) We need a new market to support scaling.
When it comes to bringing great ideas to scale, the market is very inefficient. It shouldn’t be so hard for funders and donors to find proven solutions with the potential to grow. And it shouldn’t be so hard for social innovators with proven ideas to find funding. That is why we have been an early supporter of the Social Impact Exchange, which is creating a marketplace where the most effective social change enterprises can more easily access the capital they need to grow.
Conclusion
The lessons we have learned over the last decade through The Green House Project are already being applied to an array of other areas, like stopping shootings and killings by treating the spread of violence as a disease, or keeping children out of foster care through an innovative housing model that stabilizes fragile families.
Our most complete scaling experience may be about caring for our elders with dignity in the last phase of their lives. But, when it comes to nurturing social innovation and bringing effective solutions to where they are needed most, this is the dawn of a new era.
Jane Isaacs Lowe, Ph.D. is the team director for the Vulnerable Populations Portfolio at the Robert Wood Johnson Foundation. This portfolio focuses on factors outside of the medical care system that shape our health, such as poverty, education and housing. Lowe directs the Portfolio’s strategy, investing in social innovations that demonstrate potential for widespread replication and national impact in improving the health of the most vulnerable among us. She also oversees programs in the area of mental health, aging and violence.
References
Jenkens, R., T. Sult, N. Lessell, D. Hammer and A. Ortigara. (2011). Financial Implications of THE GREEN HOUSE® Model. Seniors Housing and Care Journal. 19(1):3-22
Footnotes
1. This edition of the Philadelphia Social Innovations Journal highlights another of the Robert Wood Johnson Foundation’s national initiatives, Playworks. Both reflect the Foundation’s commitment to growing meaningful projects to scale.