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My Top 10 Movements in Long-Term Care

May 5, 2011
by Richard L. Peck, Contributing Editor
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Long-term care (LTC) does not lack for crusaders. Although the progressive forces in this field are little known to the general public, which tends to focus on the dirty laundry of LTC facilities, major LTC reform movements have been afoot for nearly a quarter century. Some of these movements train providers in culture change and resident-centered care; some rely on architectural design to foster the process, as mentioned in the “Ten senior living design innovations” outlined by Margaret P. Calkins, PhD (Long-Term Living, March 2011, p. 40); others focus on stabilizing the financial base of the industry.

Having followed most of these major movements during the 18 years I served as editor-in-chief of Long-Term Living (formerly Nursing Homes/Long Term Care Management), I offer my personal take on what these groundbreaking initiatives profess and where they're heading.


The Green House® ( movement might be described as Eden Alternative founder Dr. William Thomas's second act: a bricks-and-mortar approach to culture change. From its early days in Tupelo, Mississippi, in the mid-1990s, the Green House has propounded a basic layout of a central dining/kitchen/living area bordered by 10 (in some cases, 12) private resident rooms. In what might be described as a case of function following architectural form, this homelike arrangement encourages personal interaction among residents and staff and flexible scheduling of services and activities. The Green House model has even evolved its own language-the living area is the Hearth space, its universal workers are known as Shabazim, and its administrators serve as staff “coaches” and “guides.” Some 25 functioning Green House sites have arisen since the mid-1990s and are documenting increased resident and staff satisfaction with significantly reduced staff turnover.

Leonard Florence Center, DiMella Shaffer Architecture. Robert Benson Photography

The familiar one-story Green House model is evolving, with a multilevel set of Green Houses six-stories high-the Leonard Florence Center for Living-up and running in Chelsea, Massachusetts. Two for-profit Green Houses operating in Arkansas are meanwhile helping demonstrate the business case. In short, says Executive Director Anna Ortigara, “It's a model that keeps adapting with the times. With the recent uptick in activity as the economy recovers, the model will continue to evolve and spread.”


If there is one organization that can be described as both the wellspring and the catalyst for progressive LTC reform, it is the Pioneer Network (, founded in 1997. “Back in the 1990s, people who didn't know each other were all pushing up against the status quo with the same goals in mind,” notes Pioneer Board Member Megan Hannan. “Pioneer was an effort to bring them together.”

Such long-time senior care activists as Carter Catlett Williams, Joanne Rader, Charlene Boyd, and Barry Barkan formed the nucleus for this classic outreach campaign. “We were not and are not a membership organization,” Hannan says. “We're very small”-the Network's annual budget is slightly north of $1 million-“but we serve as an umbrella for culture change groups at the state and local levels, along with collaborative research with not-for-profit partners and national networking. We are conveners for person-centered care (PCC) and the self-directed life.”

Pioneer is moving ahead with a growing focus on home-based care. Working through state-based culture change coalitions, Pioneer is supporting efforts to draw in home-based caregivers to the PCC drive, a drive that shows no signs of abating. Hannan says, “I don't believe that today's hard times will stop the change that's happening. The movement is growing across the country, and there's no turning back.”


Children of the 1960s might be forgiven for experiencing a “blast from the past” when observing the more recent advent of cohousing communities-some 120 of them to date-throughout the United States. To this point, cohousing communities have typically been clusters of two or three dozen homes planned and developed by homeowners interested in the highly collaborative model. Complete with resident governing boards, cohousing communities resemble condominiums in structure, but with more active involvement by residents and richer services. A handful of these communities have been age-restricted for people over 65 years of age-the so-called elder cohousing model-but, for the most part, communities have tended to encompass younger “seniors,” many of them still working.

(2nd row, left to right) Pioneer Valley, Amherst, Massachusetts; Pleasant Hill, Pleasant Hill, California; (bottom) Hearthstone Cohousing, Denver, Colorado. Photos: Zev Paiss, Neshama Abraham (Pleasant Hill).

As with many of the real estate-oriented movements, cohousing development has slowed of late and, says Zev Paiss, a long-time cohousing activist, the movement is taking a breather to re-evaluate. “Much of the conversation these days,” says Paiss, “is centering around a full-rental model. Baby Boomers these days have seen their 401ks decline and their homes lose value, and some are beginning to think they're perhaps not so interested in holding mortgages anymore.”