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From ‘nursing home’ to ‘home’: The small house movement

April 1, 2008
by Judith Rabig and Donald Rabig
| Reprints
From the growing movement toward “small is better,” notes from a conceptual leader

Individuals who seek long-term care have three distinct needs: housing, assistance with activities of daily living, and chronic disease management. The goal of nursing home reform should be to provide satisfactory performance in each of these areas. While the culture change movement has provided the nursing home industry with many innovative, humanistic, life-enhancing approaches, it is a piecemeal tinkering with a delivery system that is fundamentally flawed. Culture change leaves largely in place the root cause of nursing home failure: the institution. To achieve the desired outcomes of good quality of care and good quality of life, the institution must be removed from the nursing home equation.

“Small house” is the generic name for a deinstitutionalized nursing home. Small house achieves deinstitutionalization by reframing the philosophical view of the person, changing the architecture, and reengineering the design of the organization. Small house programs have been implemented, thus far, in a variety of ways. Tightly defined registered trademarked models, such as the Green House®,1 loosely defined consultant-led implementations that accommodate individual organization choices,2 and internally envisioned and self-implemented versions all exist. While each organization has configured its implementation in a unique manner, there are a set of characteristics that define an implementation as a small house (table 1). A small house is an intentional community of 10 to 14 persons and a staff of highly trained workers who live and work in a well-designed environment organized and operated around the humanistic guiding principles of autonomy and dignity. When completely implemented, small house reframes the philosophical view of the person, restores the metaphysical and physical home, provides good chronic disease management, and supplies sufficient staff and equipment to support personal care.

Characteristics of a “Small House”

Architecture that includes:

  • Conscious elimination of the signposts of the medical model

  • Small, self-contained homes or communal apartments for 10 to 14 people

  • Private room for each person

  • Private bathrooms for each person with showers and sinks with grooming space tilt-mirror and storage

  • Home configuration: front hall, living room, dining room, kitchen, and den

  • Short walking distances from bedrooms to living areas

  • The people who live in the houses have access to all areas of the house

  • Residential finishes and hardware

  • Access to outdoor space/connections with nature

  • Accessible details—windows, faucets, light switches, doors, floor transitions, power outlets, switches, thermostats

  • Driveways, sidewalks, and exterior lighting that are residential in size and configuration

  • Interiors that echo the neighborhood

  • Lighting that meets guidelines for the aging eye

Policies for people who live in the house that include:

  • Participate in their own care planning meetings

  • Participation in household activities of choice

  • Resident selection of all bathing choices

  • Decisions honored regarding all aspects of care

  • Opportunity to “make home” by personalizing their space, including bringing their own furniture and belongings

  • Opportunity to access outdoors easily, without barriers to navigate or the need to secure permission

  • Food at will

  • Visitors at will

  • Greater community access at will

Staff structure that includes:

  • The house as the operating unit

  • Minimized bureaucracy

  • Shared leadership and decision making

  • Collaborative work processes

  • Self-scheduling

  • Interdisciplinary participation in quality assurance

  • Self-directed learning

Staff training that includes:

  • Change and its effect on people and organizations

  • Safe restoration of choice

  • The holistic view of all people who live in the house

  • Maslow's hierarchy of needs

  • Habilitation in ADLs

  • Communication and collaboration

  • Caregiving effectively for persons with cognitive impairment

  • Alternate bathing practices

  • Leading and being led

  • Convivium, food practices, safe food handling

Dining that includes:

  • A pleasant social dining experience

  • Access to food and drink at will

  • Choice of mealtime, food, and quantity of food

  • Opportunities to participate in food prep or cleanup activities

Clinical care that includes:

  • Advanced training in geriatric nursing for all nursing staff

  • Evidence-based clinical protocols

  • Management of polypharmacy

  • Early identification of problems related to chronic disease

  • A robust program of advanced directives discussion

  • Therapies that are integrated into the household

Technology that inclues:

  • Electronic medical records

  • Wireless call system

  • Nurse-line staff voice communication system

  • Lift-free environment