My Top 10 Movements in Long-Term Care

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.”

Cohousing. (top) Commons on the Alameda, Santa Fe, New Mexico; (2nd row, left to right) Pioneer Valley, Amherst, Massachusetts; Pleasant Hill, Pleasant Hill, California; (bottom) Hearthstone Cohousing, Denver, Colorado.

Paiss also sees the model “flexing” in terms of allowing more outside management and becoming more economically focused on harboring local businesses, local agriculture, and modern “cottage industries” involving home offices. The model may also have a principal role to play, he says, in rescuing banks and other lenders from the real estate meltdown. “There are an amazing number of properties out there that are not helping the banks, the residents, or anyone else. There’s got to be a way to put these properties to work serving a growing housing need.”


Twenty years ago, Harvard University-trained family physician William Thomas finally decided what it was that bothered him about the nursing homes he visited near his Sherburne, New York home. He sensed that residents were beset by not one but three “plagues”: loneliness, helplessness, and boredom. He concluded that this arose from being cut off from all human and natural stimulation. Dr. Thomas’s basic prescription: Instill life in the nursing home through PCC, introduce pets and plants into the environment, and invite children to visit the residents. With that, the Eden Alternative (EA) was born.

EA has been satirized at times as “fur and feathers,” but it was, in fact, LTC’s first formal approach to delivering PCC. Since then, EA has grown into a nationwide training organization, inculcating caregivers and administrators in its “10 Principles” of care.

Like the Pioneer Network, EA has also taken the lead in focusing on home-based caregiving, with a program called Eden at Home that convenes not only direct caregivers, but family members and service providers at the local level, to develop a team approach to home care. “This has taken three or four years to develop,” says Executive Director Chris Perna, “and we’re just starting to push out into the marketplace. Between this and a new distance-learning Web-based initiative we’re gearing up, we expect our trainings to increase dramatically this year.”


When the National Investment Center for the Seniors Housing & Care Industry (NIC) was in its early 1990s start-up phase, standard financial analysis for the LTC industry added up to “an aging demographic + dependability of government programs (Medicaid and Medicare) = a sound investment.” Many an investor went bust in the early and mid-′90s thinking along just those lines. Enter the NIC.

Founded to generate the more in-depth, sophisticated data required by professional lenders and investors, NIC has steadily refined and expanded its offerings to the point they compare favorably with other financial information services in the real estate field. NIC’s annual reports and studies, long-awaited and fully studied by industry observers since the early ′90s, culminated in 1996 with its “The Case for Investing in Seniors Housing and Long Term Care Properties.” This was followed three years later by the more specific, locally oriented Key Indicators and by NIC MAP in 2004. The subscription-based NIC MAP encompasses the top 100 metropolitan areas in the United States. Within these regions, it tracks data such as inventory growth, absorption, occupancy, revenue per unit, and new construction for nearly two-thirds of institutionalized housing accommodating people age 75 and above.

A MAP offshoot is a Portfolios Program allowing providers, lenders, and investors to benchmark individual organizations against local competitors in their metro areas. All of this serves to encourage and stabilize capital investment in the LTC infrastructure-the whole point of the NIC movement. “If the last three years have taught us anything,” says Mike Hargrave, vice president of NIC MAP, “there are major market forces in play that affect local performance. The industry needs to think globally and act locally. That’s what we’ve been working to support.”


Offering the same resident care philosophy as the Green House but with a more varied physical model, the Small House movement took off only a few years ago. “Although the similarities are greater than the differences,” says National Alliance of Small House Projects (NASH, Executive Director (and Green House alumnus) Jude Rabig, “the differences are important to those who favor more flexibility in implementing the model. This would include, for example, those who can’t base their economic model on households of only 10 or 12 residents, or who prefer some centralized services and workers to universal workers, or who want to physically attach the small house to an existing nursing home. We try to collaborate with these individuals at whatever level they’re coming from.”

The Small House concept does appear to be catching on-the judges for this magazine’s DESIGN 2010 competition remarked on the prevalence of the basic model in projects reviewed. Although the recent economic downturn has impeded progress, Rabig notes that NASH is constructing a formal small house training center in Northampton, Massachusetts, with lectures and observational visits open to interested providers coming from throughout the United States. Groundbreaking is scheduled for August, with completion anticipated in early 2012.


Paradoxically, one of the oldest movements in long-term care-the household movement-has one of the newest flag-bearers, the Association of Households International (AHHI). The household concept goes back at least 25 years to the experiments of David Green’s Evergreen Retirement Community in Oshkosh, Wisconsin, with architect Gaius Nelson, resulting ultimately in four operating households of nine residents each in 1997, followed by four more households of 11 each in 2005. Evergreen helped define the “household” as a central kitchen/dining/living area bordered by resident rooms. But it was only in 2009 that a small nucleus of providers similarly engaged in developing households for their organizations came together to create an organization dedicated to fostering the concept.

Evergreen household design, Architect Gaius Nelson

“My personal involvement in this,” says Rich Newman, AHHI president and chairperson/president of the Pennsylvania CCRC Pennybyrn at Maryfield, “came from my seven or eight years’ experience with culture change and developing six households for our community. I became convinced that this was the way to go for long-term care.” AHHI is in its earliest days of organization, looking to engender interest at a post-Pioneer Network conference seminar in August 2011, and building membership from there. Meanwhile, Elma Holder, the prominent LTC consumer leader representing the consumer view on the AHHI board, is bringing a new twist to the movement: In conjunction with the Pioneer Network’s culture change coalition in Oklahoma, Holder will convene meetings of consumers at the local level to spread the word about culture change and the role of households. Says Holder: “There is a tremendous hunger out there for new information and a wish to believe that this can be done.”


Now approaching its 10th anniversary, Beacon Hill Village (BHV) embodies the Holy Grail of long-term care: full-service care and support for people aging in place at home. Some 400 senior residents of this central Boston community receive, for a truly nominal annual fee of $640 (individual) or $890 (family), an array of discounted services provided by vetted grocery suppliers, exercise instructors, affinity group organizers, geriatric care managers, and more, without ever having to leave their homes. Now generally called the “village model,” similar communities have emerged throughout the United States in recent years-at last count, 57 in 30 states, principally in the Northeast, upper Midwest and West Coast, according to Judy Willet, executive director of BHV. An online support/information network ( has emerged as well.

Although these villages vary considerably in their scope and services offered, Willet notes, “These are all consumer-driven membership organizations responding to the wants and needs of their particular communities. Self-financing, philanthropic donations, and volunteer work are all part of the mix in varying degrees. But they all observe the basic tenets of the village concept: They’re open to everyone qualified by age and at all income levels.” It remains to be seen how extensive or financially sustainable all this will prove to be but, for now, the village model is society’s most literal interpretation of aging in place.


For years the drive to create a private insurance market for long-term care has bumped up against a wall: exceedingly slow public acceptance of this product. Two main reasons: First, competing priorities-the customer base for whom this insurance is most suitable, people in their 40s, are at a point when they’re confronting their maximum financial responsibilities (college expenses for kids, maximum outlays for houses and cars, and, increasingly of late, the expenses of taking care of Mom and/or Dad). Second, the myth that government programs, particularly Medicare, will cover the cost of long-term care.

Private insurance has had significant allies, though, over the years. In 1987, for example, the Robert Wood Johnson Foundation underwrote a “public-private partnership” program combining Medicaid with private insurance to fund LTC in four states-California, Connecticut, Indiana, and New York. The Deficit Reduction Act of 2005 removed a legislative barrier to program expansion and currently 40 state-insurance company partnership programs are underway throughout the United States. But, says Mark Meiners, PhD, the George Mason University professor who has spearheaded the program since its inception, private insurance is still struggling to make headway. “Marketplace miscalculations on utilization of these policies, along with serious losses in the stock market, forced some major carriers to reconsider participating in this field,” he notes. “Also, convincing Baby Boomers to plan this far in advance does not play to their strong suit.”

Policies offering a broad range of coverage for a shorter period of time may prove more useful and affordable to moderate income groups, Meiners says, particularly those who don’t find the forthcoming CLASS Act social insurance program to be an attractive option. But, for now, this unsettled insurance pool has barely been able to crack the 10% level of LTC expenses.


Although it’s not quite a “movement” yet, universal design might soon be. The concept of building or modifying homes to accommodate the decrements of aging-declining vision and hearing, unsteady balance, increasing disability and, for some, encroaching dementia-has been around for decades, but has not caught on in a general way. Architect and planner Maggie Calkins, in her above-mentioned Long-Term Living article, noted, “Despite…making such conceptual sense that it’s hard to argue against, [universal design] has yet to be widely adopted.”

This perplexing situation is explained by long-time universal design advocate Walton D. Dutcher, Jr., as resulting from lack of public knowledge. “People don’t know about the benefits of universal design and builders haven’t been trained in it.”

Dutcher, himself a quadriplegic who has planned and modified many homes for seniors as a Medicaid waiver consultant, says the modifications prescribed, including roomier doorways, blade-style door handles, minimal stairways, and bathrooms accommodating various degrees of capability-make common sense for people aiming to age in place in their homes. “Rather than calling this ‘accessible’ housing,’ which conjures up an image akin to hospitals and the like,” says Dutcher, “I would emphasize the real changes that might benefit people at all stages of life. I would call it life span design.”

Things may be lagging now, says Dutcher, but a confluence of rapidly growing interest in home care by Medicaid-strapped states, families’ growing exposure to the problems of their aging parents, and everyone’s desire to age at home is adding up to the “perfect storm” for universal design. We just happen to be present at its creation.

Long-Term Living 2011 May;60(5):26-33

Topics: Advocacy , Articles