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Creating the Nursing Home of the Future

March 1, 2006
by Richard Peck
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Creating the nursing home of the future

Interview with Michael Follett, Administrator, St. John's Lutheran Home, Billings, Montana

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What if the traditional "nursing home"-that (average) 120-bed structure designed to look like a mini-hospital-disappeared from the national landscape? What if people gave up on trying to make such structures "homelike" and decided to walk away from the institutional model altogether? What would come next?

How about residents living in cottages-say about 12 per cottage, with common dining and living areas, each with a dedicated, specially trained staff? Although it sounds like the famous Green House model conceptualized by long-term care pioneer Bill Thomas, MD, a set of small structures in Billings, Montana, has grown independently from the Green House movement and is on a fast track to replace a 120-bed nursing home by next year.

These are the cottages of St. John's Lutheran Home, two of which opened about a year ago on this 40-plus-year-old multilevel campus, with another five scheduled for construction starting this summer. The initial cottages-named Langemo and Moorberg after former St. John's board chairpersons-are designed to accommodate persons with mild-to-moderate Alzheimer's disease. The next ones are aimed at broadening the resident populations served in these intimate settings to encompass all 120 of the existing nursing home's residents, skilled and otherwise. The cottages, costing $2.9 million for the two, are approximately 8,000 square feet each , with all-private rooms with baths, large open kitchen/dining area, living room with fireplace, den, and outdoor patio. Monthly rates are $3,780 for a private room and $4,110 for a deluxe. All together, 23 of the nursing home's staff have received 257 hours of training to function in this setting. Needless to say, adapting to this has involved extreme staffing and logistic challenges for St. John's management. Recently, Administrator Michael Follett, who is the spearhead bringing this to fruition, discussed the whys and hows in a recent interview with Nursing Homes/Long Term Care Management Editor-in-Chief Richard L. Peck.

Peck: Why are you replacing your nursing home with cottages?

Follett: I think it's because we've found that the nursing home care model is fundamentally broken. Virtually no one in the country would choose to live in a nursing home; in fact, people usually feel that they're "sentenced" to this by their physical condition and their kids. One way the traditional model is broken is in the way we staff these institutions-they're so departmentalized, with the wrong idea that "bigger is better" when it comes to efficiency. We have department upon department in our organizations: nursing, nutrition, laundry, housekeeping, maintenance, and more. No one's actual home is like this and, as it turns out, the "bigger is better" approach doesn't work the way it's supposed to.


Peck: But how did you come up with the cottage idea as an alternative?

Follett: First, a little bit of history. St. John's Lutheran started in 1963 as the first HUD-financed retirement home in Montana, and that was followed four years later with construction of the nursing home. We added on to that structure in the mid-1970s, as mental hospitals in the area started emptying out their geriatric populations. By the 1990s it had been obvious for years that we had an aging plant and that, no matter how much carpeting and paint we applied to it, it was still pretty much semiprivate rooms and less than nurturing bathing facilities. We began looking at alternatives in the 1990s, such as "pod" design, but it was still institutional. Then, in the fall of 2002, I received a phone call.

My grandmother, the matriarch of the family, had suffered a stroke. She had made us promise never to put her in a nursing home, but life doesn't work that way, and we placed her in an institution. However, in spring 2003 my parents invited me to see her new accommodations in an assisted living facility in Washington State. It was located at the end of a cherry orchard, and it was a Thomas Kinkade'looking cottage with private rooms for the residents. I videotaped this and showed it to our management, and everyone was quite interested. Then, in early 2004, I heard about the Green House conference in Tupelo, and found the Thomas Kinkade cottage all over again. The people managing that faith-based organization are in many ways similar to us and were happy to share their insights. I later took three architects and a construction manager to see it and live it firsthand.

By this time we knew we had a shortfall in our organization. Although we take pride in our continuum, which encompasses skilled nursing, assisted living, independent housing, and adult day care, we were lacking in accommodations for people with moderate Alzheimer's who weren't in need of skilled care. We were losing them to other assisted living organizations in the area. We decided to fill this niche by building two prototype assisted living cottages designed to skilled nursing standards. We opened them last August; they're full, and they're meeting and exceeding our dreams and expectations.

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