Toni Davis spent much of her childhood roaming the corridors of a nursing
home in West Orange, N.J., where her mother was the director. Even now she
recalls the pleas of the residents there: ³ ŒPlease help me, please take
me home with you,¹ they¹d beg,² Ms. Davis said. ³I remember asking my mom,
ŒWhy can¹t we take them home for dinner for just one night?¹"

Following in her mother¹s footsteps, Ms. Davis is now director of Green
Hill Retirement Community, a nursing home and assisted living facility,
and she is determined to make it into a place where residents feel little
reason to leave. She has added fish tanks and bird cages, hung pictures on
the walls carpeted the corridors, and brought in dogs for pet therapy.

Still, the nursing home looks like... a nursing home. ³No matter what you
do, you can¹t get that homelike feeling in an institution because it¹s too
big,² she said.

So now Ms. Davis, along with two dozen other nursing home operators across
the country, is trying something different. This year, behind two large
institutional buildings on the Green Hill campus, she has opened four
small Arts and Crafts-style houses for elderly residents.

Just 10 residents live in each so-called Green House, which looks nothing
like a traditional nursing home. The front door opens onto a large living
and dining area; on one side is a hearth surrounded by upholstered chairs,
and on the other is a long communal dining table where meals are served.
An open kitchen faces the table, so caregivers can chat with elderly
residents while preparing meals.

Private bedrooms and baths surround the main living area. The house has a
front porch and back deck with tables and chairs. There are no corridors,
no nursing stations, no medicine carts (each room has a locked cabinet
containing the resident¹s medications) and no trays of food delivered to
the rooms.

There are 117 Green Houses across the United States now, part of a quiet
but intriguing effort to de-institutionalize elder care. The movement has
its roots in the 1987 Nursing Home Reform Act, which declared that
residents of long-term care have the right to be free from abuse or
neglect. Nursing homes across the country have tried a variety of
strategies to become more ³resident-centered.²

³It¹s happening all over the country, in a lot of different models,² said
Sarah Wells, executive director of the National Consumer Voices for
Quality Long-Term Care, an advocacy group based in Washington.

The Green House concept is the most comprehensive effort to reinvent the
nursing home, experts say ‹ including the way medical care is delivered.
In traditional nursing homes, employees typically have narrowly defined
jobs: Some give baths, some cook, some do laundry. It¹s a system based on
efficiency that tends to ignore individuals¹ preferences and needs.

In a Green House, each home is staffed with two certified nursing
assistants who perform all of these jobs, but for fewer residents. In
addition, one registered nurse typically supports two or three houses.

³If you have one person doing everything, they can spend more time with
the residents and get to know somebody as a real person,² said Robert
Jenkens, a director at NCB Capital Impact, a nonprofit community
development finance institution that has partnered with the Robert Wood
Johnson Foundation to provide consulting and loans for organizations
developing many Green Houses.

³You¹re also less locked into a rigid Œwake, meal, bath¹ schedule, and you
can reorganize someone¹s day based on her preferences,² he said.

If nurses¹ aides aren¹t feeling rushed to dress and bathe residents, the
thinking goes, they¹re more likely to let them perform more of these tasks
themselves, fostering independence.

Erika Dickens, a certified nursing assistant, worked in the traditional
nursing home at Green Hill for 20 years but recently was transferred to
the new Green House.

³I used to feel like my hands were tied. I had to get the elders out of
bed at a certain time, even if they didn¹t want to,² she said. ³Now if
someone doesn¹t want to get out of bed for breakfast one day, I¹ll bring
her a milkshake.²

The notion that elder care should be de-institutionalized is a popular
one. According to a poll released in September by NPR, the Robert Wood
Johnson Foundation and the Harvard School of Public Health, 82 percent of
pre-retirees (adults over age 50 who have not retired but plan to) and 78
percent of retirees are somewhat or very concerned about being in an
institutional environment that is not as comfortable as a home.

³Loneliness, helplessness and boredom are the three plagues of nursing
homes,² Mr. Jenkens said. ³Arguably, much of the institutionalized
practice induced this.²

Still, it¹s not clear that the Green House model can be widely duplicated.
Though the day-to-day costs are no greater than those of larger nursing
homes, the homes are typically built in clusters of two or more and
require comparatively large initial capital investments. ³It would
increase long-term costs if it were implemented to replace every nursing
home in the country,² said Dr. Catherine Hawes, director of the program on
aging and long-term care policy at Texas A&M Health Science Center.

Perhaps more important, whether the Green House model improves care for
the elderly, compared with institutional settings, is not known. Several
small studies, none particularly rigorous, have found that Green Houses
deliver similar care for no more money than traditional nursing homes. The
homes do this largely through reducing supervisory positions and training
certified nurse assistants to take on more responsibility.

Green Houses also have a lower vacancy rates than conventional nursing
homes, and they accept patients on Medicare and Medicaid, making them an
option for low-income elderly. On average, about 54 percent of Green House
residents are on Medicaid, while the rest pay for the care privately.

Residents of Green Houses experience fewer bed sores than those in
conventional nursing homes, according to one survey, and each day they get
24 minutes more of direct and personalized care and 1.5 hours more of
nursing staff time than those living in traditional nursing homes.
Residents say they feel like they have deeper relationships with the
staff, and family members report higher satisfaction with the physical
environment, privacy, their own autonomy, health care and meals.
Employees, too, report less stress. The turnover rate is significantly
lower than in a traditional nursing home. Green House certified nursing
assistants are paid on average about 5 percent more than those in
institutional settings.

Even if this model of elder care turns out to be impractical on a large
scale, Ms. Wells said, ³we can learn a lot from what the Green House is
doing and can translate these methods into things that existing nursing
homes can use.²

Many residents and their families find the Green House to be a substantial
improvement over standard nursing home care. Diane LoCicero moved her
88-year-old mother, Evelyn, from the traditional nursing home into one of
Green Hill¹s Green Houses this year. Her mother is far more relaxed now,
said Ms. LoCicero, and she actually enjoys visiting the place.

³Before, it was like a hospital and I hated to visit,² Ms. LoCicero said.
³Now, I¹ll stay here for hours.²

On a recent day in September at Green Hill, Jane Larkin, 82, a retired
home economics teacher who suffered a stroke in 2007, sat in her
wheelchair at the long dining table and marveled at the differences
between this residence and the traditional nursing home in which she¹d
once lived.

³There¹s more opportunity to be social here. We can get outdoors easily,
and people like to visit more,² she said. ³Sometimes, I give the girls
advice when they¹re cooking, like I¹m their teacher. There was no
opportunity to do that in the other place, because we were isolated in our