Small House care models offer personalized care and connection to community

Numerous studies show that when continuing care homes reflect the layout, activities and personalized aspects of a typical house, it leads to positive outcomes for people living with dementia. For residents in small home models, benefits include less agitation, greater social engagement, maintenance of functional abilities, as well as positive impacts on staff. Meanwhile, for residents in traditional institutional and medical models of care, there is a risk of greater agitation and faster cognitive decline.

Carefor’s Guest House in the Ottawa region of Ontario and THE GREEN HOUSE® Project in the United States are two “small house” care models that provide people living with dementia personalized care, a connection to community, and the opportunity to live independently and with dignity.

Guest House (Short-Term Stay)

Robin Meyers is the director of community and personal support services for Carefor, a not-for-profit home health care and community support service for clients and caregivers in the Ottawa region of Ontario. Recently, a member of Meyers’ team was picking up an older gentleman to participate in Carefor’s community day program. Program staff had come to know him well, and right away the driver sensed something was wrong.

“When we arrived to pick him up, he just didn’t seem himself,” Meyers says.

Meyers’ team learned that his wife, who was his primary caregiver, experienced a medical emergency the previous day and was taken to hospital by ambulance. For whatever reason, he was not brought along. Instead, he had been home alone for almost 24 hours, an incredibly stressful experience for both spouses. The team was spurred into action, with Meyers contacting the social worker involved and eventually visiting the hospital where his wife was admitted.

“I was able to tell her, ‘Your husband is fine, he’s with us,’” Meyers says. He was provided a private room in Guest House, Carefor’s unique short-term respite model care home, until his wife was able to return home after her medical issue.

For people living with dementia, the ability to live at home for as long as possible depends on many factors, including access to safe and effective respite. In 2007, Carefor joined with the Perley and Rideau Veterans’ Health Centre and the Dementia Society of Ottawa and Renfrew County to launch Guest House, a new model of short-stay respite care based in the community instead of in an institution. Its goal is to provide a familiar, household environment for people living with early to moderate dementia, where they can continue their daily routines when their caregivers require temporary breaks from their duties.

“It really is a home away from home for our guests,” says Meyers.

The Guest House home is a stand-alone bungalow, built on the grounds of the Perley and Rideau Veterans’ Seniors’ Village in Ottawa’s south end. The house has 12 private rooms, each with a private bathroom, as well as a common living room, kitchen, dining area and secure courtyard. Clinical health monitoring is not available in the program, but Guest House staff are able to assist and supervise medication requirements.

Meyers says the bungalow was designed with a “no-fail” layout, with directional cues built into the design. For example, sliding bathroom doors are within direct sight of the bed, prompting guests as soon as they wake in the morning. The home’s two hallways are equipped with handrails, and each hallway leads back to the main common area regardless of which direction guests turn when leaving their room. Thresholds throughout the home are level, and the flooring in the common area is made of soft material to limit bodily harm in the event of a fall. Everything about Guest House was built and operates to empower people living with dementia, says Meyers.

“Guests have the opportunity to accomplish tasks that they are able to perform,” she says, such as gardening, assisting staff with baking or laundry, and participating in leisure activities, group discussions, games, art, music and modified exercises.

“Living with and supporting someone living with dementia isn’t something we typically plan for, so having these types of resources obviously make a huge difference,” says Meyers. “We do what we can to help people in our communities.”

How it works

People living with dementia may stay overnight at Guest House for as many as 30 consecutive stays, up to a total of 90 overnight stays per year. Guest House also offers day stays for varying lengths between the hours of 8 a.m. and 10 p.m., and emergency stays for returning guests if beds are available. Guests are responsible for a co-payment of $40.24 for an overnight stay, or $20 for a day stay of one to five hours. The remaining balance is subsidized by the Government of Ontario and fundraising efforts by Carefor Health & Community Services.

The Green House Model

Entering the world of long-term care placement can be a stressful passage for people living with dementia and their families. Susan Ryan, senior director for the Green House Project (GHP) in the United States, has accompanied many families on this journey throughout her almost 40-year career as a nurse and an advocate for elders. She recalls meeting a family in Arkansas whose beloved grandmother was living at home with her husband, her primary caregiver.

“Her dementia became more and more pronounced, to the point where she was no longer engaging with the outside world,” says Ryan. “Her husband [told the family], ‘I’m not putting her in a nursing home. There’s no way.’”

This reaction is common, says Ryan, and one of the reasons GHP advocates for radical transformation of long-term care and post-acute care environments. One such initiative is The Green House Model, a care home that is small in size, has a low staff-to-resident ratio, reflects the architecture of its surrounding community, and is completely self-sufficient. It’s not “home-like,” it’s a real home where meaningful life can happen.

“This is a model that, from a consumer perspective, you or I or our parents would want to live,” she says.

Over the past 17 years, GHP has supported organizations to build more than 300 licenced Green House models across the United States, including four campuses with 34 Green House homes across them in the state of Arkansas.

Luckily, the granddaughter from the aforementioned family did find a Green House home for their beloved gran, where she has her own private bedroom and bathroom, and shares an open kitchen, dining and living area — the “hearth” — with 10-11 other residents. The homes are licensed and include 24-hour nursing care. Ryan visited the home in Arkansas a year after this grandmother moved in and noticed a profound change. The woman was dancing, singing and building relationships with residents and staff — including one staff member’s newborn baby, whom she loved rocking during visits. Her husband, who visited his wife frequently, saw the change as well.

“He said, ‘She’s really engaging in life in a way that I could not get her to at home,’” recalls Ryan.

Outcomes like this are powerful demonstrations of what it looks like when older adults live with meaning, beyond just having their care needs met. Residents are in more control of their environment than they are within a traditional setting, from their schedules to their privacy to the temperature in their room. The Green House Model de-centralizes care delivery, such as dining and laundry and housekeeping, so the rhythm of care revolves around the residents and staff as opposed to institutional efficiency. The homes are equipped with clinical systems and regulatory standards, but that’s not what you see when you walk in, says Ryan.

“When we see elements of the institution, that can reinforce that feeling of, ‘I’m sick, I’m infirmed, I’m less than,’” says Ryan. Instead, residents of Green House Homes live “in common” with one another, in a normalized environment and as part of their communities and are seen as individuals with intrinsic worth. [ ]