LTSS Choices

Small-House Nursing Homes

Published January 6, 2021

Well before the coronavirus pandemic, long-standing problems in traditional nursing homes, such as infection control violations, low staffing ratios, and safety concerns, led many individuals and their families to explore alternatives. This report, part of AARP Public Policy Institute’s series on transforming long-term services and supports called LTSS Choices, is about one alternative, the Green House model.

St. John's Green Home in Rochester NY

What is the Green House Model?

Unlike traditional, large-scale nursing homes, Green House and other small-house nursing homes are typically self-contained buildings occupied by small numbers of residents. With small-house nursing homes, typically a cluster of small houses is licensed as a nursing facility, or they can be part of a licensed traditional nursing home. The design's overall goal is to achieve a better quality of care and quality of life for residents, and higher satisfaction rates among staff and families than experienced in traditional, institutional nursing homes. The model assumes that a person-centered approach to services enhances a resident’s quality of life. Residents decide on critical aspects of their day-to-day activities, from the types of services they want to levels of interaction with other residents.

The staffing model is a defining feature of the Green House model, with Certified Nursing Assistants (CNAs) holding more responsibility for, and empowered to achieve, quality of care and quality of life for residents. CNAs, who undergo additional hours of specialized training, including dementia care and culinary education, operate as a self-managed work team, and are all trained to provide a diverse range of supports including personal care, meal preparation, laundry and housekeeping. This allows for any staff member to respond in the moment to resident needs. By contrast, in larger nursing homes, workers typically perform only one or two functions and do so for large numbers of residents, which means delays in meeting residents’ needs while awaiting the arrival of specialized staff members.

Some Facts About Today's Green House Homes

There are currently 3200 Green House residents nationwide

  • The majority receive nursing care
  • The majority pay out of pocket
  • 45% are covered by Medicaid

There are currently 300 licensed homes in 32 states

  • 87% are licensed as skilled nursing facilities
  • 37% are located in rural areas
  • 63% are located in urban areas
  • 82% are not-for-profit
  • 18% are for-profit
  • 89% remain active in Green House peer network

The Evidence: Is the Green House Model Resulting in Improved Outcomes?

Preliminary evidence suggests that Green House homes achieve their goals of better quality of care, quality of life, and higher satisfaction rates among staff and families. Existing studies are limited in scope, and further research is needed to confirm findings and determine which elements of the Green House model are most effective. Limited research on other small-house home models such as the Household model also makes it difficult to compare among them. That said, the findings are promising:

  • Prior to the COVID-19 pandemic, studies documented better clinical outcomes for residents in Green House homes than residents in traditional nursing homes.
  • A 2015 study found that Green House home residents were 16 percent less likely to be bedridden, 38 percent less likely to have pressure ulcers, and 45 percent less likely to have catheters and had lower hospital readmissions rates than traditional nursing home residents.
  • Other studies have documented the effect of the model on a broad range of measures, including quality of life and quality of care, family satisfaction, and staff satisfaction
  • Green House homes are faring far better than traditional nursing homes in handling COVID-19, with 2.8 confirmed deaths per thousand residents through July 2020, compared with 38 deaths per thousand residents.

Challenges for Expanding the Availability of Small-House Homes

In spite of being around since the early 2000s and having attributes that would seem highly appealing, Green House model adoption rates remain relatively slow, due to both consumer- and provider-related factors.

The challenges for consumers trying to access small-house homes are two-fold: limited availability and cost. The challenges for providers seeking to offer or expand small-house homes are more complex, and include: financing the cost of development; regulations, particularly state approvals needed for building health care facilities; workforce challenges, which result from this being a relatively high risk, low wage industry even as Green House homes offer higher than average compensation, retention and staff satisfaction.

The report concludes with four policy recommendations which directly address these challenges. It also carries three appendices: Core Values and Elements Essential to the Green House; Appendix B – Three Design Models of the Green House Home; Six Selected Studies of Green House Homes.

Suggested Citation

Reinhard, Susan and Edem Hado. LTSS Choices: Small-House Nursing Homes. Washington, DC: AARP Public Policy Institute, January 6, 2021.


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