Finding a better way to do things doesn't always mean spending more money on the biggest and the best. In the related worlds of senior housing and health care, it turns out that a very small-scale solution can deliver a terrific quality of life for seniors that is not beyond their financial reach.

The Green House Project is backed by the Robert Wood Johnson Foundation and by a nonprofit, NCB Capital Impact, which provides a range of financing, design, operational and training services. The project has spent the past 10 years developing and refining The Green House model for assisted senior living. There are now nearly 150 Green House projects operating in 22 states.

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A Green House home is designed for only 10 to 12 senior residents. Each occupant has a private room and bath, including a lift to allow them to get into and out of their beds. Each room has separate heating and cooling controls. And each room also has the resident's own locked medication station, allowing a licensed caregiver to dispense needed medications in the privacy of a person's own room.

Built like a home for a large family, Green Houses include a shared kitchen that everyone uses, not an institutional kitchen for food preparation and serving. Central to making Green Houses work, explains project director David Farrell, is that nearly all of the care is provided by certified nursing assistants (CNAs). Traditionally at or near the bottom of the nursing-home skills ladder, these CNAs receive special training to allow them to perform nearly all of the staffing and management tasks needed inside a Green House. This flat management structure can save a lot of money, Farrell notes, while empowering the people in a Green House who know the most about what its residents need.

For many of its 10 years, the Green House Project has had to swim upstream against traditional attitudes about nursing homes and the best business models for caring for seniors. Size and scale were the models that determined what was built and the related government payment supports.

Fair or not, however, size has become associated with an uncaring, institutional approach that warehouses older people and doesn't treat or even see them as individuals. "People don't want to be in a nursing home," Farrell says. "Most nursing homes were built 35 to 40 years ago, and most of them are falling apart."

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Green Houses, by comparison, are seen as individually oriented projects. Local backers often attract imaginative designs from project architects. And while cost is always important, there is a "pro bono" aspect to many projects that draws designers and builders who often have a moral as well as economic motive for working on the project. Nearly everyone has a story to tell about an older family member or loved one, and there is a strong desire to build comfortable and respectful senior housing.

To date, Green Houses have been built largely by the substantial nonprofit component of the senior housing industry. Projects may be located on the campuses of continuing care retirement communities where, Farrell says, members have said they don't want to be relocated to a traditional nursing home environment.

Special-use houses have also been built, such as for military veterans with disabilities, Alzheimer's patients and other groups. In another case, 10 individual Green Houses were built on top of one another in a mid-rise building.

While the houses are often more expensive to build per unit than larger nursing homes, Farrell says the staffing changes can make them economically competitive. Only about 20 percent of Green House living units are occupied by people who pay market-rate prices, he says. Most occupants are on Medicaid or other assistance programs.

Surveys have found that people are willing to pay more for Green House living units than for other types of assisted living. "It varies by state," he explains. "But people would be willing to pay up to 20 percent more [for a Green House room] than they would pay in the market for a private room in a nursing home."

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Despite the appeal of the homes, they are dwarfed by the need. After all, even if all 150 homes built in the last decade held 12 members each, that's a total capacity of only 1,800 people. More than five times this number are turning 65 every day, and the numbers of additional people needing assisted-living help every day dwarfs the small scale of Green House rooms built so far.

Still, Farrell also believes conditions are ripe for scaling up the Green House model. Obamacare encourages care facilities that produce good health outcomes, and Green House Project facilities do so. Also, nursing home owners are faced with big modernization needs, and Farrell believes many of them will turn to Green Houses and other smaller-scale projects that are much more appealing to seniors than traditional nursing homes.

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