with plants, pets, and visits by children (Hamilton and Tesh, 2002). The Eden Alternative also decentralizes the organizational structure of nursing homes to empower certified nursing assistants (CNAs) to develop their own schedules and daily assignments and to provide companionship to the residents. GHs take the concept one step further by creating a more residential social setting.

The initial development and implementation of the GH model was supported by grants from private foundations. The model involves three key elements. First, the environment is composed of a small, technologically sophisticated house that functions as a home for eight to ten residents. Each resident has a private room and bathroom, and the residents’ individual rooms are clustered around a central area with a shared kitchen, dining room, and living room. GHs serve as real homes in appearance and function and, as such, do not have nurses’ stations, medication carts, or public address systems (Kane et al., 2007).

Second, the frontline caregivers have broad roles that include personal care, cooking, housekeeping, and assuring that residents spend time according to their preferences. These direct-care workers, referred to as shahbazim, receive 120 hours of training above those required to be a CNA. This level of training is significantly beyond federal and state requirements and reflects the CNAs’ expanded role in a GH. In addition, there are “sages,” older adults who serve as coaches or mentors to the shahbazim, and “guides,” who are supervisors and serve as liaisons between the shahbazim and other staff. This system of support is the basis of the care team.

Third, professional healthcare providers (e.g., nurses, physicians, social workers, and pharmacists) form visiting clinical support teams that provide specialized assessments for residents. Licensed nurses are available and responsible for the clinical care in the GH. A nurse is available to shahbazim whenever needed, 24 hours a day, by emergency pager (NCB Capital Impact, 2007).

While information on the effectiveness of GHs is preliminary, a recent evaluation of the model showed that GH residents reported better quality of life on several measures, higher satisfaction with their place of residence, and better emotional health than a comparison group (Kane et al., 2007). No difference in self-reported health was noted. Quality of care was at least as good in the GH group as in the control group. The GH group also had a lower prevalence of residents on bed rest, fewer residents with limited activity, and a lower prevalence of depression compared with residents of traditional nursing homes.

In addition to its potential to promote patient-centered care, the GH model also holds promise for improved recruitment of direct-care workers. The first GH site received only two responses to advertisements for a CNA but received more than 70 when the ad was for a shahbaz (Angelelli, 2006).



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