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In 1996, Dr. Bill Thomas proposed that in long term care facilities—particularly nursing homes—loneliness, boredom, and helplessness were prevalent. He believed that these were factors that negatively affected residents’ quality of life and downed their spirits. This may seem like common sense now, but at the time, there was no empirical evidence to support this claim.

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The Eden Alternative model is designed to reduce boredom and feelings of helplessness.

Hence, researchers conducted a quasi-experimental study on older adults from a state veteran home. According to the National Library of Medicine, the study conducted was on the effects of the Eden Alternative model on quality of life issues. When the Eden Alternative model was applied to the study group, lower reported levels of distress, boredom, and helplessness were reported. However, loneliness was reported to be the same. The findings suggested that there is an opportunity to improve residents’ overall quality of life in nursing homes and other long term care facilities.

For Thomas, this was an outstanding achievement, and it served as proof of his theory. “I take great pride in the Eden Alternative because loneliness, helplessness, and boredom are universal, and they can be solved,” he said. Thomas recently joined Peter Murphy Lewis LTC Heroes podcast to discuss the Green House project and the Eden Alternative.

So what is the goal of the Eden Alternative? According to Thomas, medical treatment for residents in nursing homes is necessary, but it isn’t enough. Residents also need to be comfortable and experience quality living, and this can be achieved by addressing the three plagues of nursing homes:

  1. Loneliness
  2. Helplessness and
  3. Boredom

The Eden Alternative, then, as described by Sherbrooke, is a philosophy that seeks to address these three plagues of nursing, and it serves as a template for driving successful culture change in long term care facilities. It is focused not only on the care of the human body, but also on the human spirit and the well-being of residents in nursing homes.

WD International lists the Eden Alternative seven domains of well being as: 

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A summary done by for the domains of well-being at an Eden nursing home.
  1. Identity: It means a person is well known, has a sense of individuality, and has a history.
  2. Growth: It is when a person experiences development in their life or they “evolve” in how they think about and view things.
  3. Autonomy: This is when a person has the freedom to make their own choices.
  4. Security: This means a person has personal safety, privacy, dignity, respect, and they are also free from doubt or fear.
  5. Connectedness: This is when a person has a sense of belonging and is engaged with their community.
  6. Meaning: This is when a person has a sense of significance, purpose, and hope
  7. Joy: happiness, pleasure, and contentment are indicators of joy in a person.

Dr.Thomas went on to found the Eden Alternative organization, an international non-profit dedicated to the creation of quality life for elders in nursing homes and other long term care facilities, as well as the Green House Project—an organization that aims to destigmatize aging, and also humanize the care of residents by transforming nursing homes.

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The Green House Project Explained

In 2001, Thomas visited  the Robert Wood Johnson Foundation to discuss the concept of abandoning nursing homes’ cold, dreary design. He proposed a radically simple alternative to the traditional nursing home. With support from the foundation, the idea evolved into what is now known as the Green House Project.

The Green House Project is a non-profit organization founded on the belief that everyone has the right to age with dignity. The organization aims to destigmatize aging and humanize care for all residents in nursing homes and other long term care facilities. Thomas states that:  “Greenhouses have radically better outcomes for the people living in them than conventional nursing homes. Also, there’s a lot of academic research that has shown that it yields superior outcomes and greater satisfaction among residents.”

The first Green House homes opened in 2003, and in 2005 the concept gained momentum when it received a ten million grant from the Robert Wood Johnson Foundation (RWJF). RWJF provided additional funding in 2018 to further the development of Green House homes nationwide. In 2011, the total number of Green House homes reached 100, and in 2015 the organization transitioned to a new sponsor under the auspices of the Center for Innovation, Inc. (CFI). As of 2021, there are currently more than 260 Green House homes in more than 32 states.

How The Green House Project Is Implemented

The idea behind the Green House Project is to have small homes that provide high-quality personalized care. All this while still giving control, dignity, and a sense of well-being to the residents of nursing homes. Ave Maria Home describes green house homes as a radical departure from traditional nursing homes.

Medscape describes the Green House model as small homes with 6-12 residents, in which the care, comfort, and well-being of a resident is given as much attention as their treatment. In addition, the residents feel that they are in a family-type setting as they each have their own private bedrooms and bathrooms, with a central living area where residents can gather.  

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The designs of Green House project homes is different from other nursing homes.

The US National Library of Medicine notes that the Green House model of nursing homes shows substantial variation in practices to support resident choice and decision making. They do, however, exclude the residents from critical decisions affecting their health – for obvious reasons.

Green House homes do not appear the same as traditional nursing homes, as their interior design, organizational structure, staffing, and delivery of professional services are quite different. Green House homes are designed from the ground up to look and feel like residential homes. A Green House home has three main focuses:

  1. Warmth: this is created by choosing home-like floor plans, décor, and furnishings. It should have what you would typically find in the average American home, not in an institutionalized nursing home.
  2. Smart: the home will use cost-effective technologies that make the lives of its residents easier, e.g., lifts.
  3. Green: this involves using indoor plants, letting in sunlight in the home by using large windows and skylights, and using outdoor spaces such as the yard for resident activities.

Food is cooked on-site, and medical equipment is stored in cupboards away from sight. Shahbazim—an alternative to CNAsprovide care to the home residents with the assistance of nurses and therapists, but without the administrative and supervisory layers typically found in nursing homes. A Shahbaz acts as a guardian to elders in the nursing home.

Dr. Thomas believes in using the word Shahbaz instead of “certified nursing assistant” because, as he explains his thinking behind this element of the Green House Project, “We didn’t want to drag that old language into this model. So we took the word Shahbaz, which is Persian, and it means ‘a royal Falcon’.” 

But this is not simply the outward change of terminology. Rather, the Shahbazim are more competent and compensated as such. Thomas added that their training was “vastly” expanded and their pay raised by 30%. “The Green House Project isn’t just about having nursing assistants to care for elders, but is about having people who can help elders have a great day,” he said.  

What Qualifies as an Eden Nursing Home

Although it’s not a formal accreditation, an Eden nursing home agrees to abide by the Eden Alternative’s principles and work to create a better and more comfortable environment for its residents. A nursing home can apply to become an Eden registry member on the Eden Alternative registry page.

Once approved, the now Eden nursing home receives an “Eden tree plaque,” which they can display on their website. This lets others know that they are committed to the Eden Alternative 10 principles as an Eden Alternative member. These principles are:

  1. The elimination of loneliness, helplessness, and boredom, which can negatively affect the health and well-being of residents in long term care.
  2. Residents experience a feeling of well-being in a caring, inclusive, and vibrant community.
  3. When residents have access to the companionship they desire, they thrive. This is an effective way of combating loneliness.
  4. An antidote to helplessness is when residents have purpose and the opportunity to give as well as receive.
  5. An antidote to boredom is when residents have variety, spontaneity, and unexpected events in their lives.
  6. Having meaning in their lives is essential for residents. Meaning lifts the human spirit and contributes to their overall health and well-being.
  7. Medical treatments should support and empower residents to experience a life worth living. This is because residents in long term care facilities are more than just their medical diagnoses.
  8. Decision-making should involve the residents who are impacted the most by the decisions. This gives residents a feeling of empowerment, and they don’t feel helpless.
  9. Keep learning, adapting, and growing. This is because changing a nursing home’s culture to create a better one takes time, and it is a never-ending process.
  10. Wise leadership is needed for meaningful and lasting change.
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In addition to these principles, the Eden Alternative organization emphasizes one golden rule to be followed by all its accredited members: “As management does unto the staff, so shall the staff do unto the elders/residents.” Nursing home administrators should especially take this into account, as they are responsible for their residents, and their treatment should abide by regulations.

The above principles appear to be working, as the National Library of Medicine mentions that Eden Alternative dementia care resulted in improvements for residents when it was implemented in the UK over the past ten years. Nursing Times gives detailed case studies on dementia care taken from nursing homes in the UK and Ireland. The case studies showed that implementing the Eden Alternative model enhanced residents’ quality of life and greater job satisfaction among staff.

The Future Of The Eden Alternative

The Eden Alternative is a relatively simple approach with far-reaching consequences for nursing homes and other long term care facilities. After attending the short intensive training sessions, Eden associates can introduce the philosophy in their own nursing homes, improving the well-being of their residents.

With over 129 Eden registry members, one can expect the numbers to continue to grow as more and more nursing homes seek to provide more than just medical care for their residents.For more on recent trends in long term care, read our blog and subscribe to the LTC Heroes podcast.

Elijah Oling Wanga