As they get older and some help becomes important, many people dread the idea of going to a nursing home or to “assisted living.” A big part of the reason is fear of a loss of control and loss of privacy, since safety and health often get put first over all the things people want that give them a reason to live. And there are other intangibles about what makes a place seem like home. There have been many good innovations in nursing homes and assisted living to make them more appealing. One that is important because it has been scaled up is the Green House Project. Here is what Atul Gawande says about the Green House Project in his wonderful book Being Mortal: Medicine and What Matters in the End:

Around 2000, [Bill] Thomas got a new itch. He wanted to build a home for the elderly from the ground up instead of, as he’d done in New Berlin, from the inside out. He called what he wanted to build a Green House. The plan was for it to be, as he put it, “a sheep in wolf’s clothing.” It needed to look to the government like a nursing home, in order to qualify for public nursing home payments, and also to cost no more than other nursing homes. It needed to have the technologies and capabilities to help people regardless of how severely disabled or impaired they might become. Yet it needed to feel to families, residents, and the people who worked there like a home, not an institution. With funding from the not-for-profit Robert Wood Johnson Foundation, he built the first Green House in Tupelo, Mississippi, in partnership with an Eden Alternative nursing home that had decided to build new units. Not long afterward, the foundation launched the National Green House Replication Initiative, which supported the construction of more than 150 Green Houses in twenty-five states—among them the Leonard Florence Center for Living that Lou had toured.

Whether it was that first home for a dozen people in a Tupelo neighborhood or the ten homes that were built in the Florence Center’s six-story building, the principles have remained unchanged and echo those of other pioneers. All Green Houses are small and communal. None has more than twelve residents. At the Florence Center, the floors have two wings, each called a Green House, where about ten people live together. The residences are designed to be warm and homey—with ordinary furniture, a living room with a hearth, family-style meals around one big table, a front door with a doorbell. And they are designed to pursue the idea that a life worth living can be created, in this case, by focusing on food, homemaking, and befriending others.

… He took the control away from the managers and gave it to the frontline caregivers. They were each encouraged to focus on just a few residents and to become more like generalists. They did the cooking, the cleaning, and the helping with whatever need arose, whenever it arose (except for medical tasks, like giving medication, which required grabbing a nurse). As a result, they had more time and contact with each resident—time to talk, eat, play cards, whatever. Each caregiver became for people like Lou what Gerasim was for Ivan Ilyich—someone closer to a companion than a clinician.

This sounds attractive to me. You can see the map at the top of this post of which states have Green House homes. There are three in Colorado, two near where I live now. The Green House Project website says “Don’t See a Green House home in Your Area? Build one!” I hope many people do this.

I’d be interested in other initiatives like this to given people more autonomy, privacy and sense of home in a nursing home/assisted living that have been scaled up.

In Being Mortal, Atul Gawande’s main theme is that we must face our mortality and the limitations of old age, but then choose freely within those limitation the things we care most about in our final years—and that people should be supported in doing so. Our final years are an important part of life. Without thinking about them, it will be hard to make them as good as possible.

For organized links to other posts on diet and health, see:

• Miles Kimball on Diet and Health: A Reader's Guide