Pros and Cons of Smaller Long-Term Care Facilities

Have you ever visited elderly people in a nursing home or assisted living facility and felt like you were just going there to watch them die? Did the experience make you swear you’d never put your own parents in this kind of group care facility, and you’d do everything you could to keep yourself out of one?

Some facilities are trying to solve this problem by taking a different approach: the "small home" model. Instead of multi-story buildings where residents share rooms along long, bleak corridors—facilities that resemble hospitals at worst and corporate hotel chains at best—these alternative facilities try to create a homelike environment where no more than a dozen residents live in real houses with private rooms and en suite bathrooms. But these homes aren’t necessarily a better option than traditional facilities for all patients. Let’s take a look at the pros and cons of small-scale residential care, focusing on the Green House Project, a national brand of small-scale residential care facility.

The small-scale model is trying to get away from the hospitalization of the elderly, which is what traditional, large facilities—trying to achieve operational efficiencies based on the current Medicaid, Medicare and health insurance reimbursement environment—are doing, says Matt Norris, a San Diego-based commercial real estate developer. Motivated by memories of the depressing facilities his grandparents and other relatives endured, Norris is working to develop more Green House homes across the country.

“Within the small home-based market, [we're] trying to recreate the personalized, patient-centric care given to a loved one in a home environment,” Norris says. The big difference between large, traditional elder care facilities and small, home-based care facilities like Green House is "in the organizational structure,” he explains. “Traditional elder care facilities are hierarchical, task-centric organizations, where large staffs focus on executing a strict routine of tasks associated with the care of the patients. Green House homes are patient-centric facilities each run by small, self-managed teams, meaning the patients dictate how they live within the Green House home, much like being at home, and the staff can better cater to the patient’s preferences and needs.” 

Small-scale care facilities aim to offer a superior quality of life. The buildings are often designed to have private rooms and bathrooms, cozy living rooms where residents can gather with each other or with visitors to socialize, and a more residential feel overall.  The rooms let in plenty of sunlight and offer easy access to outdoor areas and gardens. Residents can set their own schedules for when they want to wake up, eat meals and go to bed. They’re also able to enjoy customized, cooked-on-premises meals instead of being restricted to a set menu of institutional food. 

The core attributes families are looking for, no matter what out-of-home residential care they are considering, include quality healthcare, staff who are compassionate, friendly and responsive, and security and safety, says Leah Eskenazi, MSW, operations director of the Family Caregiver Alliance, a community-based national nonprofit that addresses providing long-term care for loved ones.

Small residential care homes aim to excel in these areas where larger institutions often fall short. Nurses in Green House homes, for example, spend 24 minutes more per day directly caring for residents, compared with nurses in traditional skilled nursing facilities, a 2010 study published in the Journal of the American Geriatrics Society found. A low ratio of residents to staff in residential care homes means staff are more likely to notice problems early, when they are small, and help patients get treatment before those problems become serious. 

For anyone with specialized needs, whether it’s a doctor-mandated diet, a lifestyle choice like veganism, a cognitive disability such as dementia, or having a race, religion, culture or gender identity that lies outside the mainstream, a small residential care home can be ideal. Such facilities can more easily cater to these needs than a large facility can. There are also specialized facilities dedicated to serving only individuals of a particular group, such as gays and lesbians or those with special needs like Alzheimer’s patients. 

One potential drawback of smaller facilities is they may offer fewer amenities and activities. Also, while a resident might be able to have an entire apartment in a traditional assisted living facility or continuing care community, he or she might have a smaller personal space in a residential care home. (For related reading, see: How to Find the Right Retirement Community)

It’s also important to think about future care needs, because moving can be traumatic. Some residential care homes may offer primarily companionship and comfort, and are less well-equipped to handle intensive medical tasks such as tube feeding, wound care or medication management. “You really want to make sure the staff is skilled in terms of the level of care need for the individual and for their family,” Eskenazi says. Some Green House Project homes offer a continuum of care, making it possible to go from independent living to assisted living to skilled nursing. This isn’t the case with all residential care homes.

Large, traditional facilities dominate the market; small, alternative models can be hard to find. Even a national brand like the Green House Project doesn’t have homes everywhere. While it has homes in 33 states with more underway, they are often spread out.  That can be tough if having a home in close to or convenient for relatives, is a priority.

At first glance, the small-home model seems to offer the elderly a much better life than the institutional norm. Unfortunately, as so often happens, there's little empirical data to back that up.

Academic studies published in 2007 and 2008 found that Green House residents were able to take care of themselves for longer in their lives compared with traditional nursing home residents. They were also less likely to be depressed and their families were more satisfied with the facilities and care their loved ones received. And a small 2012 study funded by the Robert Wood Johnson Foundation, a major source of financial support for the Green House Project, found that Green House residents were less likely to be hospitalized than nursing home residents.

That being said, a study of 93 Green House home residents and 149 traditional nursing home residents in the January 2016 International Journal of Nursing Studies found occupants of both types of facilities experienced the same rates of deterioration in their ability to perform activities of daily living over the 18-month study period. A closely related study by the same authors published in 2015 in International Psychogeriatrics found that while Green House residents were more socially engaged, they had a higher rate of increase in depressive symptoms. 

Residential care homes offer the opportunity for close relationships with staff and other residents, since residents see the same few people every day. That’s great if you like the people at the facility, but terrible if you don’t, since there are fewer options when seeking companionship or care. The small community also might not offer enough variety for extroverts who enjoy interacting with lots of people.

For seniors who are no longer able to live at home but who want to avoid an institutional setting, the homey alternatives to traditional nursing homes can appear to have much to offer, with few drawbacks. But if you’re considering moving yourself or a loved one into one of these facilities, carefully assess how well the place matches up with medical needs, potential changes in those needs over the years, and lifestyle preferences.

The Green House Project’s search tool lets you find facilities by location. Where else should you look for options, especially if there isn't a Green House near you? One tool is SeniorAdvisor.com, a consumer ratings and reviews site for senior care in North America, whose site lets you specifically search for senior group homes, also called residential care homes. Some of your search results will be for large facilities, but you can easily scroll through to find the small ones, then read reviews (including for Green House homes), see photos and check out prices.

Another source for general information, especially if the cost of care is a concern, is the Family Caregiver Alliance’s Family Care Navigator.

(For related reading, see: Alternatives To Nursing Homes.)