The Health Care M&A Monthly: Q&A With Robert Jenkens

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Robert Jenkens is Director of the Green House® Replication Initiative and Vice President of NCB Capital Impact (formerly NCB Development Corporation). Through a grant from the Robert Wood Johnson Foundation, NCB Capital Impact, a not-for-profit organization based in Washington, provides policy and development consulting to states, communities, and organizations that are interested in developing a Green House Program. This innovative senior-care model deinstitutionalizes long-term care by eliminating large nursing facilities and, instead, creating habilitative, social settings. Jenkens, who is also a founding board member of the Center for Excellence in Assisted Living, studied architecture (with an emphasis on residential care for older persons) at Cornell, real estate development at MIT, and public policy at Harvard’s JFK School of Government.
What is the Green House philosophy? A greenhouse is an environment that enhances life and growth. Being old and needing nursing home care doesn’t mean that your life is over. Our Green Houses are places where elders can continue to thrive and grow. The mission of the Green House Program, then, is to shift the way we provide long-term care in this country from the current large, institutional model to a small home environment. People still receive very high levels of care in a Green House environment, but the primary focus is on providing a comfortable home and a meaningful life for the residents.
How is the Green House model unique? Each Green House has six to 10 private bedrooms and bathrooms, with a kitchen, living room, and dining room in one big area called "The Hearth." All food is prepared from scratch in the house by the self-managed work team, because that encourages socialization, creativity, and a sense of family. Workers engage the residents in activities — including helping with meals and offering advice — which leverages the staff in ways that have been pretty much shut down in traditional nursing homes. It may be easy to build a 10-bedroom house; but it’s difficult to operate a successful Green House without fully understanding the philosophical and organizational shift. The physical environment — the architecture, aesthetics, and scale of the home — reflects only about one-third of the model. The balance is in the reorganization of the way care and services are delivered.
How are care and services delivered? The direct-care workers in each house are called Shahbazim, a title derived from the Persian word for royal falcon and from a tale about how a falcon protected, sustained, and nurtured a dying elder in the desert. After receiving special training, Shahbazim are organized into self-managed work teams that run each house. The ratio is two Shahbazim to 10 elders in shifts covering 24 hours a day. They cook, clean, provide personal care, and do some therapy work. As a result, they know the residents as family. If any aspect of a resident changes, a Shahbaz will notice right away. The Shahbazim have power and authority over the management of the house and become part of the overall Green House system in a very meaningful way.
How is NCB Capital Impact using its grant monies?
In November 2005, the Robert Wood Johnson Foundation provided a $10 million grant to help spread Green Houses to 50 campuses over five years and to create an ongoing, self-sustaining, replication center. At the end of five years, and without additional funding, we will be able to continue to help people create and implement Green Houses. The grant allows us to provide technical assistance — financial viability, fundraising, financing, development, pre-opening planning, training, and post-opening operational assistance — to anyone wanting to create a Green House. It also directs us to create a tool kit (design guidelines, policies and procedures, and Web-based training manuals) to help people create Green Houses. And we will create an ongoing quality assurance and research element to ensure that Green Houses don’t just look good — they really are good.
Is the model for both for-profits and not-for-profits?
The Green House model is designed for nursing homes that have to rebuild or for organizations that are building new long-term care facilities, typically skilled nursing homes. It is suitable for any nursing home in the country — whether for-profit or not-for-profit. Most current adopters are not-for-profits. The typical pattern when an innovative idea spreads into the culture is that mission-driven people don’t need a lot of evidence and will adopt it first. They see something, think it’s better, and figure out a way to make it happen. The for-profits typically need evidence that something works before jumping in. They’re concerned about the financial and regulatory implications. Our first Green House was built in Tupelo, Mississippi, in 2003. We have eight campuses open today, another 25 projects in development, and are just now beginning to get calls from for-profit operators.
How do costs compare? The physical structure should cost no more than rebuilding in a traditional fashion, but Green Houses require private bedrooms and baths. So developers must compare apples to apples when comparing costs. On the operations side, cutting down on the departmental structure can offset the added cost of self-managed work teams. We have a very sophisticated financial model. In fact, the first piece of our technical assistance is to work on the financial pro forma.
Do you expect the Green House model to catch on?
While we don’t expect every nursing home to convert to a Green House model, we do hope that in 10 years we will have made substantial headway in eliminating the old institutional models. We hope Green Houses will be one of the options available to people in their communities.