Small-house nursing homes

What it is, and what we are not going to claim

Green House is the best-known small-house design. The Green House Project says residents make their own choices, and that the design is built around dignity and independence, with private rooms and a setting that feels like a home and not an institution. It says it has helped groups build nearly 400 homes across 35 US states, plus Australia and Canada.^[1] The first homes opened in Tupelo, Mississippi in 2003.

This page used to give many more details: 10 to 12 residents in each house, a private bathroom for each, one open kitchen and fireplace, a small team trained to run the whole house, 87% licensed as skilled nursing facilities, about 82% nonprofit, about 45% taking Medicaid. Those numbers get repeated a lot. The network's own page does not state them, and we could not confirm them, so they are gone.

That matters more than it sounds. A house with twelve residents is very different from one with twenty-four. A house with private bathrooms is very different from one without. Those differences are the whole reason a family would pick this kind of home. So treat the name as a place to start, and ask each home: how many residents live here, what license do you hold, do rooms have private bathrooms, who works in this house and is it the same people each day, and what kinds of payment do you take?

The COVID study, and who wrote it

This is the study people usually point to for this kind of home. It is worth telling in full, not just as a headline.

A researcher named Zimmerman and her team published it in the Journal of the American Medical Directors Association in 2021. They compared 219 Green House and small nursing homes with 177 regular homes under 50 beds and 215 regular homes of 50 beds or more. The small-home numbers came from 43 groups, which was 75% of the 57 that could have taken part. The study covered January 20 to July 31, 2020.^[2]

• Median (middle) COVID-19 case rate per 1,000 resident days: 0 in the Green House and small homes, 0 in regular homes under 50 beds, and 0.06 in regular homes of 50 beds or more.^[2]
• Median deaths per 100 positive cases: 0, 10 and 12.5.^[2]
• All of the differences were statistically significant at P < .025, which means they were unlikely to be due to chance.^[2]

Now the facts that belong next to those numbers. The study compared groups of homes. It did not run an experiment. So it shows a link and not a cause. This page used to say the private rooms and small staff "made it safer," and that is more than the study can back up. It covers six months of 2020, before vaccines. The authors state their own limits: they cannot vouch for the federal data they used, and they used data only through July 31, 2020.^[2]

And one fact we think you should be told and not have to dig for: three of the seven authors worked for The Green House Project.^[2] That does not make the finding wrong. Other experts reviewed it before it was published, and the numbers are what they are. But it is not an outside look at these homes, and you should weigh it with that in mind.

An earlier version of this page also cited an article in Health Affairs for happier residents and families and fewer staff leaving. We could not open it, so we took that claim out.

The practical questions

If a home is approved by Medicare, it shows up in the federal data. That means you can look it up in our directory like any other nursing home, with its inspection record. Check that for each home. Don't assume it.

The real limit is how few there are. With a few hundred houses in the whole country, your county may have none. The network's list answers that in one search. Look before a discharge planner is standing over you with a deadline, not during.

Find homes: aginginnovation.org. A listing there comes from the network itself. It is not a license check, a quality rating, or proof that a home takes your kind of payment. Questions to ask has what to bring on a tour.

Quick answers

What is a Green House nursing home?

It is a small-house design, meant to give skilled nursing or other live-in care in a place that feels like a home and not an institution. The Green House Project describes private rooms and a way of living where residents make their own choices. It says it has helped groups build nearly 400 homes across 35 US states, plus Australia and Canada. This page used to give more details: 10 to 12 residents, private bathrooms, one open kitchen, staff trained to do many jobs, 87% licensed as skilled nursing, 45% taking Medicaid. We took those out because the network's own page does not state them. Ask each home directly. [1]

Are small nursing homes safer than traditional ones?

A 2021 study in a medical journal called JAMDA compared 219 Green House and small nursing homes with 177 regular homes under 50 beds and 215 regular homes of 50 beds or more. It covered January 20 to July 31, 2020. The median (middle) COVID-19 case rate per 1,000 resident days was 0 for the small homes, 0 for regular homes under 50 beds, and 0.06 for the larger ones. Median deaths per 100 positive cases were 0, 10 and 12.5. The differences were too large to be likely due to chance. But the study only compared homes over six months, and three of its authors worked for The Green House Project. It does not show that private rooms or staffing caused the difference. [2]

Does Medicaid pay for Green House homes?

It depends on the home, and we can no longer tell you what share take it. Is this house approved by Medicare? Does it take Medicaid? Does it have the kind of bed you need? Those are three separate questions for that home and your state. Use the network's list to find homes, then confirm each of those directly before you plan around one. [1]

Where to go next

• The in-between options
• Nursing-level care (crisis-side)
• Choosing a nursing home — the checklist