The Household Model: Creating a ‘Home’ in Nursing Homes

For a person living in a nursing home, achieving a quality of life is dependent on a variety of factors.

For starters, many of us dread the prospect of moving into a nursing home and consider it the worst possible option for later life.

And yet for some people, a nursing home provides the services, supports, and care that might be best delivered in a skilled-care setting. Moreover, the poor quality of care that people fear has been significantly enhanced over the past few decades through a notable improvement of clinical measures. Incidents of pressure sores, tube feedings, and physical restraints have been radically reduced throughout long term care.

Despite these shifts, for many elders, a high quality of life remains elusive.

Household and small home models have been created to radically redesign nursing homes. They strive to create real homes of personal control and meaningful lives for the elders who live in these settings. This model challenges every aspect of the structure, process, and outcomes associated with traditional nursing homes. Here’s what you should know.

What is a household model?

A household model (“household”) reimagines three core elements of a traditional nursing home: the physical environment, the philosophy of care, and the workforce model. The goal of a household is to create real community within a space that elders recognize as home. Personal choice, the natural rhythms of the day, and meaningful life all undergird the household philosophy—with the goal of ensuring that elders live in a state of well-being. The third element is the workforce redesign that supports staff to be real partners with elders in responding to their wishes and needs.

Physical Environment

The physical environment is designed to be warm, accessible, and residential in nature. The number of elders is typically limited, ideally to 10-12 people and no more than 18 -20. The small scale is key to a sense of control and ownership for those living and working in this setting. Direct access to the kitchen; outside, well-protected private space; and comfortably shared spaces are key to the physical environment. This is truly a case where the small environment helps grow relationships and creates a sense of home.

Person-Directed Living

In the household model, elders live on their own terms, according to their rhythms and daily choices. They wake up when they choose and breakfast is prepared in their homes so that the smells and sounds of morning are normal and relaxed. Ideally, the elder has direct access to the outside environment, not just the sanctuary of their private room. Traditional schedules and boundaries such as wake-up lists, shower schedules, rigid menus, and activity schedules are eliminated so that life in the home is natural and tailored to each person.  This is “home”—so residents have the power to control it.

Empowered Staff

This element involves the redesign of the workforce structure and reporting. The roles and responsibilities of workers are often overlooked when creating a household model, but they are critical for a household to succeed.

In a household model, CNAs are often referred to as care partners, since they support and uphold the philosophy of person-directed care. The elder/care partner relationship is at the heart of the household. Care partners need the authority to respond to the choices and needs of each elder. If an elder wants to sleep until 10:30 am, the care partner needs the authority to respect that choice and the responsibility to uphold the elder’s decision. In traditional long-term care, those decisions sit with nurses and administrative staff, who are often far from the elder/care partner. This model represents a major power shift towards the elder/care partner.

Some households go further in their workforce redesigns by creating self-organized work teams with care partners. When this structure is in place, teams are responsible for managing the household. Beyond providing direct care for elders, care partners may also order supplies; lead the cooking, housekeeping, and laundry; and be responsible for creating meaningful engagement. The team also does self-scheduling and holds regular team meetings for planning and decision making. This is an advanced level of staff empowerment.

PHI’s Success in the Field

PHI Coaching Supervision® provides a foundation for household managers to become coaches for their teams. Care partners need the support of managers who are committed to the philosophy of the household and the empowerment of the workforce.

Here are a few experiences that care partners have shared with PHI about working in the household model:

“It’s home for the elders–they have choice and control. They have choice and can do what they want, when they want. Someone wants coffee and breakfast in the middle of the night, so I make it! Then she has me read her Christmas cards until she’s ready to go back to bed.”

“Team work is strong.  I work with everyone – get along with everyone. Over here, it isn’t like ‘you do your job and I’ll do mine’ – it’s like we all work together to get things done.”

“Staff mentor one another. I love working with the nurses and care partners. They teach me things.  I ask them what needs to be done and I do it. I can keep myself busy doing things (mopping the floor, dusting, etc.).”

“Scheduling has been great! We watch out for each other and make it work.  A great deal of empathy in the process – willingness to pitch in for each other. It really works well.”

To learn more about creating a household model, click here.