Longitudinal Comparison of ADL Function Between Green House Nursing Home and Traditional Nursing Home Residents

Purpose:  In the past few decades, many traditional nursing homes have attempted to transform themselves from hospital-like environments to be more homelike. This model change is generally referred to as a nursing home culture change which includes comprehensive efforts to redesign nursing home environments and transform care delivery to residents. Although care outcomes are significant and ultimate evidence that shows the effects of the new models, research findings about the resident outcomes are still limited and mixed. The purpose of this study is to investigate the effects of a small-scale nursing home model from the longitudinal health outcome trajectories. This study used Green House (GH) homes in the U.S as a representative small-scale nursing home model, and compared the change patterns of activities of daily living (ADLs) over time in GH homes and traditional nursing homes. There were two specific research questions in this study: (1) Does the facility type (whether GH homes or traditional nursing homes) influence the change in ADL function over time? (2) Does the facility type (whether GH homes or traditional nursing homes) predict different patterns of change in ADL function over time?

Methods:  This study is a retrospective longitudinal analysis using minimum dataset (MDS). The total sample included 95 GH home residents and 146 traditional nursing home residents. The health outcome was measured with ADL function indicating higher scores are more dependent (range: 0 – 40). Growth curve modeling (GCM) was utilized to examine the effect of the facility type on the mean ADL function trajectories between the two groups controlling for age, comorbidity score, cognitive function and depressive symptoms. Growth mixture model (GMM) was employed to identify different patterns of change in ADL function over time and examine the effect of facility type on predicting different patterns of change in ADL over time. After deciding the latent classes (number = 2 in this study), the logistic regression was applied to examine the effect of facility type to predict the class membership controlling for age, comorbidity score, cognitive function and depressive symptoms.

Results:  Major study findings are: (1) the ADL function of both groups were reported to become worse over time (slope = 0.56, p=0.017), but no statistically significant differences of the overall pattern of change in ADL function over time between the two groups controlling for age, comorbidity score, cognitive function and depressive symptoms at baseline. (2) Two different patterns of change in ADL function were identified using GMM including persistent independent group (n=41, intercept = 8.34 [p = 0.049], slope = -0.78 [p = 0.199]) and persistent dependent group (n=200, intercept = 19.70 [p = 0.000], slope = 0.61 [p = 0.823]). Again, higher ADL scores were more dependent status. After controlling age, comorbidity score, cognitive function and depressive symptoms at baseline, the facility type factor staying in the GH homes did not predict the resident’s likelihood of being in the persistent independent group than being the persistent dependent group at the statistical level (Odds ratio = 1.19, 95% Confidence interval = [0.58, 2.46]).

Conclusion:  As a conclusion, the changes in ADL function over time were not different between the two types of nursing home residents whether in GH homes or traditional nursing homes. The essential elements of small-scale nursing homes include private rooms and bathrooms in a small-scale unit, and encouraging independence for residents, so a physical environment that inspires self-care in private areas is generally expected to improve ADL function in small-scale nursing homes. Furthermore, GH nursing homes philosophically emphasize communal eating in the dining area like a family and self-care in their private rooms and bath-rooms, which may encourage mobility or walking with or without assistance compared to other types of nursing homes. However, while there are positive aspects to private rooms, isolation has been identified as a potential problem in the GH nursing home model because many residents who are not cognitively intact spend more of their time in their rooms. In addition, the limited involvement in structured activities may lead nursing home residents to not have many opportunities to improve or maintain physical or ADL functions in small-scale nursing homes. Thus, further replication studies to examine the effectiveness of small-scale nursing home models using larger number of sample size are necessary. In addition, as concrete strategies of care processes are important to provide practical information to improve residents’ functional status, the kinds of care processes that may influence the maintenance or improvement of ADL function of nursing home residents need to be explored together in the future.