At Home with Old Age
Reimagining nursing homes
As the keynote speaker at an AARP workshop on elder care, William Thomas, M.D. ’86, is telling the story of Eos, the Greek goddess who fell in love with the Trojan prince Tithonus. The couple lived happily until one day Eos saw something strange poking out of her husband’s head. “‘What is that???’” Thomas shrieks in mock shock and disgust as the audience laughs. “Well, it was a gray hair.” Soon, Thomas continues, the prince’s entire head was white and he grew older and older—but he could not die because he had been made immortal. His once booming voice became feeble, and his strong legs and shoulders shriveled up. In the end, Eos took pity on him and turned him into a grasshopper. “The myth,” Thomas tells his audience, “offers the proposition that old age is inside of us; it is welded to the human condition.”
An internationally known geriatrician, Thomas is used to lecturing about the need for attitudinal adjustment when it comes to aging. Growing old entails “elements of decline, [but] the larger truth,” he maintains, “is that aging is a complex, multifaceted, and poorly understood component of normal human development.”
Thomas takes this holistic view to work every day. A bullish reformer, he has spent his career pushing for seismic cultural and economic changes in long-term care and public policy toward aging, which has meant challenging the $122-billion nursing-home industry.
In some ways the timing for such reforms could not be better. Many nursing homes built in the 1960s and 1970s in response to Medicare and Medicaid legislation now need major renovations just as aging baby boomers begin to create rising demand for geriatric care. (Seventy million Americans are expected to be older than 65 by 2030.) “The boomers are already changing the face of aging,” says Thomas, who is 48. “They aren’t going to take the declinist label: ‘I am broken down and unimportant.’”
Thomas is out to improve nursing-home conditions—or, better yet, supplant them with smaller group homes where customized, flexible care is the norm. “I am talking about a vision for alleviating the main causes of human suffering in older people—loneliness, hopelessness, and boredom,” he says. “The changes I am talking about are really just applying common sense. Would you rather live in an institution, or in a garden?”
Thomas calls himself a “nursing home abolitionist.” The vision of an “Eden Alternative” for elders began in 1991 when he took a part-time job as a doctor at the nonprofit Chase Memorial Nursing Home in upstate New York. He was seeking respite from harrowing 24-hour shifts at a local emergency room, but quickly realized two things: that there was “something very wrong” with the way people were living there, and that he had “just fallen in love with the people, their families, and the nurses.” He also recognized opportunities to effect deep change. “Morale is often so low at a nursing home that just about anything you could do there would have a huge impact,” he says. “I met people who had literally given up on living. And you can bring joy to them—that’s what turned me on.”
Within two years Thomas had also brought the residents 80 parakeets, 10 finches, two lovebirds, six cockatiels, two canaries, and dogs, cats, rabbits, and chickens. Fresh-cut flowers and home-grown food—from gardens dug into Chase’s once-manicured lawns—graced the hallways and dining room. He introduced new approaches to dementia, frailty, and the human need for companionship that also improved working conditions for the staff. (Staff turnover is a major problem in geriatric care.)
The Eden Alternative’s most enduring contribution, he emphasizes, is not “the fur and feathers” but the Eden Golden Rule: As management does unto the staff, so shall the staff do unto the Elders. “We teach the people who own and operate these facilities how to provide staff with the same vital experiences that they want the staff to offer to the elders: dignity, respect, affection,” he says. The New York State Health Department studied the impact of this unprecedented approach and found a 50 percent reduction in infections, a 71 percent drop in daily prescription-drug costs, and a 26 percent lower turnover rate among nurses’ aides.
Based on that success, Thomas “Edenized” several other upstate nursing homes and then founded the nonprofit Eden Alternative to spread the word. To date, the organization has 300 registered nursing homes around the world and has trained more than 18,000 people in what he considers the 10 basic principles of creating a “human habitat” for elders.
Thomas knows personally about living with debilitating frailty. He and his wife, Judy, have five children; their two daughters, Haleigh and Hannah, have been diagnosed with Ohtahara syndrome, a progressive neurological disorder, and have always required around-the-clock, home-based nursing care. Although Thomas criticizes the pharmaceutical industry for many things—like pushing too many drugs on older people and marketing pills to “cure” such normal aspects of life as shyness, grief, and occasional insomnia—he is always quick to thank modern medicine for keeping his girls alive.
Balancing family life with his workload and travel schedule—he is gone from their Ithaca, New York, home 30 to 45 days a year—is not easy. He is still on the Eden board, but since 2002 has left daily operations to an executive director. He is a regular consultant for AARP, the author of five books, including What Are Old People For? How Elders Will Save the World, and a professor at the Erickson School of Aging, Management, and Policy at the University of Maryland-Baltimore County, where he writes the blog “Changing Aging.”
In 2003 Thomas pushed beyond Eden to pilot a newer concept in elderly housing—the Green House Project in Tupelo, Mississippi. The challenge was to create better alternatives that meet demands for high-quality care and meaningful lives while complying with government regulations and building codes—and remaining affordable. Each house provides 10 to 12 seniors with 24-hour nursing care, well-trained and -supported staff, and private rooms and bathrooms in a layout designed with an open kitchen and dining room and plenty of light and access to the outdoors. The pilot project was funded by the Robert Wood Johnson Foundation; an additional $13-million grant from the foundation has enabled NCB Capital Impact, a Washington, D.C.-based nonprofit, to complete 41 Green Houses in 10 states, with another 18 projects in development. The goal is to open a Green House in every state.
Thomas views the nursing-home industry—which draws about 78 percent of its revenues from Medicare and Medicaid—as a powerful and daunting competitor. Unpopular as nursing homes may be, as of 2004 they housed 1.5 million of the frailest Americans, almost half of whom were over age 85, according to a 2007 AARP report; Thomas notes that 50 percent of people aged 65 or older will spend at least some time in a nursing home before the end of their lives. The expenses—largely absorbed by the government—are hard to bring down. (This year, the average private-pay cost for a private room is $209 per day, or $76,285 a year; a semi-private room averages $187.)
The Green Houses cost more to build than conventional facilities, Thomas says, but the elderly residents get more as well: more privacy, to begin with, and a much higher quality of life. In his model, money and resources are shifted away from middle management and used more for direct care. Operationally, the Green Houses cost the same to run on a daily basis as a nursing home, he says, adding, “This should not be that much of a surprise since the nursing home was never a paragon of efficiency.”
Thomas’s persuasive powers spring in part from his earthy public persona—he typically wears roomy blue jeans and Birkenstocks to speaking engagements. His speeches, while laced with philosophical references, are akin to kitchen conversations; he hands out advice like a caring, grown son and reassures people with phrases like “no worries” or “cool beans.” His knowledge of the healthcare and pharmaceutical industries is formidable—he can reel off the detailed history of commercialized use of heroin and the relationship between “horse piss and hormonal supplements”—but he also tends to recall the simpler past when his grandmother tended his cuts with a milk and bread poultice, and old people worked outside and didn’t take 20 pills a day.
Growing up in rural Nichols, New York (near Binghamton), Thomas was the first member of his family to attend college. He thrives on winning over a tough audience. As an undergraduate at the State University of New York at Cortland, he was a charismatic student leader—campaigning for new student-run evaluations of professors—and even ran for mayor. “You know how you are at 20,” he says now. “I thought I could run the city better than my opponent, who had a college-bashing platform. I lost the election, but my consolation prize was that I got into Harvard Medical School—the first person from Cortland ever to do that.”
Thomas found Harvard stimulating and ultimately advantageous. Just as “Nixon was the only politician who could go to China, because he was immunized against the claims of selling out to communism,” he points out, “what better person than a Harvard-trained medical doctor to lead the way against the medical model in nursing homes? If people get up in my face about the medical issues—the main excuse given not to enact reforms—then I have the facts to back them down.” The medical model makes illness and treatment the paramount issue, he says, and “what happens then, especially in nursing homes, is that people’s pancreases get more attention than anything about their lives or what they need as people.”
He says he would have been happy in politics, and the work he does now is far from apolitical. Ultimately, his constituents are old people. They like him for his ungodlike doctoring and for his essential championing of autonomy.
“I’m a firm believer in the rights of elders to do whatever the hell they want,” he told the seniors at the AARP workshop. “If you only have the right to make the ‘good, wise’ decisions that your grown daughter agrees with, then you’re not running your own life anymore.” Old people, he says, can make decisions even if they are bed-ridden and confused. “I’ve taken care of lots of people who didn’t even know their own children,” he notes. “Sure, they probably shouldn’t be making decisions about their 401(k) plans, but they can decide what to wear and what to eat and whether to go outside on a daily basis. People think that if old people cannot make the big decisions, they cannot make any decisions—and that is just wrong. They have the right to folly.”
Thomas’s vision seeks to shift our underlying cultural philosophy. “Old age is and will always remain difficult. It demands much from us…and seems to offer very little in return,” he writes in What Are Old People For? “It is the fearfulness of this vision that has led us to ignore the old, to deny aging, and to hope that someday a cure for this malady might be discovered….Such a hope, while understandable, ignores the possibility that there is something vital and true to be grasped and then savored with the distinctly human experience of growing old.”
“Young and old alike,” he says, “aspire to long lives full of warmth and meaning. The myth is that aging is mainly the concern of old people. The reality is that aging touches, changes, and influences everyone and everything.”
~Nell Porter Brown