Fast Company

(Not) the Same Old Story

Eden Alternative is a change-minded organization determined to save a critically ill patient: long-term care for the elderly. The nursing-home industry should be about living, argues founder Bill Thomas, not about dying. Here's his prescription -- and lessons for changing any industry.

In 1999, after writing a book about improving long-term care for the elderly, Bill Thomas did what authors do: He hit the road for a promotional tour. He appeared on radio and television. He also met with public officials, offering his perspective as a gerontologist -- a doctor who specializes in treating the elderly -- on what was wrong with nursing homes: They were utterly devoid of hope, love, humor, meaning -- the very stuff of life. He gave lectures on the changes he had in mind, which included adding pets, plants, and children to nursing-home life. But at each stop, he also demonstrated why this is no ordinary book and this was no ordinary tour -- and why he is certainly no ordinary doctor.

Thomas, now 42, didn't write a prosaic account of the principles behind Eden Alternative, the nonprofit organization that he and his wife, Jude, operate out of their farm in Sherburne, New York. Instead, he told a story, a fantastic tale interweaving fact and fiction. Learning from Hannah: Secrets for a Life Worth Living (VanderWyk & Burnham, 1999) is a novel that doesn't call itself a novel. It begins with Thomas and his wife completing a book about the medical aspects of aging and then taking a much-needed vacation. While sailing south from San Juan toward the island of Montserrat, they get caught in a storm that leaves them shipwrecked. For nearly a year, they live in a mysterious place called Kallimos, where they learn the ways of a society in which the elderly play a vibrant role in the community. Instead of living apart from younger generations, the oldest inhabitants are embraced by them. The wisdom and experience of the elderly are valued as a resource. When Thomas and wife eventually return home, the lessons from Hannah, the old woman who mentored them, become the inspiration and foundation for Eden Alternative.

It wasn't enough for Thomas to communicate his vision for better long-term care through an imaginative book. He also developed a one-man show based on the tale. In the summer of 1999, the Harvard-educated doctor turned novelist turned actor launched the Eden Across America Tour, traveling by private bus to 27 cities in 31 days with his wife, their five children, and his parents. It's not hard to imagine Thomas on stage; he's alternately funny, exuberant, and sincere, offering glimpses of a natural theatricality. After a performance at a medical school in the Midwest, he wrote in his online journal, "I had the strange sense that the ghosts of medical professors past were looking on us and clucking their tongues. I didn't care."

For Thomas, the Eden Across America Tour never ended. It can't. Not if he's going to fix long-term care in this country. For all practical purposes, he says, the industry is broken. "Does anyone want to leave his home and go live in a nursing home?" he asks. "Does anyone want to put a parent, spouse, or loved one there? That's why we're turning the industry upside down."

It's an audacious mission and a truly big fix -- one that requires more than just fresh ideas. It demands an unorthodox approach to mobilizing and motivating a wide range of forces, many of which have little incentive to change. "You need to have people go a little nuts about what you want to do," Thomas says. On its own, the industry isn't going to do an about-face and overhaul its core ideas. And individual nursing homes are often too overwhelmed by the day-to-day demands of caring for residents in a heavily regulated field to try anything new. Hoping to prod people into going a little nuts about radical reform, Thomas appeals to their imaginations and their hearts. Hence the book, the tour, and the play. "A lot of innovators don't focus enough on the story that they're telling," he says. "But the story is the only thing that ever gets people to change. It captures your passion and conviction and inspires others to feel the same way."

It's no accident that Eden Alternative evokes another story: that of the Garden of Eden. A garden is the central metaphor behind Thomas's vision. "Human beings aren't meant to live in institutions," he says, "but that's what most nursing homes are: big, impersonal, cold institutions that don't treat people the way they want to be treated. People are meant to live in a garden, a place where they can grow and thrive as human beings."

So far, about 300 nursing homes in the United States (as well as a handful in Europe and Australia) have been "Edenized." Which is to say that these institutions have been deinstitutionalized and turned into warm, nurturing human habitats. The results have proven not only good for residents but also good for business. Impressed by the improved quality of care, residents' health, and staff retention, several states have begun offering Eden grants -- using the fines that more backward-looking facilities pay for violating regulations.

Typically, an Eden nursing home is divided into neighborhoods, with a staff that knows the residents personally -- their background and interests as well as their medications. There's all sorts of activity: children playing, dogs and cats visiting rooms, birds chirping. The institution becomes a close-knit community teeming with life.

The transformation, however, is often arduous. Creating an Eden home involves major organizational and cultural change, because the facility has to think differently about care, priorities, and old habits. For instance, the residents have more input into how the facility operates, as do the staff members who work closest with them -- a shift that often proves difficult for traditional-minded administrators.

"Out of all the people we've talked to about creating Eden homes, no one says, 'This is a horrible idea,' " says Jude Thomas, who conducts Eden workshops with her husband. "But some people think that all they have to do is bring in a dog, and everything will be better. It won't be. This is an entirely different philosophy. It's a total change."

Voices in the Garden (Part I) Jane Lough, administrator, Toomsboro Nursing Center, Toomsboro, Georgia: "This one lady, Mrs. Miller, dressed nicely every day and got her hair done once a week for the first year and a half she was here. Then she went into the hospital for pneumonia, and when she came back, she wouldn't get out of bed. She gave up. So I got her a blue parakeet named Mercy, and we put the cage on an IV pole next to her bed. She would feed it crackers and sing to it. After three or four months, she got up, got her hair done, and started going everywhere with Mercy. She'd tell people she loved that bird."

Mission: Overcoming the Three Plagues

After graduating from Harvard Medical School, Bill Thomas had his heart set on the emergency room. He liked the action and the adrenaline rush. But in 1991, after completing his residency in family medicine at the University of Rochester, he tried something different: becoming the physician at Chase Memorial Nursing Home in New Berlin, New York. He discovered that he enjoyed working with the elderly, getting to know them, hearing their stories. He also discovered that nursing homes were seriously flawed -- even the best-performing facilities. At Chase, the equipment was up-to-date, the staff was dedicated, and the inspection record was spotless. Yet the residents were miserable. "What appalled me was how lonely and bored they were," Thomas says. "It was painfully obvious to me that they were dying in front of my eyes."

He concluded that nursing-home residents suffer from three plagues: loneliness, helplessness, and boredom. They feel lonely because they've been uprooted from their family, friends, and even their pets. They feel helpless because they've lost control of their lives; for the most part, they eat, sleep, get dressed, and bathe according to the institution's schedule. Finally, they feel bored because the few activities that are available to them, such as watching television, aren't meaningful or fulfilling. "Care for the elderly is not simply about health care or medicine or technology," Thomas says. "It's about creating the right environment and caring relationships that sustain an older adult in his last years."

While working at Chase, Thomas received a $200,000 grant to improve life for the facility's residents. The experiment gave rise to Eden Alternative. Bringing animals into nursing homes was not a new idea, but in the past, they were usually brought in for visits. They didn't live on the premises, as Thomas prefers. That way, the animals become companions, and the residents grow attached to them. As one of the 10 Eden principles says, "Loving companionship is the antidote to loneliness."

If the elders -- Thomas finds the term more dignified -- are able, they lend a hand in grooming or feeding the animals, watering plants, or reading with children. These activities not only allow residents to engage in everyday physical therapy, but they also satisfy another fundamental human need, one that often gets neglected: giving care, as opposed to only receiving it.

At Eden facilities, residents and staff are partners. Whenever possible, the two groups work together, voting on what type of pet to add or what type of decorations to put up. Staff members understand that what they call the workplace is a far more intimate and personal place to residents: It's home. And that understanding shapes decisions. Eden removes hierarchical or autocratic management. Like the residents, the certified nurse assistants, who make up the bulk of the staff, have more control over their schedules and help make decisions about how to divvy up work. "What you find is that as the managers do to the staff, the staff does to the elders," says Thomas. "So if you treat the staff well, the elders will benefit."

That's the case in the Toomsboro Nursing Center, a 62-bed facility in rural Georgia. Since adopting the Eden model, the staff has become more responsive and more unified, and the care has become more compassionate and individualized, says Jane Lough, an administrator at the center. Instead of giving orders, Lough tells the certified nurse assistants, "You know this resident. Tell me what you think she needs." By working in teams -- the Conquerers, Earth Angels, Outrageous Girlfriends, and Untouchables -- employees began seeing beyond their roles as cook, laundry aide, nurse, and housekeeper. They realized that every staff member provides care in one way or another. As the stickers that they wear declare, "I'm a world-maker." "That's one of Dr. Thomas's terms," says Lough. "In a nursing home, very little of the outside world comes in, except for the staff. They are the residents' world, and they have the opportunity to make it a special place."

Eden does not reverse the aging process, of course, but studies, including one done by the Texas Long Term Care Institute in San Marcos, Texas, indicate that the residents' overall health does improve: They had fewer infections and required less medication. Meanwhile, the staff absenteeism went down and retention went up -- a significant improvement in an industry that is notorious for high turnover.

"Relationships are the foundation of good health care," Thomas says. "This is nothing new. But it's not something that the industry has made a priority." In fact, some institutions actively discourage relationships between staff and residents. "When I started out, I was told, 'You don't share yourself with residents, because it hurts too much when they die,' " says Lough. "That's definitely not the attitude here."

Voices in the Garden (Part II) Kathleen Perra, director of nursing, St. Luke's Home, New Hartford, New York: "Every day last summer, we had school-age day care here. There were kids screaming down the hall, cats jumping on tables. It was bedlam, but it was great. You want those unpredictable things happening for the residents. Of course, health-care workers favor predictability. We work around schedules. I'd say the biggest change with the Eden program is for the staff."

Method: Warmth, Suction, Frost

Nursing homes that are designed like gardens provide an apt metaphor for Bill Thomas's program, because, like a garden, Eden Alternative doesn't occur naturally. It requires preparation, hard work, and continuous scrutiny as it evolves. Otherwise, if the changes are taken for granted or neglected, Eden eventually shrivels up and dies.

Since founding their organization, Bill and Jude Thomas have become change experts out of necessity. Merely tweaking facilities wasn't effective. Creating an Eden involves a complete transformation. "Some homes think that Eden and the operation of the facility are two separate things," he says. "But Eden is all over. It affects everything you do."

The duration and success of the change process depends on what Bill Thomas calls the "warmth" of the organization. A warm culture is open to change, because employees have trust and generosity for one another, whereas a cold culture is characterized by pessimism and cynicism. After conducting a survey to determine an organization's temperature, the Thomases or one of 5,000 Eden associates nationwide begin "warming the soil." In some cases, managers hold a potluck dinner at someone's house, where they can't discuss work. Employees also perform good deeds, or mitzvahs, for their colleagues and the residents without expecting anything in return. "You open people's minds by opening their hearts," Thomas says.

Before virtually every step -- before adding pets, before switching to self-scheduling -- the staff votes. If the outcome isn't unanimous, the group continues the education process. "You can't force change on anybody," says Thomas. "Consensus is the only way. You have to get the entire staff to see the advantages for themselves and become excited about what you're going to do. We call it creating 'suction.' "

Thomas also expects setbacks, or "frost," as he puts it. It's a natural part of change. "I tell the leaders to expect that what they're changing will be smashed to bits, and when that happens, they have to be ready to pick up the pieces and move forward," says Thomas. "People are going to get scared. They're going to make mistakes." Every year, about 5% of Eden homes drop the program. But Thomas doesn't give up hope for them. He prefers to think that they're experiencing a long frost.

Voices in the Garden (Part III) Ron Rothstein, president and COO, Levindale Hebrew Geriatric Center and Hospital, Baltimore, Maryland: "You don't cure the three plagues overnight. Some of our residents have been here a while, and they've become depressed. It takes time to bring out the best in them. I'm a type A personality -- a 'gotta get it done today' type. But culture change is slow. And subtle. You don't necessarily see the relationships between people every day."

Momentum: Progressives vs. Stalwarts

Eden Alternative's headquarters isn't located in an actual garden. But almost. It's on a lush farm in the rolling hills of upstate New York, 60 miles southeast of Syracuse. On 220 acres that had been abandoned for 50 years, Bill and Jude Thomas brought Summer Hill Farm to life, building a house, barn, retreat center, and 14-room lodge. It's here that you fully appreciate how much of a Renaissance man Thomas is. In the fields behind his house, he uses draft horses to pull the machinery that cuts and rakes the hay. Come wintertime, he takes the family on a horse-drawn-carriage ride into the snowy woods to tap maple sap in order to produce Summer Hill Syrup.

In a very real sense, Summer Hill is the Thomases' personal Eden, a home with dogs and children and individuals who need long-term medical care. Hannah and Haleigh Thomas, 5 and 7, suffer from a rare neurological disorder that prevents them from being able to see, speak, and walk. During a break in the Eden training, Jude checks on them and their nurse and dotes on the dark-haired girls in the double stroller. "When people ask if the Eden program can make a difference in someone who's in a nursing home, I tell them that it can, because I see how Hannah and Haleigh respond to loving care," says Jude. "I honestly believe they're alive because of Eden."

When her husband isn't at Summer Hill, he's spreading the word to nursing-home administrators, regulators, insurance companies, policy makers, and industry associations. He gives about 40 talks a year. Thomas is an optimist -- "It can be different," his business card says -- but he's also a realist. He knows that he can't fix the country's nursing homes on his own. He relies on Eden associates to promote the program, share success stories, and conduct training sessions in their communities.

Part of changing an industry is about choosing wisely where to focus your energy. In long-term care, as in any field, the stalwarts vastly outnumber the progressives. In general, Thomas says, the progressives have ideas and enthusiasm but lack real authority or management skills, and the stalwarts have authority and experience but resist changes in the status quo. Thomas doesn't turn down invitations to address the latter, but he doesn't court them either. "The reason I'm not racing to Edenize 17,000 nursing homes across the country is because I know that I'll never win over the stalwarts," he says. "I'm focusing on the progressives, because they're interested in changing things."

Ultimately, Eden Alternative is a repair for a broken industry. The replacement, says Thomas, is his Greenhouse Project. It involves houses that are built for small groups of elders and that have a dedicated staff. They are actual homes, instead of an institution that calls itself a home. St. Luke's Home, where Thomas used to be the medical director, expects to break ground on the first greenhouses within the next couple of years. After that, he says, the next logical stage is an Eden Village, where the greenhouses and the elders are part of a larger community.

But why stop there? he wonders. Why not apply these principles to other institutions, such as schools and prisons? Thomas jokes about starting a group called "Institutions Anonymous." Maybe he's only half joking. "Don't get me started," he says.

Chuck Salter (csalter@fastcompany.com) is a Fast Company senior writer based in Baltimore. Learn more about Eden Alternative on the Web (www.edenalt.com), or contact Bill Thomas by email (thomaswh@edenalt.com).

To find out more about Learning From Hannah: Secrets for a Life Worth Living, go to http://www.vandb.com/hannah.html

Sidebar: How Does Your Garden Grow?

Through Eden Alternative, Bill Thomas is making a difference in long-term care for the elderly. He's turning institutions into places where residents actually enjoy living. Here's how he's fixing things.

Have a good story to tell. Stories help people understand your ideas. Through your passion, stories inspire others to get on board and make your vision a reality. "You need a mythic, heroic story that people will respond to," Thomas says. "Ours is about creating gardens for our elders where they can thrive. That's something that people want for their mothers and fathers."

Watch your language. Eden has a vocabulary all its own, most of which grew (pun intended) out of its defining metaphor of cultivating gardens. Eden practitioners know what they mean by "warming the soil" and "experiencing a frost." It may sound goofy, but it's a way of changing the conversation within an organization.

Don't mistake tokens for real change. The most visible component of Eden is the animals that reside in nursing homes. But "fur and feathers," says Thomas, aren't a shortcut to transformation. Unless you change the culture and philosophy, the facility won't be different. It will still be an institution -- but with pets. Big deal.

Make innovation a group activity. Thomas doesn't claim to have all the answers for improving nursing homes. The Eden program gives a framework and some ideas, but individual facilities decide which changes are best to make. Administrators share ideas through Eden's Web site and at get-togethers. Thomas has the same "open source" philosophy about the Greenhouse Project, which involves building homes for small groups of elders. He's sharing his ideas online and letting others build on them. "You can't do it alone," he says.

Expect setbacks. Failure is an inevitable part of the change process. So you'd better be prepared for it, or you won't be able to bounce back. Understand that people are going to get scared and revert back to doing things the old way. Forgive them and move forward -- and expect it to happen again. "Frost always comes," says Thomas. "We've never been wrong on that one."

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