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FIELD HEARING: CARING FOR AMERICA’S 

AGING VETERANS 

HEARING 

BEFORE THE

COMMITTEE ON VETERANS’ AFFAIRS 

UNITED STATES SENATE 

ONE HUNDRED TENTH CONGRESS 

SECOND SESSION 

JULY 3, 2008 

Printed for the use of the Committee on Veterans’ Affairs 

( 

Available via the World Wide Web: http://www.access.gpo.gov/congress/senate 

(II) 

COMMITTEE ON VETERANS’ AFFAIRS 

DANIEL K. AKAKA, Hawaii, Chairman 

JOHN D. ROCKEFELLER IV, West Virginia 

PATTY MURRAY, Washington 

BARACK OBAMA, Illinois 

BERNARD SANDERS, (I) Vermont 

SHERROD BROWN, Ohio 

JIM WEBB, Virginia 

JON TESTER, Montana 

RICHARD BURR, North Carolina, Ranking 

Member 

ARLEN SPECTER, Pennsylvania 

LARRY E. CRAIG, Idaho 

KAY BAILEY HUTCHISON, Texas 

LINDSEY O. GRAHAM, South Carolina 

JOHNNY ISAKSON, Georgia 

ROGER F. WICKER, Mississippi 

WILLIAM E. BREW, Staff Director 

LUPE WISSEL, Republican Staff Director 

(III) 

C O N T E N T S 

JULY 3, 2008 

SENATOR 

Page 

Wicker, Hon. Roger F., U.S. Senator from Mississippi ......................................... 1 

WITNESSES 

Thomas, Bill, M.D., Founder, The Eden Alternative ............................................ 3 

McAlilly, Steve L., President and Chief Executive Officer, Mississippi Methodist Senior Services, Inc. ................................................................................... 5 

Prepared Statement ......................................................................................... 9 

Cutler, Lois J., Ph.D., Research Fellow, School of Public Health, Division 

of Health Policy and Administration, University of Minnesota ....................... 12 

Prepared Statement ......................................................................................... 13 

Attachment ................................................................................................ 15 

Jenkens, Robert, MSRE, Director, The Green House® Project, Vice President, 

Community Solutions Group ............................................................................... 23 

Prepared Statement ......................................................................................... 25 

Attachment ................................................................................................ 29 

Hojlo, Christa, Ph.D., Director, VA Community Living Centers and State 

Veterans Home Clinical and Survey Oversight, Office of Geriatrics and 

Extended Care, Office of Patient Care Services, Veterans Health Administration, Department of Veterans Affairs ............................................................ 32 

Prepared Statement ......................................................................................... 34 

(1) 

FIELD HEARING: CARING FOR AMERICA’S 

AGING VETERANS 

THURSDAY, JULY 3, 2008 

U.S. SENATE, COMMITTEE ON VETERANS’ AFFAIRS, Washington, DC. 

The Committee met, pursuant to notice, at 10:35 a.m., In The 

First United Methodist Church, Tupelo, Mississippi. Hon. Roger F. 

Wicker, Member of the Committee, presiding. 

OPENING STATEMENT OF HON. ROGER F. WICKER, 

U.S. SENATOR FROM MISSISSIPPI 

Senator WICKER. Well, thank you very much. I want to tell you, 

as a member of the Senate and as a veteran myself, I very much 

believe in punctuality. But the press grabbed me, and Kyle Stewart 

tells me, when the press wants to quote you or give you a little 

publicity, it is a good thing to cooperate, even if it makes us a 

minute or two late. So, welcome. We will have a few introductory 

words and then begin. At this point, I would ask that all of us 

stand for the flag presentation which will be made by Troop 12, a 

troop where my son, Daniel, achieved the rank of eagle scout. 

Troop 12 is a part of the Yocona Area Council. 

[Whereupon, Troop 12 presented the flag of the United States of 

America.] 

Senator WICKER. Thank you. And our pledge will be led today by 

Mr. Rex Mooney, president of the Vietnam Veterans of America, 

Chapter 842. Brother Pastor, after the pledge, I am going to ask 

you to come up and lead us in an invocation. 

Mr. MOONEY. Please join me in the Pledge of Allegiance to our 

flag. 

[Whereupon, the Pledge of Allegiance was recited by all present.] 

PASTOR. Let’s pray. Lord, on this day of a new beginning of a 

new day, we honor You with our lives. We remember how we are 

to respect our elders and those who have given of their service. And 

so we come today to deliberate, to understand what it is that 

makes our Nation great, to honor those who have come before us 

who have given sacrificially of their lives. We remember this because of Your sacrificial giving of Your Son and our Savior. So be 

present in this hearing. May we honor You with our lives. Be in 

our speech and be in our hearts and be in our action. Be in all that 

we do for the sake of Your kingdom, amen. 

Senator WICKER. Thank you, Brother Andy. You may be seated. 

I very much appreciate your attendance today, and welcome to this 

field hearing of the U.S. Senate Committee on Veterans’ Affairs 

2 

dealing with the subject of caring for America’s aging veterans. At 

this point, I want to introduce to you two Members of the Committee staff who have traveled from Washington, DC, to be with us 

today. And stand as I call your name. Aaron Sheldon. Aaron is a 

staff member for the Chairman of the Senate Committee, Senator 

Daniel K. Akaka of Hawaii. Then, John Towers, please stand. John 

is a staff member for Senator Richard Burr of North Carolina, the 

Ranking Minority Member of the Committee. We appreciate these 

staff members taking their July 3rd to come here and be with us 

today. 

Now, we have a distinguished panel of witnesses that I will 

speak more about later, but let’s just have them, at this point, 

stand and turn around, if you don’t mind, so that we can make 

sure that we get a face with a name. Dr. Christa Hojlo—now, did 

I pronounce that correctly? 

Ms. HOJLO. Yes, sir. 

Senator WICKER. I think I butchered it pretty bad on public radio 

this morning. But just think of high and low. Dr. Hojlo is director 

of VA Community Living Centers and State Veterans Home Clinical and Survey Oversight. Then, next to her—and we’ll just go 

down the line—Dr. Bill Thomas, founder of The Eden Alternative; 

then, in the center, our own Tupelo representative, Steve McAlilly, 

chief executive officer of Methodist Senior Services, Incorporated; 

then Robert Jenkens, director of The Green House Project; and Dr. 

Lois Cutler, research fellow, School of Public Health, Division of 

Health Policy and Administration, University of Minnesota—came 

all the way from Minnesota. So, thank you, and let’s give a warm 

Mississippi welcome. 

I am going to make just a few remarks, and then we will take 

testimony individually from each of these witnesses. I’ll give Dr. 

Thomas warning that I will ask Dr. Thomas to go first. But welcome to this hearing. I did not realize, until we got into this, that 

I am the first Mississippi senator ever to serve on this particular 

Committee—the Senate Veterans’ Affairs Committee. We have had 

many distinguished Mississippians precede me in the halls of the 

U.S. Senate, but they have served on other very important committees. I am glad to be holding this Committee hearing in Tupelo, 

Mississippi. 

Now, Tupelo is famous for many things. We had a big tornado 

one time. We have a native son named Elvis Presley, who hasn’t 

been around here very often recently. And we’re proud of the many 

accomplishments that we have made, in terms of job creation and 

manufacturing and economic development; but increasingly, this 

city has become known as the birthplace of a revolution in longterm health care. In Mississippi, actually, we are proud to be on 

the cutting edge of long-term health care reform. We’re here today 

to discuss ways to keep that momentum going and consider how we 

might expand the successful formula that we have put into place 

here known as The Green House Project, to work within the Department of Veterans Affairs and the VA system. 

These distinguished witnesses have, I think, set some sort of 

record for long distance traveled to a Senate Veterans’ Affairs field 

hearing, and I do appreciate their attendance today, as well, of 

course, as the staff members. And thank you all for coming and 

3 

participating. We have many veterans here, and we have representatives of a number of the veterans service organizations. So 

welcome, and let’s begin the testimony with Dr. Bill Thomas. He 

is the one who started this excitement. Do we call you Bill or William? 

Dr. THOMAS. Bill is fine. 

Senator WICKER. Bill is OK. Bill is a geriatrician and a trailblazer in the realm of elder care. He developed the Green House 

model and created The Eden Alternative to help facilitate longterm care transformation in the United States of America. Dr. 

Thomas, welcome, and proceed in your own fashion. We’re glad to 

have you. 

STATEMENT OF WILLIAM H. THOMAS, M.D., FOUNDER, 

THE EDEN ALTERNATIVE 

Dr. THOMAS. Thank you very much, Senator. And thank you for 

hosting this hearing, and thank you for holding it in Tupelo, Mississippi. I think it is very important that we draw attention to the 

fact that the first Green Houses were created right here in this 

community by pioneers from this community. 

I have given thought, of course, to what I wanted to say to you 

and to the Committee, and I will leave it to others to talk about 

some of the details about the Green House. I think that is important, but I thought I might spend some time talking about the nature of the field of long-term care, in general, and the nature of 

change in that field; and what is going on; and how I believe our 

veterans should be benefiting from the improvements in the field 

of long-term care that are underway right now. 

Let me say, first off, that historically, it is our Nation’s commitment to veterans that started us down the path of providing care 

to older, frail, and disabled people. It was actually after that—what 

I’ll refer to as the War Between the States, otherwise known as the 

War of Northern Aggression—it was after that conflict that our 

governments, respectively, started making a provision for commitment to veterans. And, indeed, that commitment was expanded 

upon, enlarged after World War I, and again after World War II. 

So, in fact, it’s been an important part of the fabric of our national 

promise to our veterans that we would provide for them in their 

later years as they provided for us in their earlier years. 

Now, early on, that promise was delivered in the form of institutional long-term care. We, as Americans, I think, as we’re prone to 

do, we followed the logic of economics, economies of scale. We followed the logic of the Division of Labor and created large institutions that focused primarily on the tasks that needed to be accomplished and put those tasks, unfortunately, ahead of the people 

being served. And the result was really what we have come to 

know in America as the 16,000 long-term care institutions created 

and are currently being managed today—16,000. And I would like 

to point out something that people often don’t realize; there are 

more nursing homes in America than there are McDonald’s restaurants. It is a fundamental part of our health care system, and 

it is increasingly clear that it is based on flawed assumptions from 

decades and decades ago. 

4 

So, what is changing? What is changing is an industry-wide acknowledgment that you have to put the person first. You have to 

put relationships first, that economies of scale cannot and do not 

apply to human relationships. Fundamentally, long-term care is, 

more than anything else, about the care. And care is a habit of the 

heart. It is a human activity, and it does not scale up the way a 

furniture factory does, where, clearly, it is better to build a bigger 

factory and a bigger assembly line, because it is more cost effective. 

What we’re increasingly learning—and I think Dr. Cutler will address this, in part—is that it is not cost-efficient to attempt to scale 

up human relationships and caring. Because what happens is people begin to feel lost. They begin to feel that they are just a number. And I think it is wrong in all circumstances, and I think it’s 

particularly wrong when that kind of existence is what we offer to 

our veterans. 

So, what is changing? We’re learning to put the person first. 

We’re learning to create small scale environments where relationships matter most. And I think our veterans deserve the benefit of 

this research. I know that some of the other speakers are going to 

talk about some of the research funding and the grants that are 

being made to support this. I think it is really essential that our 

veterans get the full benefits. And I’ll close, actually, my comments 

with a simple analogy that I use that is really effective for me in 

my work. I grew up in a rural area, a good close-knit small town 

family. And one of the things—— 

Senator WICKER. Where did you grow up? 

Dr. THOMAS. Upstate New York—a fine, fine place. 

Senator WICKER. Absolutely. 

Dr. THOMAS. I am actually the grandson of World War II veterans, and my boy, I’m proud to say, is enlisted in the United 

States Coast Guard. So it is personal to me, as well. So my feeling 

about this is—my family taught me that—sometimes half a loaf is 

better than no loaf at all. And I grew up understanding that you 

don’t always get what you want, and sometimes you have to have 

something for less than you might have preferred. But my work on 

the reform movement of the Green Houses has taught me another 

lesson, and that is: sometimes it’s not about half a loaf, it is about 

getting it right. 

I sort of imagine what it would be like to tell our service people, 

you know, half an aircraft carrier is better than no aircraft carrier. 

Half a fighter jet is better than no fighter jet. Half a tank is better 

than no tank. Well, it doesn’t make sense. People need the tools 

that are properly created and properly designed to do the job you’re 

asking them to do. And one thing I want to make clear to the Committee and Committee staff, and to you, Senator, is that I think it 

is very important that, as the Veterans’ Affairs Committee looks at 

this, and the agency looks at this, that you understand that the 

Green House is a complete model created to do a specific thing, and 

that is to create a life worth living for the people it houses and 

shelters; and that taking one piece, or half of it, or one little part 

and calling that enough is a mistake. Just as providing our service 

people with a one-winged aircraft would be a mistake. 

This is a case where we have to get the whole thing, because in 

order for it to work effectively—and I’ll leave it, for example, to 

5 

Steve McAlilly to talk about the experience right here in Tupelo— 

this is a case where half-measures are not necessarily the desired 

outcome. So, you have given me the honor of your attention and 

the honor of testifying before you, and I want to say thank you very 

much. 

Senator WICKER. OK. I think I am going to change the order 

here. First of all, can everybody hear in the back? I think, Mr. 

McAlilly, I am going to go to you next, if you don’t mind. But I 

want everyone to understand exactly what we’re describing here. I 

think what we have said is that this is an innovation that began 

here in Tupelo. It has moved to other sections of the State of Mississippi now. United Methodist Senior Services has been very active in this, and without which, we probably wouldn’t be here 

today. 

We want the best care possible for everyone, but certainly for 

someone who has served our Nation in the armed services and kept 

us free and risked life and limb during the time of conflict. We deserve and they deserve the very best that we can provide. And we 

have heard from Dr. Thomas that this involves relationships, and 

we’re trying to research this. But, Mr. McAlilly, you have got your 

testimony in front of you, and I don’t want to throw you off, but 

I would hope that you could describe, for those who have not been 

out to the Green Houses here in Tupelo, exactly how it looks, how 

it differs from traditional long-term health care, and why you think 

it is better. 

Now, having thrown you that curve, we welcome Steve McAlilly. 

Let me tell you a little more about him—CEO of Methodist Senior 

Services here in Tupelo. His leadership and vision were important 

in advancing a new, and at that time, unproven concept in longterm health care. Perhaps you can discuss, Mr. McAlilly, whether 

that has now been proven. We look forward to hearing your insights, and we appreciate your work here locally and your willingness to be part of this hearing. Steve, take it away. 

Mr. MCALILLY. Thank you, Senator Wicker. We welcome you 

back home. 

Senator WICKER. Well, thank you. It is good to be home. 

By the way, your prepared statements will be made part of the 

permanent record for the Committee. We appreciate that. 

STATEMENT OF STEPHEN L. McALILLY, PRESIDENT AND CEO, 

MISSISSIPPI METHODIST SENIOR SERVICES, INC., TUPELO, MS 

Mr. MCALILLY. And we’re honored to be here with you and the 

staff members from the U.S. Senate and this panel of witnesses. 

We are honored to be able to have this chance to talk about the 

very thing you mentioned. I feel a little bit like Dustin Hoffman in 

the movie Tootsie with the curve you just threw me, except I’m not 

the one throwing the curve. You were. I hate to be stuck to a script, 

so I was already thinking of varying from that, anyway. So that 

will fit just well. 

Essentially, a Green House is a small group home for 10 or fewer 

elders who need skilled nursing care or assisted living services. The 

design is crucial to it, just as the keystone of an arch is crucial to 

the arch. If you pull the design, you pull the space away, and the 

whole thing falls, we believe. In that small group home, we provide 

6 

private rooms and private baths for the elders. There is a hearth 

in the center of the house with recliners from Sam’s; and everybody 

has their favorite chair and their favorite spot. The kitchen is like 

a great room. The kitchen is right there. There is food always 

available, like there is at home. They can go into the refrigerator 

or eat cookies off of the kitchen counter—their kitchen counter. 

There is a big table next to the kitchen where all of the elders 

and the staff members sit down together and eat. And the way 

we—I don’t think operate is the right word—but the way it functions is just like at your house. The kitchen table, I would bet, is 

the most sacred space in your house, and if your best friend comes 

over at mealtime, you’re going to put a plate out for them, and they 

will join in fellowship and activity at the kitchen table, rather than 

go into the dining room with the fancy china and sit down. That’s 

the way we function in a Green House. And we’ve had family members develop weight problems because they come over and eat, because the food is so good. 

Senator WICKER. That is another Mississippi problem. 

Mr. MCALILLY. Dr. Thomas describes it—and I steal his words 

all of the time, and he knows it. I think I have permission, and 

usually I give him credit, but he describes it as the world’s most 

inefficient nursing home or the world’s most efficient home health 

delivery system. The nurses come over and ring the door bell, just 

like they would if you were having home health brought into your 

home. And they come in, and they do their nursing. They do their 

medical treatment, and then they locally have 10 clients there 

within 6500 square feet, rather than 10 clients scattered all over 

Tupelo, Mississippi. And they do their thing, and then they leave 

and go to the next house. 

The house revolves around the elders, the people who live there. 

And we make decisions and we put the resources as close to the 

elders as possible, because that’s where they make the biggest difference. So what that means to us, they are dollars that go into 

buildings. And so the building is better. It is home. It costs a little 

more than a traditional semiprivate nursing home. It does. But we 

move those dollars that are in the system to the front line, where 

they make the biggest difference. The other part of that is the 

staffing levels among the front line staff, and pay. I will go ahead 

and put this word out there. It used to be hard to say this in Mississippi. The front line staff member is a shahbaz. And that 

means—— 

Senator WICKER. How do you spell that? 

Mr. MCALILLY. S-H-A-H-B-A-Z, and it comes from a great story 

that Bill Thomas tells about the first shahbaz. It’s a Persian word 

that means, ‘‘royal falcon,’’ and it’s given to the CNA—the certified 

nursing assistants. They are the shahbazi. That is the plural of 

shahbaz, or so Bill tells us. We believe it, anyway. But, it has given 

them a new purpose and function. Their job is to protect, sustain 

and nurture the elders who live in their house. They cook. They do 

light housekeeping. They do the personal laundry. They oversee 

and participate in the activities in the house. They are a self-managed work team. They self-schedule themselves. 

And just in terms of growth of people who work there, we have 

seen astounding results like decrease in turnover, and just selfVerDate Nov 24 2008 10:28 May 06, 2009 Jkt 000000 PO 00000 Frm 00010 Fmt 6633 Sfmt 6633 H:\DOCS\070308.TXT SVETS PsN: PAULIN
7 

worth. They have become people—they were people stuck in jobs 

that, I think, the system caused them to be smaller than they were. 

But in this vessel, in this system, in this house, in this space, they 

have been enabled to become who they were created to be. Now, 

that is the first part, I think, of what is a Green House—a small 

group home where we do skilled nursing care. But the other piece 

is the culture. 

Senator WICKER. The same people who would be admitted, traditionally, to a nursing home—— 

Mr. MCALILLY. Absolutely. 

Senator WICKER [continuing]. As we have known to expect it, are 

housed in the Green House. 

Mr. MCALILLY. Cared for in the Green House. There has not 

been a person yet in Tupelo, Mississippi, in our Green House 

homes that, because of their frailty or medical needs, that we 

haven’t been able to serve in a Green House. They are designed to 

provide everything, in terms of treatment and care, that the traditional nursing home was designed to provide. And we do it. 

People are doing that in Tupelo every day. The people who have 

the finances to provide ’round the clock care, they are doing it. And 

that is why, to us, it is not that novel. It is just, duh, that kind 

of reaction. Why did we ever do it the other way? Because people 

still do it, and people are cared for there in their homes, if they 

have the money to do it. But in this system, there is the money 

there to do it right now, today. And we have proven that over the 

last 5 years. 

Senator WICKER. OK. Let’s do this, Steve, let’s take another 4 to 

5 minutes on your testimony, and then I’ll have a couple of questions. And I think we’ll probably have an opportunity for some back 

and forth. Can everyone hear? 

UNIDENTIFIED SPEAKER. We’re having a little of trouble hearing 

the—— 

Senator WICKER. OK. We’ll ask the witnesses to speak right into 

the microphone. I think it is on. Just speak—just put your mouth 

right up to it like you are Mick Jagger. 

Mr. MCALILLY. Can you hear me now? Basically, as we started 

this journey—you met Bill Thomas, and when he talked about relationships, that’s what it is about. And it started with the relationship that he and I developed that’s gone on now about 10 years. 

And as you heard, when Bill talks, he talks about truths with a 

capital T. And the truths that he talked about in Eden Alternative 

made perfect sense to us. 

We started this journey in 1994. We wanted to build a nursing 

home. We believed the essence of dignity was a private room with 

a private bath. We didn’t understand why, when people got old and 

frail, they had to move in with a stranger with a sheet pulled between their beds. That just didn’t sound right to us. The other 

thing is we wanted to create a place, as we built this new nursing 

home, in which the children of frail elders would feel pride, rather 

than guilt, that their parents were living there. 

So we started this journey looking for the best design. And Bill 

started talking about the Eden Alternative, and we got to know 

him. And we realized we were asking the wrong questions, and the 

system is asking the wrong questions. The stakeholders asked, 

8 

what quality insurance and total quality system can we put into a 

nursing home to improve quality? What the question really ought 

to be is, why has proven quality systems in other industries not 

made much of a difference in a nursing home? The stakeholders 

asked, what type of regulations or penalties can we put on people 

who are operating nursing homes so that they will improve compliance, when the question ought to be, what is wrong with the system that, no matter how many regulations and how tough penalties 

are, that quality and satisfaction is not consistently changed? 

The stakeholders asked what oversight and control can we put 

on this industry to improve outcomes? Here’s what you have got, 

you’ve got a CMS, State Departments of Health, State Medicaid division, ombudsmen, State Attorneys General, looking over this industry’s shoulder. The question is, what is wrong with that picture? 

Why does this industry need that much control and oversight? And 

the bottom line is people still say a short prayer when they walk 

in the door of a nursing home. God, save me from this. 

And so we started asking those questions and moving along, and 

we came up with a wonderfully-designed nursing home. And Bill, 

pick my brain—it was going to be a 140-bed replacement for Cedars Health Center on the Traceway Campus, a state-of-the-art design with 20-unit neighborhoods, or pods, and a town hall in the 

middle that would remind them of home. And we were proud of 

what we had come up with. 

One day Bill was in Mississippi, and we were talking, and I was 

enthusiastically describing that nursing home, and he says, ‘‘you 

know, I don’t think that’s what we ought to be building anymore.’’ 

And that question haunted me for a long time. Then he came up 

with the Green House concept. 

To the credit of the good people in Tupelo, our board of directors 

here had the courage to stop that project that we had invested 

thousands of dollars in, and evaluate Bill’s ideas. And when we did, 

we realized they made sense. We realized that the question was 

home, not home-like. The question was, why do we do it this way? 

Why was this ever a good idea? The question is, why don’t we cook 

the food in the presence of the elders, instead of having it carted 

down the hall? The ideas just made plain sense to us, and as a 

matter of intuition and a matter of heart, our board of directors 

had the courage to go off on this idea without scientific data. 

Now, I think Dr. Cutler will talk about the research data that 

verifies that we were right, but our anecdotal data is that people 

who were in wheelchairs are walking again. People who wouldn’t 

eat in the nursing homes started eating and gaining weight again. 

People who hadn’t had a visit from a friend or a family member 

in years started having company again. Family members, as I mentioned, started gaining weight. Every way you look at it, it’s been 

good. 

Now, it is hard, because we’re not transforming something. It is 

not just the design, it is the culture. We’re replacing the whole culture. And when you get to deal with changing people’s paradigms, 

it is hard. Sometimes the paradigms filter the data so that we don’t 

see the need to change. I think that’s really where we are in the 

system. 

[The prepared statement of Mr. McAlilly follows:] 

9 

PREPARED STATEMENT OF STEPHEN L. MCALILLY, PRESIDENT AND CEO, 

MISSISSIPPI METHODIST SENIOR SERVICES, INC., TUPELO, MS 

My name is Steve McAlilly and I am the President and CEO of Mississippi Methodist Senior Services, Inc., a 501(c)3 not-for-profit corporation that provides housing 

and long-term care services to elders in eleven locations in Mississippi. Among our 

1,600 residents, over 30 percent receive either Medicaid assistance or housing assistance through HUD’s programs for low-income elders. 

In May 2003 we opened the Nation’s first Green House homes here in Tupelo. 

Now, five years later, we are even more convinced that this model of care is the 

right thing to do. 

Our journey actually began in 1994 with a realization that something was wrong 

with the way elders were being treated when they needed skilled nursing care. We 

recognized that most people said a short prayer when they entered the doors of a 

nursing home: ‘‘God, please save me from this.’’ We intended to do something about 

that, but had no idea at the time where it would lead. Our guiding vision on the 

journey was that we believed the essence of dignity for elders started with a private 

room and a private bath. And we intended to create the kind of place that children 

of frail elders would feel pride, rather than guilt, that their mothers and fathers 

lived there. 

We began to realize that the system of long-term care was broken; that it was 

giving the kinds of results it was designed to give and no one was satisfied with 

those results. More than that we realized that everyone connected to long-term care 

was asking the wrong questions: 

• The stakeholders ask, ‘‘What quality assurance or total quality management 

system can we put in place to improve quality in nursing homes?’’, but the right 

question is ‘‘why do sound and proven quality systems in other industries not consistently give us the results we are looking for in nursing homes?’’ 

• The stakeholders ask, ‘‘What tighter regulations and tougher penalties can we 

develop to force compliance in nursing homes?’’, but the right question is ‘‘what is 

wrong with a system that no matter how tight the regulations and tough the penalties, results do not significantly and consistently improve?’’ 

• The stakeholders ask, ‘‘What form of oversight and control can we develop to 

ensure compliance and quality in nursing homes?’’, but the right question is ‘‘why 

does this industry require oversight from CMS, State Medicaid Divisions, State Departments of Health, State Attorneys General and Ombudsmen—at least five major 

agencies—and the industry is still not meeting expectations?’’ 

As we began to realize what the right questions were, we started designing. Little 

did we know we were still on the wrong track—a better one to be sure, but wrong. 

Our searching for the best designs and systems led us to a friendship with Dr. William H. Thomas, the founder of The Eden Alternative. Even there, though, we were 

about to make a $12,000,000 mistake—a state-of-the-art institution with rooms arranged in ‘‘neighborhoods’’ or ‘‘pods’’ of about twenty residents and a wonderful 

‘‘town square’’ in the center to remind the residents of their homes. Bill Thomas 

started talking about something he called ‘‘Green House,’’ It made sense: home, not 

home-like; small detached homes for ten or fewer elders who needed nursing care; 

systems designed around the elder rather than medical treatment; resources like 

money, buildings and staff moved as close to the elder as possible. 

Our board of directors had the courage to stop our $12 million state-of-the-art 

project in its tracks and to study Bill’s ideas. We forged out to implement and pioneer the ideas . . . at a time when there was no ‘‘scientific data’’ which pointed in 

that direction. It was a matter of intuition, a matter of heart, that led us on down 

that road. We understood that if the world has to wait on scientific data to change 

a paradigm or start a revolution, we would still be riding trains, rather than flying, 

across the country. 

We learned the right questions are about home, and making a home for the elders. 

As I said, now five years later, we are even more committed to the concept. The 

results, both anecdotally and scientifically, prove we were right: 

Dr. Rosalie Kane, Ph.D., University of Minnesota, reports after 30 months of research: 

– Residents report better quality-of-life and greater satisfaction 

– Family members report greater satisfaction with relative’s care and life 

– Family members report greater satisfaction with how they as family members 

were treated 

– Staff felt more empowered to assist residents, knew residents better 

– Staff experienced greater intrinsic and extrinsic job satisfaction and were more 

likely to remain in the job 

10 

– Minimum Data Set-based Quality Indicator analyses showed either no difference in Quality Indicators or statistically significant advantages for GH 

– Less Activities of Daily Living decline, less prevalence of depression, less incontinence without a toileting plan, less use of anti-psychotics without a relevant diagnosis 

Dr. Kane summarized her findings at a recent meeting of the American Association of Homes and Services for the Aging: ‘‘I have never seen such good results that 

tell such a consistent story over time’’, outcome findings are ‘‘robust in support of 

Green House for residents, family and staff’’, ‘‘staff findings are striking, suggesting 

staff empowerment is possibly a vehicle for resident outcomes.’’ 

We have a lot of anecdotal evidence that this makes perfect sense: 

– People in wheel chairs are walking 

– People who would not eat food in the nursing home are eating again and gaining weight 

– People who would not talk are talking again 

– Agitation levels of people with Alzheimer’s Disease are significantly lower— 

there is a sense of peace in the houses 

– Families are involved in the lives of the elders like never before 

– So many children visit that one house had to develop guidelines for children 

visits 

– Independent living campus residents are visiting—they avoided our nursing 

home like the plague, affectionately calling it ‘‘that hell-hole down the hill’’ 

– The nursing staff and front line workers (CNA’s) have developed a sense of 

team-work and collaboration, seeing each other as equal, important members of the 

team 

– Absenteeism and turnover are virtually non-existent—in fact overtime is our 

problem; they come to work too much, ‘‘just to help out and see how everyone is 

doing’’ 

Is it the design, or the culture? I believe that it is both. I do not believe you can 

‘‘put new wine into old wineskins’’, that the design and the culture go hand-inhand—they are interdependently responsible for the results. The design is like the 

keystone in an arch—pull it out and the whole thing falls. 

The old system is designed to give us the results we are getting and no improvement or tinkering with the basic system will give us anything more than the results 

we have always had. Our paradigms have blinded us to the data that tells us the 

system is broken, so not seeing the data, we do not see the need to change—we have 

become inoculated and accept that, and even believe, that we are doing a great job; 

and we are, as much as you can in this system. 

I believe that each Member of this Committee knows this: 

– There is a difference between food prepared in your presence in your kitchen 

and food carted in from a central kitchen. 

– There is a difference between six to ten friends sitting around their kitchen 

table together, having fellowship and fun around the partaking of good food and 120 

people in tables of four, hurriedly being fed so the dining hall can be cleared for 

the next activity. 

– There is a difference between a few friends sitting around their kitchen table 

playing Rook together and a bingo game in the activity room with 60 people. 

– There is a difference between eight people sitting in their hearth, in their favorite chair (a recliner from Sam’s) and 45 people lined in their wheel chairs in the 

hall or day room, waiting. 

– There is a difference between being able to walk out of your bedroom into your 

den, or even onto your patio to tend your flowers and walking down a mock street 

to the mock town square. 

There is a difference between home and home-like; between home and an institution. 

Thirty years ago we did not know better. Twenty years ago, even 10 years ago, 

we did not know better. We were doing the best we could with the best information 

we had. Today, we know better. We have the scientific data. We have the anecdotal 

data. The results have proved this new system, this new wine in these new 

wineskins, makes all the difference in the world. 

Today, on the eve of our country’s birthday, I suggest that you can make a difference in the lives of those who have given their all for their country—those who 

have answered the ultimate call of patriotism to risk their lives for their country 

and freedom. They, more than anyone, deserve the best we can give them. They deserve the difference between home and home-like; the difference between home and 

institution. 

11 

Senator WICKER. OK. Now, we’re going to put your whole statement in the record, and then you can get back to us and make 

some other points that you would like to, after the others have had 

a chance to talk. How long have we now had Green House nursing 

home care in Tupelo, Mississippi? 

Mr. MCALILLY. Since May 2003, just over 5 years. 

Senator WICKER. OK. I think I was there for the opening of that 

one. It’s hard to believe it’s been 5 years. How many people are currently housed in that type of care here at the Tupelo campus? 

Mr. MCALILLY. There are 112. We started out with four homes 

of 10 persons each, and then we opened six more the fall after 

Katrina hit. And those houses have 12 persons each, so we have 

112 people who live in Green House homes here in Tupelo. We 

have another two Green House homes on one of our other campuses that provide assisted living, and we’re building six more 10- 

person homes in Yazoo City, as a part of the Martha Coker home 

system there. 

Senator WICKER. Does United Methodist Senior Services have 

what we would call traditional nursing home kind of beds? 

Mr. MCALILLY. We do. 

Senator WICKER. And that is all over the State? 

Mr. MCALILLY. We have three—including the Traceway campus. 

We have two other campuses with traditional nursing homes: Trinity Health Care in Columbus; and Doogan Home in West Point. 

Senator WICKER. OK. How do you decide who goes to the Green 

House and who goes to the more traditional nursing home? 

Mr. MCALILLY. Well, the first level is the people in the Columbus 

area want to stay in Columbus, so they apply to move to Trinity 

Health Care. Here in Tupelo, Traceway Campus, as you know, is 

large and has about 420 total people that live on that campus. 

Those people have—they are people who are living independently 

in cottages and apartments. People who need assisted living are at 

the Mitchell Center. Those people have first priority to move into 

a Green House when their care needs get that high. And then, if 

we have space or openings, the greater Tupelo community is able 

to move in. And it’s on a—we need to put your name on a waiting 

list. And we’ve had, in essence, 99 percent occupancy and a long 

waiting list since we opened. 

Now, the first 40, they were pioneers, too. Our medical director 

at the time thought we were crazy for moving those people out 

there in the woods. Now, if you talk to him, he thinks he invented 

the thing, and we let him think that. We’re proud for him to say 

it was his idea. 

Senator WICKER. Well, thank you for your testimony. Our next 

witness, as I said, is from the University of Minnesota, Dr. Lois 

Cutler. Dr. Cutler was part of the team that studied the Green 

Houses in Tupelo. I’m told they found multiple outcomes that we’ll 

hear about today, and these outcomes have given credence to Dr. 

Bill Thomas’ vision and proved his hypothesis—that there is a better way to handle long-term care. 

Dr. Cutler, is that true? Is this the wave of the future, or is this 

just a nifty thing that we’re spending a little extra money on here 

in Tupelo that we can’t replicate? 

Ms. CUTLER. Our hope is that it is the wave of the future. 

12 

Senator WICKER. OK. Let me just ask you to get right up next 

to that, just scoot right up next to that microphone. My dad is on 

the next to last row. He is 80-hmmhmm years old, and he wants 

to hear you. 

Ms. CUTLER. OK. My hope is, our dream is, our expectation is 

that it is the wave of the future. We can change, and our data has 

shown that this is a good model of change. 

STATEMENT OF LOIS J. CUTLER, Ph.D., SCHOOL OF PUBLIC 

HEALTH, UNIVERSITY OF MINNESOTA 

Ms. CUTLER. Now, Senator Wicker and ladies and gentlemen, my 

name is Lois Cutler, and I am one of the researchers that studied 

the effects of the first four Green Houses in Tupelo, Mississippi, 

the outcomes for the residents, residents’ family members and front 

line staff. My background is in housing and design, as well as gerontology. This testimony also reflects the views of Dr. Rosalie 

Kane, the director of the study. For the record, we would like to 

include the article on a Green House study that was published in 

the prestigious Journal of the American Geriatrics Society. Senator WICKER. That will be made part of the record. 

Ms. CUTLER. Thank you. We conducted research over the first 

two-and-one-half years of the Green House experience, and we compared the results to the traditional nursing home on the same campus and a second traditional nursing home, Trinity, located about 

an hour and one-half away. At four points in time—each 6 months 

apart—we interviewed residents, family members, and all nursesaid level staff at the Green House and at the two comparison studies. We also compared results of the minimum data set, the MDS, 

a national assessment protocol conducted in all nursing homes, for 

the residents in the three settings. 

I personally spent many, many, many hours observing how the 

space was used in the Green Houses. Were residents with dementia 

using the space differently? And I also wanted to see how the staff 

and the visitors used the physical space. And what we found is the 

Green House residents experience a better—and this means there 

are significant findings—the Green House residents experienced a 

better quality-of-life on many dimensions of quality-of-life that we 

measured, and are even more satisfied with the services in the 

nursing home and the place where they live. Now, this is just a generic version of all of the findings that you’ll find in the article. 

Family members—our Green House residents spent more time 

visiting, and we calculated the time, were more satisfied with the 

residents’ care, and were more satisfied with how their own needs, 

as family members, were met. For example, they were better satisfied with their own communication with the nursing home. Compared to the nurses-aid level staff in the comparison nursing home, 

residents’ assistants in the Green Houses had more intrinsic success and were more likely to believe that they had the ability to 

bring about better outcomes for residents in psychological and social dimensions, that they knew the residents in their care better 

and were more likely to remain in the job. 

And for me, personally, the staff change is one of the key models 

or key parts of this concept. The staff, they were partners in everything they did. Using the quality indicator measured nationally for 

13 

all nursing homes, the results for Green House residents were as 

good as in a comparison setting—in a few cases, better. This is important because we want to make sure that no harm was done to 

quality of care with the greater freedom and quality-of-life experienced by Green House residents. 

Elders in the two Green Houses that were dementia-specific 

functioned better in the Green Houses than in their previous space 

in the large dementia care units. We speculate that the Green 

Houses are successful because of the small scale and the emphasis 

on normal quality-of-life and because of the model of caregiving 

that allows front-line staff and other staff to really know the residents. The Green Houses are also successful because of the physical setting, and we feel the private rooms are incredibly important. 

And inviting shared spaces evoke a particular kind of behavior for 

residents and staff alike. 

We are pleased that the Veterans Administration is considering 

developing similar small house model nursing homes at the Trence 

Administration Medical Center long-term care programs, including 

the nursing home care units and long-stay units. The model should 

be adaptable to many veterans in the medical center campuses, 

particularly those where the nursing homes are older and are slated for rebuilding, and where land is available to build a smallhouse style nursing home. Although, perhaps, not in the scope of 

this committee, we also believe that this model is very suited to 

nursing homes in the State veteran homes that are operated by 

many State governments in partnership with the VA and the local 

veterans medical center. 

The Veterans Administration programs are characterized by a 

high degree of professionalism among the staff members, in nursing, social work and other fields, and has shown historic leadership 

in clinical geriatrics and geriatric team building. Some of the building blocks for a successful Green House project are, therefore, already in place. A small-house nursing home program such as the 

Green House requires a high degree of skill, flexibility and commitment from those who will serve as leaders, educators and middle 

managers. Please read the article, and you will find more results, 

but this is an overview, and we did find the concept to be very, 

very successful. Thank you. 

[The prepared statement of Ms. Cutler follows:] 

PREPARED STATEMENT OF LOIS J. CUTLER, PH.D., SCHOOL OF PUBLIC HEALTH, 

UNIVERSITY OF MINNESOTA

Senator Wicker and Ladies and Gentleman: My name is Lois J. Cutler and I am 

one of the researchers that studied the effects of the first four Green Houses in 

Tupelo, MI, on outcomes for residents, residents’ family members and frontline staff. 

My background is in housing and design as well as gerontology. This testimony also 

reflects the views of Dr. Rosalie A. Kane, the director of the study. For the record, 

we would like to include the article on our Green House study that was published 

in the Journal of the American Geriatrics Society. 

We conducted research over the first 21⁄2 years of the Green House experience and 

we compared the results to the traditional nursing home on the same campus and 

a second traditional nursing home, also owned by Methodist Senior Services, located 

about 11⁄2 hours away. At four points in time, each six months apart, we interviewed 

residents, family members, and all nurse’s aide level staff at the Green Houses and 

the two comparison settings. We also compared results of the Minimum Data Set, 

a national assessment protocol conducted in all nursing homes, for the residents in 

the three settings. 

14 

I personally conducted many hours of observation in the Green Houses to see how 

residents, staff, and visitors used the physical space compared to their use of the 

traditional nursing homes. 

We found that: 

• Green House residents experienced a better quality-of-life on many dimensions 

of quality-of-life that we measured, and that they were more satisfied with the service in the nursing home and the place where they lived. 

• Family members of Green House residents spent more time visiting residents, 

were more satisfied with the residents’ care, and were more satisfied with how their 

own needs as family members were met—for example, they were better satisfied 

with their own communication with the nursing home. 

• Compared to the nurses’ aide level staff in the comparison nursing homes, resident assistants in the Green House had more intrinsic satisfaction with their jobs, 

were more likely to believe they had the ability to bring about better outcomes for 

residents on psychological and social dimensions, felt they knew the residents in 

their care better, and were more likely to remain in the job. 

• Using the quality indicators measured nationally for all nursing homes, the results for Green House residents were as good as in the comparison settings and in 

a few cases were better .This is important because we wanted to be sure that no 

harm was done to quality of care with the greater freedom and quality-of-life experienced by Green House Residents. 

• Elders in the two Green Houses that were dementia-specific functioned better 

in the Green Houses than in their previous stays in the locked dementia care unit. 

We speculate that the Green Houses are successful because of the small scale, and 

emphasis on normal life and because of a model of care-giving that allows frontline 

staff and other staff to really know the residents. 

The Green Houses are also successful because the physical settings, with their 

private rooms and inviting shared spaces, evoke a particular kind of behavior from 

residents and staff alike. 

We are pleased that the Veterans Administration is considering developing similar small-house model nursing homes in the Veterans Administration Medical Center (VAMC) long-term care programs, including the nursing home care units 

(NHCUs) and long-stay units. The model should be adaptable to many VAMC campuses, particularly those where the NHCUs are older and are slated for rebuilding, 

and where land is available to build small-house style nursing homes. Although perhaps not in the direct scope of this committee, we also believe that this model is 

very suited to nursing homes in the State Veterans Homes that are operated by 

many State governments in partnership with the VA, and the local VAMC. 

The Veterans Administration programs are characterized by a high degree of professionalism among staff members in nursing, social work and other fields, and have 

shown historic leadership in clinical geriatrics and geriatric team building. Some of 

the building blocks for a successful Green House project are, therefore, in place. A 

small-house nursing home program, such as the Green Houses, requires a high degree of leadership, skill, flexibility, and commitment from those who will serve as 

leaders, educators, and middle managers. 

[The above-mentioned article from the Journal of the American 

Geriatrics Society follows:] 

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Senator WICKER. Thank you very much, Dr. Cutler. We’re now 

going to move to Robert Jenkens, who is with us today from the 

Robert Wood Johnson Foundation, a group that I came to know as 

a State senator, when I was working on the Public Health and Welfare Committee in Jackson, and later as chairman of that committee. We appreciate the work of the Robert Wood Johnson Foundation. 

The Green House Project’s goal is to put a Green House in every 

State within 5 years. So we’ll have an opportunity to hear about 

the lessons learned from Mr. Jenkens today. If you could, Mr. Jenkens, start off by telling us a little about the Robert Wood Johnson 

Foundation. Speak right into the microphone, if you don’t mind. 

And then go from there to your prepared testimony. 

STATEMENT OF ROBERT JENKENS, MSRE, DIRECTOR, THE 

GREEN HOUSE PROJECT, VICE PRESIDENT, COMMUNITY SOLUTIONS GROUP 

Mr. JENKENS. Sure. Thank you, Senator. The Robert Wood Johnson Foundation is the funder for The National Green House Replication Initiative. The Robert Wood Johnson Foundation has provided funding to the nonprofit that I work for, NCB Capital Impact, to implement the program. And they have done that because 

they are the largest grant funder in health care in the United 

States. They are a foundation that was established initially by the 

man who started the Johnson & Johnson Pharmaceutical Company, and he had an enormous commitment to the health and 

health care of all Americans. 

So, the foundation has worked for years in many areas of improving health care and health delivery systems. They have not worked 

in long-term care with skilled nursing care. They had worked to 

provide alternatives to skilled nursing care in the community, but 

they really felt that the system of nursing home care in the United 

States was, as Bill said, so deeply flawed and broken from its years 

of focusing on the medical model and the institution that they 

didn’t believe that they would have an impact. 

Last week, in a really very good Wall Street Journal article, the 

Foundation was on record for saying it was the Green House 

model—it was coming down to Tupelo and meeting Steve and seeing the enormous successes that Lois documents in her research— 

that convinced them that they could actually have an impact on 

long-term care; and changing it to be something that you or I 

would want to either have someone we loved or cared for in a 

Green House, or would ourselves be happy living in a Green House. 

And I think, as Steve said, the prayer that we all say to ourselves 

when walk into a typical nursing home doesn’t happen in a Green 

House. And that’s been a success. The Wall Street Journal article 

documents the Foundation’s amazement that they have been able 

to partner with Steve and Bill and the others to create Green 

Houses around the United States to make a change that they 

didn’t believe was possible up to 5 years ago. So, that is the reason 

for their involvement in this field. 

We have been working with the Robert Wood Johnson Foundation at NCB Capital Impact for the last about 13 years on a variety 

of programs to improve long-term care for aging Americans, and 

24 

particularly, aging Americans with relatively low income and lack 

of access to the private health care that Steve mentioned that you 

can receive. 

I am the director of The Green House Replication Initiative, 

which is the latest Robert Wood Johnson Foundation grant in this 

area. As you mentioned, the grant is a 5-year partnership. It is a 

partnership between Bill’s Center for Growing and Becoming, the 

Robert Wood Johnson Foundation, and then, very importantly, the 

really pioneering providers like Steve McAlilly and Mississippi 

Methodist Senior Services who have taken an enormous risk. As 

Steve said, they didn’t have Lois’ research, but they believed in the 

concept, and they have made this happen. The grant totals $15 million, and that provides a variety of technical assistance and tools development, and that is a small revolving loan fund to help organizations create Green House programs. 

I’ll focus my comments today on the successful implementation of 

the Green House model and how best to provide incentives and 

support to the Department of Veterans Affairs to include the Green 

House model among the many excellent culture change initiatives 

that they are working so hard on today to improve the care for our 

veterans. 

Let me say first how proud I am of the greatly-enhanced qualityof-life and care outcomes that are being achieved in the Green 

House homes across the country, and to say how important it is 

that these are based on Dr. Bill Thomas’ concept and the pioneering work of Steve McAlilly and his team at Mississippi Methodist Senior Services in Tupelo, Mississippi. We know from Dr. 

Cutler that these results show a very significant improvement in 

areas that we have worked for years and years in long-term care 

to improve, without success. And it is important that we take these 

successes forward, not as the only option, not as the predominant 

option, but as a choice among the others for all Americans, including our veterans. 

The success of the Green House homes in Tupelo has inspired 

many others, and I am pleased to report today that there are 41 

Green House homes open and operating across the United States. 

They are on 15 partners’ campuses in 10 States. We have another 

139 Green House homes in development on 19 campuses in an additional 12 States. So, in total, we’re in almost half the States. You 

mentioned our goal is to be in all 50 States, and we think we are 

well on our way to doing that. 

The dramatic improvements shown by Drs. Kane and Cutler’s research indicate that, fully-implemented, the Green House homes 

can provide the improvements in the areas that Lois mentioned, including for our veterans. What I am particularly pleased about is 

that these improvements are in the areas that have been so hard 

to crack before, areas including privacy, dignity, autonomy, individuality, emotional well-being, meaningful relationships and activities, reductions in depression, reductions in induced dependence 

and incontinence. 

Each of our operating Green Houses report similar improvements 

to the Tupelo Green House results. And next year we will start a 

broader research project to look and to document that these same 

improvements that Lois and Rosalie Kane found in Tupelo are able 

25 

to be replicated, that there wasn’t something in Tupelo, maybe in 

the water or the creeks, that made this a distinct place where it 

won’t happen again. 

The outcomes, however, I think, are important to note. We need 

to have the full implementation. Bill talked about half of an aircraft carrier or a one-winged aircraft. And I do think it is important that it is understood that while, for instance, the self-managed 

work teams stand alone as a good idea, they support all of the outcomes and accomplishments of The Green House Project. And they 

are integrated in ways that are really very complex, and they can’t 

be pulled out and segmented. So we do have people who come to 

us and say, we don’t know about the self-managed work teams, or 

we don’t know about the fully-detached houses. And I think it’s important, as you all consider helping support and spread the Green 

House concept, that it is supported in a way that at least the core 

principles, which can be implemented very flexibly, are present in 

every Green House; or we will have lost the magic that has started 

in Tupelo. I can say that because I have worked on assisted living 

for many years as an advocate, especially for people with low incomes, to have access to high-quality assisted living. And that is 

a movement that started very pure and has been diluted over the 

last 15 years by people who used the name and applied half or a 

third of the concept. And the results in assisted living today are no 

better than what they would have been in a traditional board and 

care home or another model of care that has since been really discredited. 

So, I would like to emphasize that The Green House Project, and 

helping veterans’ homes adopt The Green House Project, really 

needs access to people like Steve and Bill and the technical assistance that the Robert Wood Johnson Foundation has sponsored. Because we have learned from each success of implementation and 

the importance of the different pieces coming together in a flexible 

way to support the individual needs of campuses across the 

country. 

Let me stop there, and thank you very much for this opportunity 

to be part of the hearing. 

[The prepared statement of Mr. Jenkens follows:] 

PREPARED STATEMENT OF ROBERT JENKENS, MSRE, DIRECTOR, THE GREEN HOUSE®

PROJECT, VICE PRESIDENT, COMMUNITY SOLUTIONS GROUP

Senator Wicker and Committee Staff, Thank you for this opportunity to provide 

my thoughts on The Green House® model and its potential role in caring for America’s veterans. 

My name is Robert Jenkens and I am the director of the national grant funded 

Green House® Replication Initiative. The Green House® Replication Initiative is a 

5-year partnership between the not-for-profit I work for, NCB Capital Impact, The 

Center for Growing and Becoming (Dr. Bill Thomas’ not-for-profit organization focused on culture change initiatives), and The Robert Wood Johnson Foundation. The 

Robert Wood Johnson Foundation has generously provided over $15 million dollars 

to NCB Capital Impact to support development and replication of The Green 

House® model. 

I will focus my comments on successful implementation of The Green House®

model and how best to provide incentives and support to the Department of Veterans Affairs (VA) to include The Green House® model among the many excellent 

culture change initiatives they are working hard to make available to our veterans. 

26 

GREEN HOUSE® OUTCOMES AND REPLICATION

Let me say first how proud I am of the greatly enhanced quality-of-life and care 

outcomes that are being achieved in Green House® homes across the country—each 

based on Dr. Bill Thomas’ concept and the pioneering work of Steve McAlilly and 

his team at Mississippi Methodist Senior Services in Tupelo, MS. The success of the 

Green House® homes in Tupelo, as documented by Drs. Kane and Cutler, has inspired many others. The Green House® Project currently has 41 homes operating 

on 15 partners’ campuses in 10 states. We have another 139 homes in development 

on 19 campuses in an additional 12 states. 

The dramatic improvements shown in Drs. Kane and Cutler’s research indicate 

that, fully implemented, Green House® homes can provide significant improvements 

in the care and life of people who need skilled nursing care, including our Veterans. 

I am particularly excited that these improvements come in areas where we have 

struggled for years to improve outcomes, including a privacy, dignity, autonomy, individuality, emotional well-being, meaningful relationships and activities, depression, induced dependence, and incontinence. Each of our operating Green House®

projects report similar improvements to the Tupelo Green House® results. 

OUTCOMES BASED ON FULL IMPLEMENTATION

It is important to note that the improvements documented by Drs. Kane and Cutler at Steve’s Tupelo Green House® homes rely on the full implementation of the 

core principles of the model set forth by Dr. Thomas in his book ‘‘What Are Old People For?,’’ and documented in the current literature and requirements of The Green 

House® Project. This integrated model, carefully woven together in a web of mutual 

support, amplifies each element of the model to return outcomes greater than the 

sum of the parts and to defend against the return of institutional practices. The 

model is a whole that is greater than the sum of its parts and cannot be disaggregated or selectively applied with any certainty of approximating similar results. 

PRINCIPLES

The good news is that as a principles-based model, there is a fair amount of flexibility and creativity that may be applied to meet The Green House® principles, allowing model to address the individual needs and circumstances of many provider 

organizations. Key principles and elements of the model are: 

Philosophy 

Elders and persons with disabilities requiring skilled nursing care and living in 

a Green House® home are whole, capable, and distinct persons. As such they 

deserve: 

1. A real home 

2. True control over their lives, including schedule, activities, and care delivery 

3. Dignity, including privacy, respect, and to be known as individuals 

4. Meaningful lives, including the opportunity to give to others, form real relationships with staff and other residents, pursue their interests, and continue to participate in the larger community 

5. High level and high quality services to allow them to age-in-place in the intentional community formed in a Green House® home 

Direct care and clinical staff working in Green House® homes are talented, creative, and giving people working hard to care for our family members. They deserve: 

6. Good jobs that are organized to use and recognize their full capacity, including 

problem solving and management skills 

7. Meaningful days during which they provide and receive respect and services. 

Environment 

Creating a real home that supports control, dignity, meaningful days, and high 

level services requires a carefully designed house delivering the feeling of home, including great flexibility in schedule and personal preferences. At the same time, it 

must support extensive personal and clinical services, appropriate life safety, and 

strong defenses against institutional practices creeping back in to the lives of the 

elders and staff. To accomplish these goals, core principles and elements that are 

required in each Green House® home include: 

1. Each home is a small, fully detached house or apartment (no more than 10 persons) designed, finished, and furnished in a manner that is consistent with the predominant residential program and design found in the immediate community. 

2. All bedrooms are private occupancy, each with a private bath, and shared only 

at the request of the elder or person with a disability 

27 

3. An open plan ‘‘hearth’’ area consisting of a kitchen, dining area, and living 

room where elders, persons with disabilities, and staff may socialize, cook, and eat 

as they would in their own homes 

4. Fully accessible, sheltered outside space available to people living in the home 

at all times 

5. Support areas and features accessible to all elders and persons with a disability, including a den, office, spa room (with bath tub and hair wash sink), laundry, housekeeping/utility closet, storage, overhead lifts, and communication/sensing 

technology 

6. A design and specifications meeting nursing home life safety standards required for persons unable to self evacuate 

7. A complete absence of institutional elements that would not be found in your 

own home (e.g., a nurses station, call lights, public address systems, medication 

carts, commercial dishwashers) 

Organization 

The organizational design is critical in supporting control, dignity, and meaning 

in the lives of the people who live and work in Green House® homes. Key organizational elements are: 

1. A self-managed work-team of direct care workers (‘‘Shahbazim’’ in The Green 

House® Model) led by a ‘‘Guide’’ who is neither the director of nursing or simultaneously in a clinical role 

2. A universal worker approach to tasks in The Green House®, including personal 

care, laundry, cleaning, cooking, and management task in the Shahbazim role 

3. A coaching approach to leading the self-managed work team of Shahbazim 

4. All food is cooked/prepared in the house according to menus selected by the elders and persons with disabilities living in the individual house 

5. Flexible schedules for meals, awakening, bathing, etc. to meet the needs and 

preferences of the persons living and working in the homes 

6. Capacity to provide the very high levels of care to allow aging-in-place 

7. No institutional practices that interfere with a home environment or the control 

of the persons living in the home 

SUCCESSFUL IMPLEMENTATION

In my experience at The Green House® Project, access to four things is critical 

to successfully implementing The Green House® concept: 

1. Expert consulting on all elements of the model to support implementation, including project management, financial feasibility and models, regulatory assessment, design, financing, operational planning, policy and procedure development, 

start-up logistics, and post-opening problem solving and support 

2. Experienced guidance for the process to assist each campus and implementation team with the principles and to challenge the team when, inevitably, institutional vestiges arise 

3. Strong and detailed training on principles and their implementation, team and 

coaching skills, communication, and policies and procedures 

4. A strong peer support network of providers who are operating and developing 

Green House® homes. 

INCENTIVES

Christa Hojlo’s leadership at the Department of Veterans Affairs offers a significant incentive for individual VA campuses to consider using The Green House®

model to enhance quality-of-life by building on their already strong clinical outcomes. However, cultural and organizational transformation is very difficult due to 

fear of the unknown and a lack of staff and capital resources. In this respect, the 

VA homes are very similar to most nursing homes in the United States. 

The following additional incentives, successful in limited state applications, may 

help overcome these barriers with early VA adopters and get the movement rolling 

inside the VA. 

1. Explicit expectations and timelines for improved quality-of-life outcomes 

2. Opportunities for professional recognition for early adopters 

3. Access to proven technical assistance resources and tools 

4. Access to a high level VA/Green House® Project workgroup established to resolve internal and external issues that arise 

5. Funding to support a dedicated team leader within the adopting VA organization 

6. Assistance with construction and training costs 

28 

RECOMMENDATION

I recommend the Committee craft a 5-pilot site demonstration incorporating these 

incentives to foster rapid replication within the VA. To assure outcomes equal to 

those documented at the Tupelo Green House® homes, I suggest that selected sites 

be required to fully implement The Green House® principles as determined by a 

workgroup composed of VA leadership, Bill Thomas, operating Green House® home 

staff, and myself. 

Thank you for the opportunity to testify and your interest in The Green House®

model. I welcome the opportunity to answer your questions. 

[The above-mentioned article from the Wall Street Journal follows:] 

29 


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32 

Senator WICKER. Well, thank you very much Mr. Jenkens. Our 

final witness is Dr. Christa Hojlo. And as we said before, she is director of the VA Community Living Centers and State Veterans 

Home Clinical and Survey Oversight. Who pays your salary, Dr. 

Hojlo? 

Ms. HOJLO. The Department of Veterans Affairs. 

Senator WICKER. The Department of Veterans Affairs. OK. Well, 

we look forward to hearing your testimony today. We have already 

heard that—we have already heard some excellent compliments 

from Dr. Cutler about the VA and the professionalism of the staff 

working for our veterans. ‘‘The Veterans Administration programs 

are characterized by a high degree of professionalism among the 

staff members.’’ So, we’re glad to have that testimony as part of the 

record. But what can you add, and what can you tell the viewers, 

the audience today, as well as the Committee? 

Ms. HOJLO. In order to do that, I would like to stay with my 

written testimony—— 

Senator WICKER. Yes, ma’am. 

Ms. HOJLO [continuing]. Because I think it is important for the 

audience to understand the context of the services that we provide 

in our VA Community Living Centers. So, if I can do that, sir. 

Senator WICKER. Absolutely. 

Ms. HOJLO. Then, I certainly would be willing to answer some 

questions as we move forward. 

STATEMENT OF CHRISTA HOJLO, Ph.D., DIRECTOR, VA COMMUNITY LIVING CENTERS AND STATE VETERANS HOME 

CLINICAL AND SURVEY OVERSIGHT, OFFICE OF GERIATRICS 

AND EXTENDED CARE, OFFICE OF PATIENT CARE SERVICES, 

VETERANS HEALTH ADMINISTRATION 

Ms. HOJLO. First of all, I would like to thank you for hosting this 

hearing. I am truly honored—and your staff knows that—I am 

truly honored to be able to appear before you as a representative 

of the 13,000 community living center employees serving our Nation’s greatest and finest. I am proud to report that the Veterans 

Health Administration is following the lead of the innovators at 

this table by providing a dynamic array of services to veterans of 

all ages who require care in VA Community Living Centers. 

The VA owns and operates 133 community living centers from 

Puerto Rico to Hawaii, with an average daily census of more than 

11,000 veterans in fiscal year 2007. These facilities range from 20 

beds to 240 beds, and we serve approximately 49,000 veterans annually with a budget of approximately $2.7 million, and we do offer 

a dynamic array of services. This is an important concept—dynamic array of services. We have identified in the VA that some 

of our services are short-stay, similar to those covered under Medicare in the private sector; and then we also cover long-stay services. And the short-stay services, for example, are for veterans in 

need of rehabilitation or short-stay, post-hospital care, or short-stay 

for veterans awaiting placement someplace else in the community. 

And short stay is generally less than 90 days. 

We also offer long-stay services for veterans with a disability rating of 70 percent or greater or who are in need of nursing home 

care for a service-connected condition requiring lifelong care. VA 

33 

Community Living Centers also offer respite care to any family 

members who care for veterans at home, and we offer hospice care 

in a kind and supportive environment so veterans may be with 

their loved ones and have the opportunity to live fully until they 

die with dignity. 

Through its Community Living Centers, the VA provides care to 

veterans of all eras. And this is very important, because in the 

nursing home arena today, we often hear reference to elders. However, our members are not all considered elders. It is a very important concept for us. So, for example, we do offer care to veterans 

from World War II, from Korea, Vietnam, the Gulf War, and then 

the new cohort of veterans of Operation Enduring Freedom and 

Operation Iraqi Freedom. 

Some veterans have short-stay needs, and others require longer 

stays, as I said earlier. Whatever their specific situation, we are 

there to help. We are sensitive to the fact that these different 

groups will have different expectations and different clinical needs. 

However, we are confident that the VA has the resources and the 

right strategy to address the interests of all veterans requiring care 

in these settings. 

The term ‘‘nursing home’’ conveys certain impressions and ideas 

that do not reflect the VA’s approach to care. Informing a young, 

severely-injured veteran, for example, that he or she will need to 

live in a nursing home can be extremely distressing because the 

term often invokes stereotypical images of being cared for in a 

large institutionalized and geriatric setting. Consequently, we no 

longer use the term ‘‘nursing home’’ to refer to our facilities, rather, 

we refer to them as Community Living Centers. This terminology 

more accurately conveys the VA’s philosophy of care and commitment, and represents more than a name change. 

This change in nomenclature is important because it emphasizes 

that the veterans residing in our facilities are unique individuals 

who have basic rights to privacy and autonomy that must be respected. The VA’s policies have evolved to clearly reflect and encourage the transformation in the culture of care. We are significantly improving work and care practices at existing VA facilities, 

and we are adjusting our designs for new centers as well as when 

renovations are in place. 

Traditional nursing home designs have been centered on the 

needs of staff. The nurses’ station, for example, served as the central gathering place, and events are planned according to the staff’s 

calendar. In contrast, the VA’s approach is similar to the Green 

House or small-house model first developed here in Tupelo. We believe that our residents should be able to live as independently as 

possible. They decide when to have guests, when to eat, when to 

bathe and when to sleep. 

Nursing care takes place in the veteran’s bedroom, not the patient’s room—a very important concept because the bedroom connotes an entirely different approach to personalized care than does 

the acute care model of a patient room, implying that the person 

is acutely ill and very sick. 

[The prepared statement of Ms. Hojlo follows:] 

34 

PREPARED STATEMENT OF CHRISTA HOJLO, PH.D., DIRECTOR, VA COMMUNITY LIVING

CENTERS AND STATE VETERANS HOME CLINICAL AND SURVEY OVERSIGHT, OFFICE

OF GERIATRICS AND EXTENDED CARE, OFFICE OF PATIENT CARE SERVICES, VETERANS HEALTH ADMINISTRATION, DEPARTMENT OF VETERANS AFFAIRS

Good morning, Senator Wicker. My name is Dr. Christa Hojlo, and I am the Director of the Department of Veterans Affairs (VA) Community Living Centers (formerly VA nursing homes) and State Veterans Homes Clinical and Survey Oversight. 

First, I would like to thank Chairman Akaka and, you, Senator Wicker, for hosting 

this hearing. I am honored to appear before you as a representative of the 13,000 

Community Living Center employees serving our Nation’s bravest and finest, and 

I am in awe of our beautiful surroundings. We recognize and esteem the history 

made here at the Mississippi Methodist Senior Service facility on the grounds of the 

First United Methodist Church in Tupelo, Mississippi. I am proud to report the Veterans Health Administration (VHA) is following the lead of these innovators by providing a dynamic array of services to veterans of all ages requiring care in VA Community Living Centers. 

VA owns and operates 133 Community Living Centers from Puerto Rico to Hawaii 

with an average daily census of more than 11,000 veterans in Fiscal Year (FY) 2007. 

These facilities range in size from 20 to 240 beds. We serve approximately 49,000 

veterans annually with a budget of approximately $2.7 billion and offer a dynamic 

array of services. ‘‘Short stay’’ services are for veterans in need of rehabilitation or 

skilled post-hospital nursing, or for those awaiting placement in a board and care 

home for a period of less than 90 days, generally. VA also offers ‘‘long stay’’ services 

for veterans with a disability rating of 70 percent or greater or who are in need of 

nursing home care for a service-connected condition requiring life-long care. VA 

Community Living Centers also offer respite care to relieve family members who 

care for veterans at home and we offer hospice care in a kind and supportive environment so veterans may be with their loved ones and live fully until they die with 

dignity. 

Through its Community Living Centers, VA provides care to veterans of all eras— 

World War II, Korea, Vietnam, the Gulf War, and Operation Enduring Freedom and 

Operation Iraqi Freedom (OEF/OIF). Some veterans have short-term needs and others require longer stays—whatever their specific situation, we are here to help. We 

are sensitive to the fact that these different groups will have different expectations 

and clinical needs. However, we are confident VA has the resources and the right 

strategy to address the interests of all veterans requiring care in these settings. 

The term ‘‘nursing home’’ conveys certain impressions and ideas that do not reflect VA’s approach to care. Informing a young, severely injured veteran that he or 

she will need to live in a nursing home can be extremely distressing because the 

term often invokes stereotypical images of being cared for in a large, institutionalized, and geriatric setting. Consequently, we no longer use the term ‘‘nursing home’’ 

to refer to our facilities—rather, we refer to them as Community Living Centers. 

This terminology more accurately conveys VA’s philosophy of care and represents 

more than a name change. 

This change in nomenclature is important because it emphasizes that the veterans residing in these facilities are unique individuals who have basic rights to privacy and autonomy that must be respected. VA’s policies have evolved to clearly reflect and encourage this transformation in the culture of care. We are significantly 

improving work and care practices at existing VA facilities, and adjusting our designs for new centers as well. 

Traditional nursing home designs centered on the needs of staff—the nurses’ station served as the central gathering place, and events are planned according to the 

staff’s calendar. In contrast, VA’s approach is similar to the ‘‘Green House’’ or 

‘‘Small House’’ model, first developed here in Tupelo. We believe our residents 

should be able to live as independently as possible. They decide when to have 

guests, when to eat, when to bathe, and when to sleep. Nursing care takes place 

in the veteran’s bedroom. Our residents also choose what they want to eat, and food 

is served as if at home or in a restaurant. We respect the dignity of each of our 

veterans and try to simulate life as it might be in a private home. 

VA is committed to a veteran-centric model of care and is developing formal guidance for its Community Living Centers with input from both residents and field 

staff. VA is the largest integrated health care system in the U.S. to adopt these 

principles, and we think there is even more we can do to provide a more personalized environment for our residents. Last month, VA held a conference for nurse and 

physician leaders in New Orleans to discuss this cultural transformation and to emphasize care for a new generation of veterans. A chairperson has been selected to 

35 

oversee the national training program and the planning committee will meet later 

this month to discuss next steps. 

We are expanding age-appropriate care models in several ways in response to the 

needs of our residents. In some locations, we pair younger veterans with each other. 

At other facilities, the populations reflect several generations. Both models have 

their advantages. In an age-specific cohort, we can meet specific needs of younger 

veterans, who are more likely to have young children and similar interests, such as, 

computer technology and electronics, that differ from the interests of older veterans. 

In mixed-generation settings, our older residents can serve as parental surrogates 

for our young veterans. Meanwhile, interaction with younger veterans can provide 

older veterans with an important connection and a renewed sense of purpose. Intergenerational support is important for veterans of all ages. 

Some of our facilities are geared specifically to younger veterans with cognitive 

deficits produced by the traumas of war, usually Traumatic Brain Injury (TBI) or 

Post Traumatic Stress Disorder (PTSD). For example, the Tuscaloosa Community 

Living Center has established a center and a TBI/PTSD program team for OEF/OIF 

veterans. VA’s Community Living Center in Washington, DC, has separate living 

areas for OEF/OIF veterans. The National Defense Authorization Act for FY 2008 

requires VA to provide age-appropriate nursing home care to veterans in need of 

such care for their service-connected disability and for veterans with service-connected disability rated at 70 percent or more. To fulfill this mandate, VA is developing proposals for future modifications to the environment of care in our facilities 

to further the goal of deinstitutionalizing nursing home care. 

While we realize we can never completely match the experience of living in one’s 

own home, VA is taking significant strides toward a more responsive and responsible model of care in a deinstitutionalized setting. 

Thank you, Mr. Chairman, for the opportunity to appear before you today. 

Senator WICKER. Dr. Hojlo, are those all private bedrooms, or are 

some of them—— 

Ms. HOJLO. Sir, because our facilities currently are very old, we 

still have a fair number of semiprivate rooms, and in some cases, 

three beds, which we are very consciously attempting to change. In 

our new construction, our new construction guidelines are very 

clear that we’re committed to private rooms. 

Senator WICKER. Thank you. 

Ms. HOJLO. Our residents also choose what they want to eat, and 

the food is served as if at home or in a restaurant. Now, again, I 

just want to deviate here for a minute and say that this is a huge 

culture change for a system as large and as complex as ours, and 

we’re actually beginning to serve, in some of our centers—we’re 

moving away from a mess hall approach to dining, and personalizing. And we have some photographs of what folks are doing. 

We respect the dignity of each of our veterans, and we try to simulate life as it might be in a private home. So we also are committed to home, not just home-like. The VA is committed to a veteran-centered model of care, and we are developing formal guidance for our Community Living Centers, with input both from residents and field staff. And again, I want to deviate from the formal 

testimony for a minute to say that we are in the process of finalizing some official guidance national policies. And for the first time 

in our history, this set of national policies, which hopes to be 

signed on fairly soon, is written from the veteran’s perspective. In 

other words, the policies are typically written by me, in my office, 

and we have engaged field staff in writing this policy and we have 

engaged field staff to incorporate veterans’ thinking. And we have 

used the Resident Bill of Rights as the foundation for the document. And again, this emphasizes the person-centered approach to 

care. 

Senator WICKER. Can I go online and find that Bill of Rights? 

36 

Ms. HOJLO. The Patient’s Bill of Rights, I believe so—the associated Medicaid services. It is a standard bill of rights, yes. 

The VA is the largest integrated health care delivery system in 

the United States. To adopt these principles—and we think that 

there is even more that we can do to provide a more personalized 

environment for our residents. Last month, the VA held a conference for nurse and physician leaders in New Orleans to discuss 

this culture transformation and to emphasize care for a new generation of veterans. 

A chairperson has been selected to oversee a national training 

program, and a planning committee will meet later this month to 

discuss the next steps, particularly so that as we design our culture 

transformation and the approach to care, that we recognize the fact 

that we are receiving a new cohort of veterans. And we’re expanding our age-appropriate care models in several ways in response to 

the needs of all of our residents. 

In some locations, we pair young veterans with each other, in our 

current models. At other facilities, the populations reflect several 

generations. Both models have their advantages. In an age-specific 

cohort, we can meet specific needs of younger veterans who are 

more likely to have young children and similar interests, such as 

computer technology and electronics, that differ from the interests 

of older veterans. 

In mixed-generational settings, however, our older residents can 

serve as parental surrogates for our young veterans. For example, 

what we’re seeing in the cohorts of veterans that we have, we see 

the young son of the Vietnam era vets are very often, for example, 

equivalent to what the young vets would see in their dad’s age, and 

then we have the grandparents. 

And in reflecting on that model, we find that, although the 

generational differences may be significant, they all have one thing 

in common: they have served our country. And that has created a 

buddy system and opportunity for these veterans of different cohorts to actually—for example, when you have a young man or 

woman with TBI, a brain injury, who is cohorted with some older 

veterans, the older veterans actually tend to look out for that 

young person. It is quite awe-inspiring to see the bonding that occurs. So this is to dispel the fact that young people may not do well 

in an old folks home. When there is a mixing of generations with 

a consciousness toward what that intergenerational activity could 

really accomplish, the outcomes are quite touching and quite profound. 

Senator WICKER. How large of a group are you talking about? 

Ms. HOJLO. For the Iraqi—— 

Senator WICKER. In this context, you mentioned the settings. 

How many people are in a setting? 

Ms. HOJLO. It varies across the country. In the new models, as 

we’re trying to reflect on small house and Green House models, 

we’re speaking of about 8 to 10. And we have not had the opportunity yet to build those structures. Currently, our individual nursing home neighborhoods or communities range anywhere from 22 

to 30 units. And within those units, we can cohort veterans as well. 

So it really differs across the country, based on what the popuVerDate Nov 24 2008 10:28 May 06, 2009 Jkt 000000 PO 00000 Frm 00040 Fmt 6633 Sfmt 6601 H:\DOCS\070308.TXT SVETS PsN: PAULIN
37 

lation needs are, what the individual veteran’s needs are. And our 

structures also limit—— 

Senator WICKER. So those are the smallest settings—those are 

the smallest groups now in a setting? 

Ms. HOJLO. Right. 

Senator WICKER. Is the VA actually looking at trying this 10 or 

12 and below setting and actually experimenting with that? 

Ms. HOJLO. Absolutely, sir. 

Senator WICKER. When do you think we might be able to break 

ground on the first one of those? 

Ms. HOJLO. We have, actually—we’re working with the National 

Defense Authorization Act, and we have submitted a budget for 

several Green Houses within the context of that act. So we’re actually having some conversations with Mr. Jenkens. Some of our facilities have engaged in conversations with Mr. Jenkens. We have 

established a design guide that is actually affirming this direction. 

I am sorry, I cannot give you an exact date, but I can tell you that 

there is a strong commitment to moving in this direction, especially 

in new facilities. 

We have an example that I brought here of our facility in Biloxi. 

It isn’t quite Green House, but it is very close to cohorting veterans 

in a smaller setting. So this is actually a first. 

Senator WICKER. Are those the pictures that—— 

Ms. HOJLO. Yes. I will go through them. All of the pictures don’t 

reflect Biloxi, but Biloxi’s model is in the drawings that we have. 

Senator WICKER. OK. I am going to go ahead and pass these 

through the audience. We have only one copy—two copies. We will 

start one in the back and one in the front. OK, go ahead. Are you 

almost finished? 

Ms. HOJLO. Yes, sir, I am. Some of our facilities are geared specifically to younger veterans with cognitive deficits produced by the 

trauma of war, usually a Traumatic Brain Injury or Post Traumatic Stress Disorder. And I would like to highlight our Tuscaloosa 

Community Living Center has established a center with a TBI and 

PTSD program team for young veterans returning from Iraq and 

Afghanistan. The VA’s Community Living Center in Washington, 

DC, has separate living areas for these veterans. As I have said, 

the National Defense Authorization Act requires the VA to provide 

age- appropriate nursing home care to veterans in need of these 

services. To fulfill this mandate, the VA is developing proposals for 

future modifications to the environment of caregiving in our facilities to further the goal of the institutionalized nursing home. 

So, even though we don’t have a Green House at the moment, 

we have developed some policies, again, that were recently signed 

off that gives specific guidance of how veterans coming into the VA 

nursing homes, particularly the younger veterans, would require 

definitely a home-like, personalized environment for actually the 

home setting, even in the context of some of our old facilities. And 

it is amazing. You’ll see by the photographs what we have been 

able to accomplish, even in some of the current facilities. 

We realize we can never completely match the experience of living in one’s own home. The VA is taking significant strides toward 

a more responsive and responsible model of care in a de-institutionalized setting. 

38 

I thank you for the opportunity to appear before you today, and 

ask if you would like me to go through the slides? 

Senator WICKER. Well, let me ask you, I think we’ll try to—it’s 

11:44. We’re going to try to wind up in 30 minutes. That will get 

us out of here by 12:15, if that’s OK. So, let me proceed on without 

that. But I do very much appreciate it. 

Let me just ask you in follow-up, there are VA settings, and you 

have changed the name, and you say that it is not only a name 

change, it is actually a change in mindset. What interaction at all 

do you have—and you can answer briefly—with the DOD retirement homes? 

Ms. HOJLO. Directly, in my position, I don’t have any direct 

working relationship with the DOD. However, through the National Defense Authorization Act, as we design these principles, 

that act does require some type of interaction between the DOD 

and the VA. However, the clarity of that interaction and relationship to the nursing homes or Community Living Centers isn’t 

there. So I certainly would be happy to interface with them. However—— 

Senator WICKER. Here’s why I ask—go ahead. I don’t want to cut 

you off. 

Ms. HOJLO. The concept of culture transformation is really very 

new. And in some ways we feel that we need to establish what it 

means for us, the VA. And in a way, it is ‘‘take care of your own 

house’’ and then move it to someplace else. 

Senator WICKER. Sure. I am just wondering if you shared data 

or concepts or research. Here’s what I’m getting to. We had a very 

interesting meeting with DOD representatives of the Armed Forces 

retirement homes, and basically they said the veteran is different, 

has a different desire for long-term health care. They loved the 

mess hall setting. They are used to it on the ship or in the mess 

hall. And so breaking it down into a 12- or 10-person home-like setting is not the way to go. I just wondered if you had found that 

to be the case in dealing with veterans yet in another agency? And 

then I’ll let others respond to that question. 

Ms. HOJLO. Thank you for that question. I believe that we don’t 

really have enough information in the Department of Veterans Affairs to be able to make a judgment either way, again, because all 

of this is so brand new. And as we develop the Green House model, 

and as we move the cultural transformation forward, we are intending to obtain data and do some research in that area. So, I personally am convinced that that’s a great opportunity. And what we 

are doing in our current settings is we are moving away from the 

mess hall model. You see photographs where we have white tablecloths with a smaller number of veterans. And, anecdotally, veterans seem pleased with that. We’re making the atmosphere in the 

dining rooms quieter. We are not providing medications or treatments during that time, as we did in the past. People would come 

in and do blood pressure checks and maybe provide insulin or 

medications during mealtime. We don’t do those things anymore. 

So we’re trying to humanize and de-institutionalize the way food is 

served, but we don’t have enough data yet. 

Senator WICKER. All right. Well, I am going to let other members 

of the panel address that question. Let me mention this Wall Street 

39 

Journal article which is already a part of our testimony, and that 

also will be made a part of the permanent record. It is dated June 

24, 2008, by Lucette Lagnado of The Wall Street Journal. And, basically, let’s start with you, Dr. Thomas. Susan Feeney, of the 

American Health Care Association, visits thousands of for-profit 

and not-for-profit nursing homes and says that you’re being overly 

harsh, that many of the traditional nursing homes aren’t able to 

scrap a large building, but they are changing and making reforms 

and changing the culture to a more home-like feel. Are you being 

a little unfair to the thousands and thousands of traditional nursing homes? Would you respond to that? 

Dr. THOMAS. I would love to, thank you. First off, I’ll tell you a 

distinction that I use in my work that is very helpful to me. There 

are the tens of thousands, hundreds of thousands of dedicated 

nurses, doctors, caregivers, speech therapists who, every day in 

America, do the hard work of providing long-term care. These are 

flesh and blood human beings, and I honor them entirely. 

Senator WICKER. In a variety of settings. 

Dr. THOMAS. Oh, yes. Then there is the institutional pattern of 

long-term care. The institutional mindset that puts tasks ahead of 

people, the institutional architecture, the nonprivate room, with a 

sheet hanging between two beds. I do not honor that. I reject that. 

I say that it is time to move forward. And I would like to make 

it really clear that the harshness of my criticism—and, yeah, I’ll 

use harsh language—is directed at the system we have created. 

What I have found—and I know Dr. Hojlo shares this with me 

over a long period of time—is that efforts to change the system are 

very difficult; that I have found in my work and research that making small changes to an institutional long-term care setting is not 

only hard to do; it is hard to make the changes stick. That is why— 

and Steve and I share this view—that I have moved toward a more 

transformational approach that says it is time to put an end to the 

warehousing and institutionalization of our elders. And that requires us to develop and test, research and improve new models. 

That’s really where I am coming from, and that is where Green 

House is coming from. And honestly, if the chief lobbyist for the 

nursing home industry says I am being too harsh, then I am probably doing my job. 

Senator WICKER. Is Mr. McAlilly warehousing elderly people in 

this traditional nursing home facility? 

Dr. THOMAS. Yes. And it is not Steve’s fault, and it is not the 

fault of the people who go to work there every day and give their 

hearts to that work. It is not their fault. It is a pattern, a system 

that does not provide the kind of dignity and autonomy that our 

elders deserve. 

Senator WICKER. Is there data on the other side of this question? 

Dr. THOMAS. Dr. Cutler would be the one to really talk about 

this, but I’ll tell you this: The funny thing is there is really no— 

I am going to say, Dr. Cutler, you disagree with me, if you can— 

there is no research that shows that institutional long-term care is 

the best model. 

Senator WICKER. OK. He has tossed it to you, Dr. Cutler. 

Ms. CUTLER. He is correct. Fortunately, in the last several years 

we have been even breaking down studying the institutional model 

40 

to private rooms, the benefits of private rooms—and one thing I 

think—one thing I do like about the Green House model, and what 

we try to do in any nursing home, traditional or not, that we go 

into is to subdivide the institution, the Green House, into three categories. You have your physical environment, of course, which is 

very easy to model or to measure. You have got your organizational 

patterns, and that is where the Green Houses went totally topsyturvy. And then you have your philosophy of care, which is much 

more difficult to measure. 

I think it kind of makes me—number one, I am not fond of the 

word ‘‘culture change,’’ but it kind of makes me a crazy lady that 

now we’re, all of a sudden, concerned with person-centered care. 

And I keep thinking, OK, over the last 40 or 50 years, who were 

you centering the care on? So, I do digress from your question. 

Dr. Thomas is correct; there is not a lot of research, probably— 

well, I won’t even add that. But there is not a lot of research on 

contentment in the traditional nursing home. 

Senator WICKER. I see. Mr. McAlilly, are these facilities in 

Tupelo coed? 

Mr. MCALILLY. Yes. 

Senator WICKER. And how are they selected? Are they intentionally coed, or does it just work out that way? 

Mr. MCALILLY. It just works out that way. We try to make the 

population in each Green House as diverse as we can make it. 

Senator WICKER. OK. 

Mr. MCALILLY. We think diversity is healthy. 

Senator WICKER. Now, what if you want to visit some friends two 

houses down? 

Mr. MCALILLY. You go visit them. 

Senator WICKER. Does that happen? 

Mr. MCALILLY. It happens. 

Senator WICKER. So it’s not that you’re just locked into these 12 

people forever? 

Mr. MCALILLY. No. And that becomes—you know, there is not a 

traditional activities program in a Green House. What the activity 

is, is living. So, if you used to visit neighbors in your neighborhood, 

you have friends two houses down, you go visit them. We know, either—if a person needs assistance to get down there, we provide 

that. But it is not like a self-contained prison that you can’t get out 

of. It is a neighborhood. 

Senator WICKER. I bet this question is in the minds of those in 

the audience. Is this something that we can afford? Now, I know, 

Mr. McAlilly, you say that you offer the care at the Medicaid rate, 

and yet Methodist Senior Services is a well-endowed charitable organization that is supported by many people of good will all over 

the State and all over the Nation. If it weren’t for that, would you 

be able to offer care at the Medicaid rate? And are we talking 

about something that would be desirable for everyone, but simply 

at a time of deficits and the skyrocketing cost of health care, we 

really can’t afford at the Federal level? 

I’ll ask each member of the panel answer that question. What 

about the cost, and can we afford this concept that sounds very, 

very desirable? 

41 

Mr. MCALILLY. I believe, absolutely, you can afford it. And the 

reason for that is our operations are strictly based on the income 

that we receive through Medicaid, Medicare or private pay residents. The operations are not subsidized by charitable giving in the 

Green Houses, except for on the front-end in the up front capital 

of building the building. We did have charitable donations there so 

we could afford the debt service of payment on the Green Houses. 

We made a commitment early on. We knew that we were going to 

spend more money, because we were going from semiprivate rooms 

to private rooms. But the outright operations on a day-in and dayout basis can be done at the current funding levels that, I think, 

pretty much everyone receives across the country. 

Senator WICKER. Mr. Jenkens, you’re scribbling notes. 

Mr. JENKENS. I am. Thank you, Senator. 

Senator WICKER. I think this really gets to the heart of what the 

Committee will need to know, and that is, is this something that 

actually can be afforded on a large scale by the Federal Government? 

Mr. JENKENS. Yes. There are, I think, three areas that are important to consider with that question. The first is that there is a 

significant body of research which shows that improvements—significant and meaningful improvements—in quality in nursing 

homes does result in lower operating costs, to the extent that we, 

as a government and a society, reimburse based on operating costs, 

which we do in many States through the Medicaid program. That 

would offer some potential for cost reductions. The Wall Street 

Journal article that you mentioned quotes one of our Green House 

providers in Billings, Montana, that when you compare their operations in a Green House to their operations in the remaining 

skilled nursing home, that they are about $42 a day less in operating costs in the Green House. 

Now, in the beginning, they were a little bit more. And there is 

a typical transition that people go through as their operations settle in, but we’re beginning to hear anecdotally that same comment 

from others. We shift costs from administrative functions and middle management into direct-care staff. So, we significantly increase 

the direct-care staff, but we believe there are savings from the 

operational redesign as well as the improvement in quality. 

Research has also shown that having about 4 hours of direct care 

time per day, which is what the Green House mandates, at a minimum, is one of the surest ways to improve your quality outcome. 

So, the model in building design, as Steve has implemented in 

Tupelo, is really designed very carefully to look at how do you get 

the best of our research, the best of our understanding in there. It 

is a nice combination, but it actually turns out to help reduce cost 

because of higher quality. 

Important from the Federal level is that—and research that we 

will start next year should show what we have heard anecdotally— 

is that the Green House also—because people know each other better and nurses and physicians can treat people better with better 

information from the shabhazi—that you are seeing fewer hospitalizations. Our project in Lincoln, Nebraska, reports their Green 

House elders, compared to their elders remaining in the traditional 

setting, had fewer acute illnesses, fewer hospitalizations. That 

42 

doesn’t translate into savings to Medicaid, but it does translate into 

savings to Medicare. So, at the Federal level, it is very meaningful 

to have a foundation of homes, like the Green House, to offer a 

combined savings to the Medicaid/Medicare program. 

Steve mentioned the capital costs, and the capital costs—if you 

were to build any new nursing home, you would face capital costs. 

We don’t fund capital costs through the Medicaid system. We have 

caps for development costs, which are generally at about half of 

what it truly costs someone like Steve to build a Green House 

home. So, the one area where the Federal Government may want 

to look at expenditures that would be different from what you 

would have in a typical nursing home setting is around the capital, 

in order to capture some of these long-term operating savings, 

which will quickly outpace any capital costs. 

Senator WICKER. Anyone else want to jump into that? 

Dr. THOMAS. I would like to say one thing. 

Senator WICKER. Dr. Thomas? 

Dr. THOMAS. I think that Dr. Hojlo and the Veterans Affairs 

group is really very ideally positioned to actually use these kinds 

of new models to increase quality and create savings. Because what 

they have, which a lot of us, for example, Steve, doesn’t have, is 

a really integrated system of health care at work. And in Steve’s 

case, he can save Medicare a lot of money, but it doesn’t save Steve 

any money—you know, his organization. And the VA has the opportunity to drive quality to higher levels, generate savings, which 

go to the system and allow them to provide even better service for 

the veterans. 

Ms. HOJLO. Would you like me to comment, sir? 

Senator WICKER. Yes, please, ma’am. 

Ms. HOJLO. Thank you. There are several pieces in this that I 

think are important to be looked at. I would like to just comment 

about what we talked about earlier about the warehouse model. 

Prior to the culture transformation movement—and I will speak 

about this in terms of VA—we simply—somebody in acute care 

wrote an order and said, ‘‘nursing home care.’’ So what my office 

did was we said, what does nursing home care mean? Well, we recognize that, first of all, nursing home care truly does offer—it is 

a set of services. So you have to be clear on why is the person going 

to a nursing home and not going home? So we actually articulate 

what those services might look like. 

Now, Medicare has a defined set of services, and Medicaid has 

the longer term. However, even within those categories, there are 

specific reasons why people have to go to nursing homes. And we 

recognize that. So that, in itself, first of all, has cost implications, 

because we no longer say, well, just go to the nursing home and 

figure out what he or she needs—a very, very important piece of 

this. 

Second, there is ample research on the fact that, you know, when 

folks don’t have attention to incontinence, falls, those kinds of 

things, and they don’t have meaningful use of time, then we increase psychotropic medication use. Costs of care significantly increase because of falls and those kinds of things. So settings and 

mindsets that provide care delivery in a manner in which you do 

pay attention to the individualized needs for care. Consistent staffVerDate Nov 24 2008 10:28 May 06, 2009 Jkt 000000 PO 00000 Frm 00046 Fmt 6633 Sfmt 6601 H:\DOCS\070308.TXT SVETS PsN: PAULIN
43 

ing, for example, is very, very important—that the same nursing 

personnel take care of that same veteran so they protect that person. They know what this person’s likes, dislikes, and needs are, 

so you can anticipate them, therefore preventing falls and—— 

Senator WICKER. And the veteran has a comfort level. 

Ms. HOJLO. Exactly, the veteran has—so the quality-of-life improves. And we know, as the quality-of-life improves, the veterans’ 

outcomes improve. And finally, the notion of meaningful use of 

time—having something to do all day, not just Bible, Bingo and 

birthdays, but actually planning the day around who is this person? We’re even changing our approach to care planning. We use 

the new methodology called I Care Plans, meaning that I, as a care 

provider, put myself in the shoes of that veteran and not talk about 

their diagnosis, but plan the care around who is this person who 

happens to have Alzheimer’s, or who is this person who has had 

a stroke? 

So, all of those things, I believe, contribute to improved outcomes 

and hopefully, cost reduction. However, we really don’t have 

enough data. We don’t have research yet to document that. This is 

all very new. And our intent in the VA is that, as we develop and 

evolve these models, that we will, in fact, contribute to the very important evidence base to make this movement go forward. 

Senator WICKER. In terms of the progress that we’re making in 

the VA toward advancing the Green House concept, Dr. Thomas 

and Mr. Jenkens, I think the testimony from Dr. Hojlo is that there 

is language in the current DOD authorization bill that will authorize an experiment in the Green House concept. And I know that 

you, Dr. Thomas, are completely sold on the concept for every single elderly American. But is the language in that bill—you have 

looked at the language, and is it sufficient to get us to where we 

need to be in terms of an honest-to-goodness experiment on the 

ground to see if this will work? 

Dr. THOMAS. Actually, I would like Mr. Jenkens to start, and 

then I will pick up on that. Because we actually were meeting and 

talking about that this morning. 

Mr. JENKENS. Thanks, Bill. First, I would like to recognize Dr. 

Hojlo for what I think has really been exceptional leadership within the Department of Veterans Affairs around this issue, not just 

with the Green House, but with culture change and the people that 

she works with who support her. It takes a courageous person to 

do this. Steve spearheaded this in the nursing home industry. And 

I think Dr. Hojlo is doing that with the VA. 

Senator WICKER. Particularly courageous to scrap thousands of 

dollars worth of design and plans when you have a board looking 

at you. 

Mr. JENKENS. It is. I think that is very true. I think that there 

are a couple of things, in looking at how to move forward and understand whether it works for the VA, particularly. I think pilot 

sites are very worthwhile. I would recommend a few more pilot 

sites than two, because I think there is such variety and diversity 

within the VA system that you might want to start with a slightly 

larger number around this. 

I think you would also want to add to that an initiative—a work 

group between people like Steve, who have done this, and Bill— 

44 

people who are providing technical assistance at a national level. 

Because I think one of the challenges that Dr. Hojlo and her team 

face are, how can a model be translated effectively into the VA system without losing its core benefits, but with not being able to understand exactly how those pieces all play into the results? Bill 

mentioned that we don’t know exactly what it is with this whole 

model that delivers any piece of the results. I think Dr. Cutler 

would agree that we haven’t disaggregated the research enough to 

know that. So, I think the only way we can do that effectively is 

to talk to each other and make our best educated guesses, based 

on what we have seen. I think a work group, as part of that initiative, would be a very healthy addition. 

Then, of course, providing incentives is very important so that 

Dr. Hojlo and her team don’t have to carry all of the weight and 

make all of the errors or changes. That can be very difficult; and 

many people can be very opposed to education performance indicators or other measures that would help people be inspired to do 

this. 

Senator WICKER. OK. Thank you. We’re nearing the end of our 

allotted time, and I appreciate everyone participating. Let me say 

I will call on each one of you, if you want to sum it up or make 

a final statement, say, 1 minute each. 

Before that, I had asked Susan Sweat, on my staff, to give me 

a list of the staff members here, and in all humility, she did not 

provide me the names of my own staff. So, let me particularly single out Susan Sweat for her hard work. She is part of my Washington, DC, staff and did a great deal of work. She has been a very 

effective staffer for you, the taxpayers, in this area of health care; 

and is now my legislative director. So, Susan, stand up. This is 

Susan Sweat. 

Kyle Stewart, my long-time administrative assistant, is in the 

back of the room. And Jamie Ellis, where are you? Jamie Ellis, 

stand up. Jamie Ellis is my new Veterans’ Affairs staff member, 

and he will be working now in the Tupelo office. Thank you, Jamie. 

As many of you know, Bubba Lawler, for some 13-and-one-half 

years, was my veteran staffer. Well, he and his family surrendered 

to a call to the mission field, and they are now in Birmingham, 

England. I would be remiss if I did not recognize, in a public way, 

his great service for 13-plus years for the taxpayers in that regard. 

Jamie, we welcome you. 

Again, we appreciate John Towers of Senator Burr’s staff, and 

Aaron Sheldon of Senator Akaka’s staff, for coming all this way 

and being part of this and for supplying me with information and 

suggestive questions. 

Starting with Dr. Hojlo, would you like to summarize for 1 

minute? And then we’ll pass the microphone right on down. 

Ms. HOJLO. Yes, sir. Once again, thank you for the opportunity 

to be present at this hearing. I would like to, just for the record, 

make it very clear that the Department of Veterans Affairs is extremely committed to moving forward with the agenda in transforming the culture of nursing home care, not only in the VA, but 

also contributing to that influence in the nursing home industry in 

the country. I think it is very courageous of you and your Committee to bring this to the front, because I think it is time that, 

45 

as a country, we start to address the plight of folks who have been 

assigned to needing nursing home care. And the circumstances in 

this country have not been ideal; so, I appreciate the fact that we 

are able to move this agenda forward through forums like this. 

Senator WICKER. Thank you. Dr. Thomas? 

Dr. THOMAS. I would like to say, first and foremost, thank you 

to Dr. Hojlo for the work she is doing, because she is there; she is 

responsible; she is the person with the obligation to move a giant 

bureaucracy forward, and I honor that. 

Senator WICKER. As do I. 

Dr. THOMAS. Yes. I want to say thank you for that. Second, I just 

want to say, if I may, I think that the Veterans’ Affairs Committee 

and your leadership on that Committee can help Dr. Hojlo by providing the tools and support that is in the legislative language that 

can help her go farther faster. 

Honestly, in the field of long-term care, we definitely have a debate about specific techniques, but it is very clear that long-term 

health care in America is moving in this direction, and our veterans need to benefit from that movement. I would like to strongly 

endorse the concept of giving Dr. Hojlo improved access to tools 

and resources to help her move her administration forward in this 

circle. Thank you. 

Senator WICKER. Thank you very much. Mr. McAlilly? 

Mr. MCALILLY. First, I want to say to you, thank you, again. We 

are honored that you and the Committee and the staff members 

are here for this hearing. It is an important time to you, and we’re 

honored that you thought this idea was worthy enough to come to 

Tupelo. I think, to sum it up for me, the statement is, ‘‘you can’t 

put new wine in old wineskins.’’ And the research is there. 

Senator WICKER. Where did you get that? 

Mr. MCALILLY. Thirty years ago, we didn’t know better, and we 

were doing the best that we could with what we knew. Twenty 

years ago and 10 years ago, we didn’t know better. We were doing 

the best that we could with what we knew. Today we know better. 

There is a difference between food cooked in your home, where you 

can smell the bacon frying and hear the dishes rattling and the 

pots rattling, and sitting down at a 120-room dining hall, or even 

in a small pod and eating food that was delivered from the central 

kitchen on a cart to your area. 

There is a difference between six friends sitting around their 

kitchen table playing rook and 45 people in the activity room at a 

bingo game. And there is a difference between being able to walk 

out of your bedroom and go into your den or even onto your patio 

and tend the flowers that you planted, versus 30 people lined up 

in the hall in their wheelchairs waiting. We know better today. We 

know better today; and the veterans of our country—those people 

who have given more than most of us—on this eve of our country’s 

birthday—these people who have risked their lives and given it 

all—deserve the best that we can give them. And we believe that 

this model of care is the best that we can give them. Thank you. 

Senator WICKER. Thank you. Mr. Jenkens? 

Mr. JENKENS. I think I would like to go back to the quote from 

The Wall Street Journal article that you mentioned from Susan 

Feeney. I think what is interesting to me about that quote, as a 

46 

representative of the nursing home industry, is that she criticizes 

Bill’s comments for being overly harsh. She did not criticize them 

for being unfair. And I think that is an important distinction. 

I think nursing home providers want to change. As Steve says, 

they now know better, and they want to change. With courageous 

leadership, leadership like Steve’s and Dr. Hojlo’s, I think they will 

change. They will change by example. They will change by inspiration. But they need appropriate support, and they need appropriate 

resources to be effective in that change. And I think that’s where 

the Committee can have a significant impact to help and assist in 

moving this forward. I would like to add my thanks for your work 

to both have the hearing and the work that you are pursuing to 

bring this as an option to the veterans. Thanks very much. 

Senator WICKER. Thank you very much. And Dr. Cutler, I am 

tempted to say you have the last word, but actually, that lies with 

me. 

Ms. CUTLER. Nor should I. I am speaking from our researchers’ 

perspective with my remarks, and what we found with our research was that, compared to a traditional nursing home model, 

the Green Houses work. So, what I would ask, that as we go forward and do research—and we desperately need more research— 

that we not study setting, philosophy, organizational patterns, anything in isolation. It is the interrelationship of these three components of the Green Houses that make them work. And therefore, 

going forward, I applaud The Robert Wood Johnson Foundation for 

the organization to uphold these three principles. Because think of 

it as the three-legged stool. You take one leg out, and it is going 

to topple. So, not only research, that we research all of the three 

components’ interrelationship, which we did in this study, but 

that—don’t try to study the model in isolation. It needs—we need 

to look at the staff and how they interrelate with the elders, and 

how they interrelate with the family, and then, importantly, which 

has been somewhat ignored, how they interrelate with the professional staff, the home health component. And I thank you as well. 

Senator WICKER. I thank you all. Let me take this opportunity 

not only to thank the panel and staff members, let me take this 

opportunity to, 1 day early, wish each of you a happy Independence 

Day and to point out to our guests in Tupelo that, until 1 p.m. 

today—and I am reading from the Northeast Mississippi Daily 

Journal—until 1 p.m. today, at One Mississippi Plaza at South 

Spring Street and Troy, there is a downtown Independence Day 

kickoff celebration featuring Kay Bain and the Morning Show Band 

with free hot dogs and lunch. So, you’re all welcome to that until 

1 p.m. today. 

And we thank the veterans groups that came today and all of the 

interested citizens. Thank you to the media for helping us get the 

word out. 

Mr. McAlilly, I am going to end with a quote that I used 5 years 

ago at the opening of the Green Houses in Tupelo. The veterans 

who are—and the elderly people who are—actually living in nursing care and living in the Green Houses, of course, can’t be here 

today. But if I could be there and speak to them, I would say that 

the words of Tennyson are very appropriate to our regard for their 

service, and particularly the service of those who are veterans. 

47 

Where Tennyson says, ‘‘Though we are not now that strength 

which in old days moved earth and heaven, that which we are, we 

are. One equal temper of heroic hearts made weak by time and 

fate, but strong in will.’’ And with those words of Tennyson, I salute our veterans, those in nursing care, and veterans everywhere 

on this, the eve of our Nation’s birthday. 

Thank you very much, and God bless America. 

[Hearing concluded at 12:27 p.m.] 

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