Date on Master's Thesis/Doctoral Dissertation


Document Type

Doctoral Dissertation

Degree Name

Ph. D.


Health Management and Systems Sciences

Degree Program

Public Health Sciences

Committee Chair

Johnson, Christopher

Committee Co-Chair (if applicable)

Jennings, J'Aime

Committee Member

Jennings, J'Aime

Committee Member

Creel, Liza

Committee Member

Roelfs, DAvid

Author's Keywords

Culture change; quality of care; deficiency citations; falls; incontinence


Nursing homes (NHs) have been described as hospital-like facilities where residents are more likely to experience isolation or abuse. The Green House (GH) model is a type of culture change which focuses on deinstitutionalizing traditional NHs to provide better quality of care and quality of life to NH residents. The two main objectives of this study are: to describe the GH model and its elements and to identify which GH elements impact the quality of care. This study also seeks to identify organizational theories used in the GH analysis. The next objective is to analyze the impact of the GH model elements on the deficiency citations. Lastly, the other objective is to examine the impact of the GH model elements on the indicators of quality of care. For the methods section, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and five databases were used. For the quantitative section, two methodological strategies were used to examine the data with Stata 14 including a propensity score and a difference-in-difference. Eighteen articles analyzed the GH model and no organizational theories were identified. Staff and physical structure were the most assessed GH elements in the literature. The GH model had a positive effect on preventable hospitalizations, falls, and in residents with pressure ulcers and catheters. For the quantitative section of the study, 5,040 facility-year observations were included in the study sample with 26 GH facilities and 254 facilities for the years 2000 to 2017. Even though the results were not statistically significant, the incidence rate ratio for deficiency citations was lower in GH facilities than in non-GH facilities. For the last objective, the incidence rate ratio for bowel incontinence was lower in GH facilities than in non-GH facilities (IRR: 0.920; P-value: 0.002), but no statistically significant difference was found between the impact of the GH model and falls and bladder incontinence. Our findings showed that there was an association between the GH model and the prevalence of bowel incontinence, but not with the other indicators of quality of care. More research needs to be done to contribute to the long-term care field.