[Senate Hearing 110-805]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 110-805
 
                  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



                     COMMITTEE ON VETERANS' AFFAIRS

                   Daniel K. Akaka, Hawaii, Chairman
John D. Rockefeller IV, West         Richard Burr, North Carolina, 
    Virginia                             Ranking Member
Patty Murray, Washington             Arlen Specter, Pennsylvania
Barack Obama, Illinois               Larry E. Craig, Idaho
Bernard Sanders, (I) Vermont         Kay Bailey Hutchison, Texas
Sherrod Brown, Ohio                  Lindsey O. Graham, South Carolina
Jim Webb, Virginia                   Johnny Isakson, Georgia
Jon Tester, Montana                  Roger F. Wicker, Mississippi
                    William E. Brew, Staff Director
                 Lupe Wissel, Republican Staff Director


                            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


           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 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 long-term 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 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 
long-term 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.
    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 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 long-term 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 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 self-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, 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:]
     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
    - 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-in-hand--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.

    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.
    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 nurses-aid 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 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 small-house 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 2\1/2\ 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 1\1/2\ 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.
    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:]
















    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 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 
quality-of-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 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.
             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
    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
                             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:]






    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 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:]
  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 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?
    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 population 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.
    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 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 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 topsy-turvy. 
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?
    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 day-out 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 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 staffing, 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--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, 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 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. 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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