Could the Netherlands' 'dementia village' be replicated in the U.S.?

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Residents enjoy a town square in the original dementia village, the Hogeweyk, in the Netherlands. It's an unusual nursing home designed like a village to make life feel as normal as possible for people with advanced dementia.

It’s been 10 years since a Dutch senior housing nonprofit opened a groundbreaking nursing home for people with dementia that was designed to look and feel like a small village.  Residents of Hogeweyk can enjoy outdoor gardens when they wish, shop at a grocery store, help make dinner, and visit a pub or storefront club.

The “dementia village” quickly earned admiring stories from newspapers and television programs.  Experts on aging  from around the world toured frequently.  Studies supported the idea that living in the village is associated with better behavior, social interaction, and satisfaction. Yet, its approach to care, based on a holistic vision of maintaining normalcy and quality time in late life, remains unusual.

Eloy van Hal, who helped found the village and now consults with others interested in replicating the concept, came to the Doubletree Suites by Hilton in Mount Laurel this week as a low-key proselytizer. He spoke at a conference on the future of elder care sponsored by the Rothkoff Law Group, which specializes in aging issues.  Jerold Rothkoff, managing attorney for the practice, was among those who visited Hogeweyk, outside Amsterdam, in 2016.  He was so impressed that he wanted to share the idea with the more than 220 people who signed up for the conference.  Rothkoff thinks the model could work in the United States and that baby boomers will find its emphasis on individualized care and living in smaller, more family-like units attractive.

Van Hal said the concept was a tough sell in the Netherlands.  Like the United States, his country heavily regulates nursing homes, and there were many concerns about safety. If residents with severe dementia could walk outside, they might fall or jump into the fountains. It seemed dangerous to let them prepare food with knives.  “Many people said, ‘You’re completely insane,’ ” van Hal said.

Camera icon Stacey Burling
Eloy van Hal is one of the founders of Hogeweyk.

As it turned out, dementia did not stop people who had used knives all their lives from safely peeling potatoes.  No one jumped in the fountain.  People did not fall outside any more than they did in other settings.  But residents benefited from fresh air, sunshine and exercise, which are rare treats in many traditional facilities.

Van Hal said more typical nursing homes, with their large scale and locked doors, increase confusion for many elders with advanced dementia.

The core of the Hogeweyk model is small houses for six like-minded people served by six to seven staff members who help with care, activities and cleaning.  People eat and live in these small groups and leave the house for other social activities.

To minimize conflict and stress, Hogeweyk houses people with similar cultural norms together. These include food, music, decorating style, and lifestyle preferences.  Do residents like the commotion of  lots of visitors or are they quieter types?  The groups would be different in another country, but, at Hogeweyk, people are in houses based on urban, traditional, formal or more cosmopolitan lifestyles.  The traditional group is locally focused and wants meals with lots of potatoes.  The cosmopolitan residents are into arts, nature, and more international food.  The formal, more well-to-do group wants classical music and high tea.  Each group gets different food made in its own house kitchen, as well as different decorating and coffee cups.

People are encouraged to make as many decisions as possible about what they’ll do each day.

Van Hal insisted that Hogeweyk’s residents — 150 live in the 3.7-acre village — are just as sick as people in U.S. nursing homes.  They just look healthier because they’re in a better environment.  Rothkoff thought that the residents were likely more akin to those with more severe problems in American assisted-living memory units.  Many of those people, he said, could also qualify for nursing-home care.

Van Hal said quite a few places are copying parts of the Hogeweyk model, but it is rare to include all of aspects of the program that he believes are essential.  These include attention to lifestyle norms and meaningful activities, favorable surroundings, medical support, and the right kind of business and staff.

One center recently opened in Australia and others are in development in Italy and New Zealand. He is not aware of any programs in the U.S. but thinks that is likely to change soon because of a big increase in interest.

Some of the elements of the program are becoming increasingly common in U.S. facilities, thanks in large part to the culture change movement. The Green House model, developed in this country in the 2000s, also features small living groups, stable staff members who multitask and lots of individual resident choices.  Growing numbers of senior living facilities now have smaller “neighborhoods,” more kitchens, and more individual choice.  A few facilities have tried incorporating storefronts that evoke old-fashioned main streets.

Cost is a barrier to implementing van Hal’s full program.  He says it operates under the same budget as other nursing homes in the Netherlands, a cost of $7,425 to $8,410 per resident per month.  Taking U.S. salaries into consideration, Rothkoff said it likely would cost about the same as a high-end assisted-living facility in the U.S.: $8,000 to $10,000 a month.  He thinks that would come down over time.

Van Hal said the biggest barrier to change is entrenched attitudes.  “It’s really hard to change existing models,” he said, “and to change the medical model to a more social-relational model.”