The eight residents of Frontier Manor near Creve Coeur, one of five Dolan Residential Care Centers for seniors with dementia, sat shaking maracas and tambourines while music therapist Troy Jones played 1950s rock 'n' roll songs on the keyboard.
After their music therapy session, the residents could choose to continue watching the Humphrey Bogart movie in the living room, go to their bedrooms or take a walk in the landscaped backyard — basically, whatever they want to do.
Frontier Manor is their home, after all.
It's one of more than 800 household models of senior care existing today, though this type of care makes up less than a half-percent of the total U.S. nursing home supply, according to research presented at last year's conference for the International Association of Homes and Services for the Ageing, a global network that uses British English spellings.
Construction for a four-house neighborhood in St. Louis to accommodate 40 people in residential household models will begin this month, said Tim Dolan, president of Dolan Residential Care Centers.
At Lutheran Senior Services' continuing care retirement community in Webster Groves, another memory care household opened last month, and two skilled nursing households not specific to memory care will open in September and November.
Since the late 1980s, a grass-roots movement known as culture change has supported transforming the physical spaces and staff duties in senior care facilities so residents have more say in what they do.
Though 31 percent of nursing homes reported they abided by culture change principles, only 1 percent said their residents live in a household model, according to the Commonwealth Fund's 2007 National Survey of Nursing Homes.
"Just because you move into a nursing home doesn't mean you give up those rights" of making decisions, said Maggie Calkins, president of I.D.E.A.S. Inc., a research and consulting organization for long-term care providers.
Households avoid the 50-plus beds, restricted-access kitchens, public address systems and medication carts often found in traditional nursing homes. A study by Les Grant, director of the Center for Aging Services Management at the University of Minnesota School of Public Health, said household models contain 25 or fewer residents.
But the barrier preventing many traditional nursing homes from renovating or rebuilding is the cost, Calkins said.
The daily tasks of life are self-contained in the household, including a full kitchen in which residents can help prepare meals and grab a snack from the fridge, a family-style dining table and a staff that can perform all the duties within the home, such as housekeeping, administering medications, cooking and leading the group in activities.
Cindy Bohnenstiehl's mother, Winnie Palecek, lives at Hummingbird Lane, an assisted living memory care home at Meridian Village in Glen Carbon.
Palecek moved to Hummingbird Lane in April after living in a Meridian Village independent living home, which is not a household model.
The furnishings in both homes are similar, Bohnenstiehl said, but the difference between the two dining areas is huge.
"She doesn't have to go down a long hallway before she even sees the dining room. The kitchen is visible to dining room residents, so the staff that is preparing the meal is interacting with residents while they're doing jigsaw puzzles," Bohnenstiehl said. "Everything is within talking distance. It's all open."
The Crossings, with just 23 rooms, is the only household model within the Laclede Groves community.
Each resident has a bedroom, private bathroom, living room and kitchenette. The staff makes sure residents are taking medications, but if residents want, they can stay in their rooms all day, said Jane Wilke, Lutheran Senior Services' administrator of communications.
A dog named Sophie roams the hallways until 5 p.m., when its owner, the nurse practitioner, leaves. Sophie can trigger childhood memories for these residents with dementia, Wilke said.
The household model is in stark contrast to what Grant calls the institutional model, in which staff hierarchy limits residents' ability to make decisions for themselves.
Some senior care homes are transitioning from the traditional nursing home into a more homelike environment.
Cathy Bono, administrator at Delmar Gardens North Nursing & Rehabilitation Center in Florissant, said that although her facility has always striven to be as homelike as possible, it can do more.
"We are learning from our patients," she said.
She said the facility needs to look for personalized solutions beyond simply renaming Division 100, one of five wings, "Cardinal Lane."
Delmar Gardens North houses 129 residents, with about 55 residents in most of the divisions. The specialized care wing for dementia patients caps the resident quota at 28.
Even though residents cannot enter the kitchen to cook their food, an activity director oversees residents in a smaller kitchen when they want to clean string beans before dinner or bake cookies.
Still, vestiges of the institutional model remain, such as a nurses' station and long hallways.
Calkins said the spatial environment needs to be similar to a house.
"People don't have a nursing station at home," she said.
She also disapproves of semiprivate rooms separated by a curtain.
"I don't think that comes anywhere close to privacy."
The prices at these three senior care homes aren't all that different either.
Delmar Gardens North costs $190 per day for a semiprivate room, or about $5,700 per month.
The Crossings' monthly cost of between $3,995 and $6,200 — based on apartment size and style — is all-inclusive, with no a la carte charges.
Dolan Residential Care Centers' monthly price of $205 a day, or about $6,100 a month, is also all-inclusive.
Some nursing homes in St. Louis cost much less. The Mary Rider Home is $1,610 per month, but it's not a household model.
At Frontier Manor, Dolan said he encourages residents to participate in their own care by helping with meals, brushing their own teeth and spontaneously organizing activities instead of always relying on a schedule. That way, he thinks, they will avoid losing a sense of purpose and self-dignity.
"It makes them whole again."