When Mark Carroll began searching for a nursing home for his mother, Virgie Carroll, he had many advantages.

Not least was her permission.

"Mother had given me the green light 20 or 30 years ago," said Mark, 43. "She told me to put her where she needs to be when she needs to be there. That's why it wasn't so hard for me to start thinking of this."

Along with the blessing from Virgie, some other factors worked in the Carrolls' favor. Mark had the ability and tools to navigate Web sites that often contain complex information about nursing homes, or details that are difficult to decipher.

In addition, Mark had a working knowledge of his parents' estate -- including the information that they had bought a long-term care insurance policy in the 1980s. He had ideas on the type and location of home he wanted, and he got advice from an experienced caregiver at the day-care center his mother attended.

All of those things helped make it possible for Virgie, 75 and suffering from Alzheimer's disease, to be put into a home where her husband, Lawrence, can visit faithfully twice a day and where she can get good care and plenty of attention.

The Carrolls planned in a way that helped them get the result they wanted.

Other scenarios, played out daily across the United States, are less successful.

In most cases, nursing home admissions arise out of crisis, usually in one of two settings:

* In a hospital: Typically, a family member is told that mom or dad will be released from the hospital in a couple of days and they must find a nursing home admission immediately.

* At home: The elderly person has an accident that makes it clear he or she can no longer live alone.

Experts strongly advise that advance planning, or, at minimum, some understanding of what's available to elderly people and their families, can ease the transition from independence to long-term care.
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Revising the mind-set

Crisis situations develop because people don't want to go to nursing homes and seldom plan to do so. Most residents have significant medical problems when they enter a home and often are depressed. Average life expectancy in long-term care is three years.

Jill Boyd, a social worker geriatric care manager with Delmar Gardens Private Services, says her best clients are the ones who try to make the best of an admittedly difficult experience.

Seven keys to quality care

Marilyn Rantz, co-author of "The New Nursing Homes: A 20-Minute Way to Find Great Long-Term Care," offers seven suggestions people can use to judge the quality of care in a nursing home. These same qualities can be sought in other long-term care settings, such as assisted living and residential care.

Rantz is a registered nurse, licensed nursing home administrator and professor at the University of Missouri's Sinclair School of Nursing in Columbia. Her book was the American Journal of Nursing's book of the year for 2001.

The qualities people should look for are:

* The home itself: It should feel more like a private home than a hospital or institution.

* Attention to care: The fundamentals of care, such as bathing, eating and going to the bathroom, should be top notch.

* Family involvement: Families should be encouraged to get involved in their loved one's care.

* The home's environment: It should be clean, odor-free, spacious and relatively quiet.

* Good communication: This must be accomplished between families and staff members, staff and residents, and between various members of the staff.

* Quality staff: The staff should be responsive, compassionate, clean, well-groomed and employed at the home for several years.

* Central focus: The home should set the right priorities, focusing on their neighborhood communities, as well as on residents, their families and the staff.

Family responsibility

Family involvement generally ensures that residents are fed, exercised and given the proper medicine. Families say they feel more confident in their relatives' care once they get to know the staff members at a nursing home.

It can be difficult for family members to walk the fine line between appropriate attention, and being pests to the point of being counterproductive. Quality nursing homes are pleased to see families get involved, but staff members are unable to spend all their time catering to any single family. Family members are advised to pick their battles carefully so they don't alienate staff members. In the worst cases, that can lead to mental or physical retaliation against the resident.

Families that lack the time to regularly oversee the care of their relative should keep in touch as much as possible, by phone if necessary. Some also install surveillance cameras, part of a growing movement among nursing home advocates. Nursing home administrators frequently order that the so-called "granny cams" be removed, which can be stressful for the family and the resident. The only state that has passed a law on this is Texas, which stipulates that roommates must agree to placement of the camera.

If families can make personal visits, they are advised to drop in at different times on different days and to make it a point to let staff members know about their relatives' personality, likes and dislikes.

A family council -- acting much like a school PTO -- can also help watch out for individual residents whose own families may not be able to visit much. Many homes accommodate family councils that work with staff members to try to avoid problems and listen to concerns.

Resident- centered care

Traditional nursing homes focus on the physical needs of the resident and on managing the resident's medical problems. People in this type of home are grouped according to their abilities or disabilities. Medical care is the main focus for residents; their social and personal needs are secondary.

Author Marilyn Rantz describes "new" nursing homes, which are homes that either practice the "Eden Alternative" or offer "resident-centered care."

The Eden Alternative emphasizes residents' quality of life. Elderly people are encouraged to bring pets, plants and other homelike amenities to their rooms. The home focuses on residents' social needs and desire to personalize their rooms.

Resident-centered care involves the residents themselves, instead of the staff, making the decisions that affect them. In this setting, residents not only personalize their rooms but also get customized care. The focus is on their individual needs.

Residents are encouraged to eat what, when and where they want. A staff member might go out to get a pizza for a resident who wants one.

A home that melds aspects of both of these philosophies -- Crestview in Bethany, Mo. -- was described in Friday's Post-Dispatch.

Costs 101: Medicaid or putting up your assets

Short stays: These generally follow a hospitalization and are intended to help patients needing rehabilitation before they move back home. Medicare will usually cover nursing home care for such stays through the first 20 days of care. After that, a co-pay -- averaging the same as Medicaid reimbursement rates -- is required. Those are $96.03 a day in Missouri and $90.06 a day in Illinois.

Many supplemental Medicare policies will pay all or most of the co-pay.

Long-term care: Nursing homes cost anywhere from $40,000 to $60,000 per resident per year. Most people start out as private-pay patients, using up their life savings and then turning to Medicaid when their finances are down to less than $1,000 in Missouri, and to $2,000 in Illinois.

Medicaid laws vary from state to state, and some lawyers can arrange assets in a way that can shield some of the money and still let the person qualify for Medicaid. Here -- in general terms -- is how the finances work:

Widowed and unmarried residents: In Missouri, a single resident must spend down to less than $1,000 in total assets, keeping a home and a car if he or she can establish a likely return home. In Illinois, a single person must spend down to $2,000, and can also keep a home and a car in some cases.

In both states, if the person does not return to the home, the state will recover money from the sale of the home when the resident dies.

Married residents: In Missouri and Illinois, residents with spouses remaining at home must transfer to the spouse their home, car, clothing and up to $89,280 in other assets such as stocks, bonds, pension income savings and bank accounts.

In Missouri, the resident must have transferred all assets over $999.99 to the spouse to qualify for Medicaid. In Illinois, the resident must have transferred all assets over $1,999.99 to qualify.

Penalties are high for people who secretly divest themselves of assets in an attempt to qualify for Medicaid reimbursements. Such efforts could disqualify those who took part in the fraud from future Medicaid assistance.

Costs 201: Long-term care insurance

Long-term care insurance is another method of paying for the potentially punishing costs of a nursing home. Policies offer a bevy of options with an array of benefits. The cost depends on a number of things: the age at which the coverage is purchased, the benefit period selected, and the types of benefits. The one thing they all have in common: expensive premiums.

Valerie Van Booven, a registered nurse, geriatric care manager and expert on long-term insurance, acknowledges that it isn't for everybody.

The insurance is designed to protect people with a minimum of $50,000 in assets, but preferably at least $75,000, who want quality care and don't want to depend on their children to make the decisions and choices for them, Van Booven said. People who can afford annual payments of at least $1,000, and often nearer to $2,000, without worrying about it are the best clients for long-term insurance.

"If you have to choose between paying for snow tires and paying for your long-term care premiums, then long-term care insurance is probably not for you," Van Booven said.

Even then, most people can afford the premiums only if they buy the insurance when they are in their 50s and 60s. Numerous pre-existing conditions -- such as Alzheimer's or Parkinson's diseases -- can disqualify a person. Rantz says in her book that people in their 70s should be wary of any company willing to sell them a policy.

Rantz and Van Booven caution people to make sure the companies they deal with are reputable and will have enough money to pay off policies 20, 30 and even more years down the road.

Policies typically have waiting periods of three to six months before they begin to pay for nursing home care, and they don't cover medical care or short-term care during that period.

A person who goes into a home within the waiting period will have to pay out of his or her own pocket. In that case, many people are likely to spend all their assets and qualify for Medicaid at about the same time insurance benefits would kick in.

Some insurance experts worry that the cost of premiums will continue to increase as the cost of care continues to spiral upward. They also note that like all insurance, long-term care insurance is a gamble. A person could pay into a policy for decades and then never qualify to use it because the person remains self-sufficient until death.

Choices 101: Limited if you have no money

People with little or no money have some options. Once a person has qualified for Medicaid, he or she can choose from among the nursing homes that will accept what is termed "Medicaid direct" residents.

The problem, according to John Riley of John Riley Elder Care Associates, a private elderly consultant firm, is that lack of personal wealth severely limits the number of homes in which a person can choose to live.

"The reality of the nursing home search in the St. Louis area ... is money," Riley said. "Families get a catalog and start looking and they may look all day and not look at one home that is financially appropriate."

Choices 201: Private pay opens doors

Ninety percent of facilities are open to people who can afford at least two years of private pay (through insurance or other means), before becoming eligible for Medicaid. During that time a resident spends his or her remaining assets with the home and then is reviewed for a Medicaid bed. In such cases, family members or caregivers must be sure they have selected a home qualified for Medicaid so the resident can remain in the home when he or she outlives their assets.

Riley said plenty of good homes are qualified to accept only Medicaid residents but that far more homes are available to a private pay resident.

"There is an enormous difference in the physical plant between private pay and Medicaid direct facilities," Riley added. "There is an enormous difference in the staff they attract and the staff they retain, in the activities, food service, and other amenities."

Counselors can help avoid pitfalls

Services like those provided by John Riley, the private consultant, and Jill Boyd of Delmar Gardens can ease the transition into long-term care.

Other names of counselors can be obtained by contacting the National Association of Professional Geriatric Care Managers. (The association's Web site is in a list accompanying this story.)

Riley is well-versed in the geriatric care industry, having spent more than 20 years in it, starting out as a social worker for the elderly. He knows a lot about homes in the area and can give sound advice on how a family can get a parent admitted and exactly what the financial burden will be.

He also functions as a reality check for adult children who may inadvertently prejudice nursing home administrators against admitting their parents. For instance, he tells them not to expect mom's cashmere sweaters to come out of the nursing home wash looking like they did when mom took them to a finicky dry cleaner.

Adult children can make it harder for a parent to adjust by being overly picky, having unrealistic expectations and hovering. Nursing home operators don't like to deal with families like that, Riley said.

Boyd has devoted her working life to elder care, and, like Riley, she started out as a social worker.

Boyd evaluates elderly people in their own homes -- or a relative's home -- to see whether they function well enough to stay in that residence.

She also manages the care of elderly people, such as arranging for community services and making referrals to doctors, nursing homes or alternative environments. She counsels older people and their families, makes necessary telephone calls, takes care of correspondence and helps with travel needs.

Boyd -- or someone just like her -- is the person to call when you live out of town and you're worried about your parents. She also can function as a "paid friend," visiting family members in long-term care as often as requested and letting the staff know that someone is keeping an eye on mom or dad.

Neither Riley's nor Boyd's services are cheap. Riley charges $150 an hour. He sees about 1,000 families a year; most families can wrap up their business in two or three visits with him. He and a business associate also provide some free counseling, if needed, by phone.

Boyd's care management services cost $80 an hour through Delmar Gardens Private Services. Assessment of an individual is $250; $375 for a couple.

The ombudsman program

What happens if the older person or the adult children can't afford such services? They can turn to the federally mandated Long Term Care Ombudsman Program in their area. Ombudsman services, available throughout the country, are free.

Unfortunately, as was reported in Wednesday's Post-Dispatch, the ombudsman program has not been as successful as was anticipated when Congress created it in 1972. The goal of the program was to prevent harm to nursing home residents, but ombudsmen were not given enough authority to meet the goal.

The ombudsman's office in St. Louis County also covers St. Louis and the counties of Franklin, Jefferson and St. Charles.

Most of the information is provided over the phone, said Richard R. Cavanaugh, executive director of the ombudsman program in St. Louis County. Cavanaugh said the ombudsman staff also helps families approach their situations calmly and with pertinent information.

Muriel Shackelford is the ombudsman for Illinois' Land of Lincoln Ombudsman Program, which covers the counties of Bond, Clinton, Madison, Monroe, Randolph, St. Clair and Washington. The regional office is in East St. Louis.

The ombudsmen help families assess types of facilities, and explain the databases offering state inspection reports on nursing homes, staffing levels and whether the homes accept Medicare and Medicaid.

The ombudsmen do not recommend specific nursing homes. They try to provide people with enough information so they have a better idea of what they need and what's available.

Ombudsmen also are advocates for those already in long-term care. Among a variety of services, they educate families and the elderly on their rights within a nursing home, listen to residents' grievances and try to resolve them, and train staff at nursing homes to honor residents' rights.

They provide the names of lawyers who specialize in elder care, explain regulations covering finances and help families recover funds that have been mishandled by long-term care facilities. They often must rely on regulators to intervene.