People who see nursing homes as places for "ancient relatives" to live and die quietly and painlessly have a limited and often inaccurate concept of what the facilities - and the people who live there - are really like."Putting someone in a nursing home is an emotional issue," MarJ Drury, Long-Term Care Ombudsman for Utah, said. "And people in that situation are not usually educated about it because they never wanted to be."

Over the past decade - particularly the past five years - nursing homes have changed dramatically. The way people view them has changed, too, but more slowly, she said.

"When you select a nursing home, you need to remember that it's going to be a person's home for a while," Drury said, noting that nursing homes offer a lot of services for the elderly who need to get over something acute, like a fractured hip.

"But it's not a hospital; it's a place to live. A lot of different people are there for diverse reasons. So don't think of it as a place where someone you love will play out the rest of his life. Most people do go home again."

Whether a temporary or long-term living solution, selecting a nursing home is a difficult task, and there are many things to consider.

Virtually everyone interviewed by the Deseret News said cost is a major issue. But it's almost impossible to talk about costs without talking about Medicaid.

"About 70 percent of the people in nursing homes are being paid for by Medicaid," Rod Betit, director of the Division of Health Care Financing, Medicaid's administering agency, said. "Less than 2 percent are paid for by Medicare; then the rest are through private payment."

The cost of a nursing home is significant. Medicaid pays from $45 a day, while private-pay costs are higher. (Because Medicaid sets the fee it will pay, and funding is chronically cut back in tight fiscal years, private patients to some extent "subsidize" Medicaid patients.) In Utah's nearly 100 facilities, the private fee ranges from about $50 up to $127 daily, and the cost of medicine and treatment may be added to those flat fees.

"We - Health Care Financing - are the market, for all practical purposes," Betit said. "About one-third of the total Medicaid budget goes to pay for 4 percent of the Medicaid clients."

Medicaid doesn't offer a free ride when it comes to nursing homes, however. Admission policies are very restrictive. To qualify, a person must meet two of four criteria, in addition to low-income restrictions.

"A person must be proven to be a clear danger to himself or others; be mentally retarded; require total care or substantial assistance with daily living; or be disoriented as to person, place or time," Betit said. "And the intensity of care can't be met in a less restrictive environment.

"We attempt to meet the needs when possible, but if someone can be treated outside a nursing home, he should be." (For a look at some of the alternatives to nursing homes, see accompanying article.)

There are also stringent financial requirements to receive Medicaid, and people who have more than the allowable income limit must "spend down" to qualify.

Betit said after the spend down a spouse is allowed $289 a month to live on, plus some approved household expenses for up to six months. Assets must be less than $3,000, forcing many couples to liquidate to qualify for help. Utah, unlike some states, doesn't force children who are financially able to pay for their parents care.

Another important consideration is the level of care available. Nursing homes provide three levels: skilled (for acute medical cases, like recovery from a broken hip), and two intermediate levels.

The lesser of the two intermediate levels might contain individuals who are confused and are taking medication for it. They require close supervision but can groom and feed themselves. This population is generally under the age of 70, Drury said.

In the worst case of intermediate care, persons are bedridden, incontinent, but don't need to be tube-fed. They need significant help, and care is generally long-term. "It's close to skilled care, but chronic, rather than acute," Drury said.

Each level of care demands different staffing requirements - there are rules about how many nurses, aides, etc., must be on duty at a given time. Betit's division inspects and monitors facilities and once a year makes a surprise inspection that includes a review of each patient's chart by a medical team.

"That's a huge part of our responsibility," he said, "and when we find problems we have to decide on further action. We take the responsibility very seriously, because with the feds there's no middle ground. You have to provide either exactly the right care or no care at all."

About 75 percent of the nursing home beds in Utah are occupied right now, Betit said.

Drury and several nursing home administrators offered suggestions for families selecting a nursing home:

-Make sure the home is licensed. There are between 200 and 300 nursing homes in Utah that are not licensed, although by law anyone who has two or more unrelated adults on a 24-hour basis needs a license to operate.

-Visit unexpectedly, at odd hours. This doesn't mean pop in at 3 a.m. But after you meet the administrator and take the "grand tour," stop by unexpectedly. Around dinner is good, because that allows you to see how patients are treated, as well as to examine and possibly sample the food.

-Pay attention to smells. There's no excuse for the pervasive "hospital smell" that was once common in nursing homes. And strong smells - like thick air fresheners - used to mask other unpleasant smells are a bad sign, too.

-Check overall cleanliness. Are the other patients clean? How about the facilities?

-Choose a location that is accessible to family members. Select a nursing home that is close to home or work so you can visit often and become a part of it. According to Drury, 75 percent of those in nursing homes nationally never receive visitors. A location close to the old neighborhood functions and friends keeps the patient from feeling isolated.

-Watch the interaction between staff and residents. Unexpected visits are a particularly good time to see what a home is really like. Is there a feeling of community? Remember, you're considering the nursing home as a place where someone you care about will have to live.

-Make sure the staff is adequate. There should be a reasonable ratio of nurses, aides and other staff members to patients. Some homes also offer physical, rehabilitation and speech therapists. Find out about nutritionists, dietitians and other key personnel.

-What recreational activities are available? Experts agree that patients who are stimulated are not only happier, but healthier, and more apt to be able to return to the community.

-What are the visiting hours? Visiting hours at most homes are from 10 a.m. to 8 p.m., but the hours are flexible so that families can make arrangements to stop by at other times.

-Go with what you feel. This is most important. According to Drury, feelings are the bottom line. "A good nursing home for one person might be a cozy place with a warm feeling, while someone else wants one that is very formal and more aloof - what some would call `sterile.' It's important to go with your feelings when selecting the atmosphere.

"Attitudes are changing slowly," Drury said, "mostly because of the work done by groups like the American Association of Retired Persons and the Nursing Home Association. Nursing homes are becoming a part of the community, particularly in small communities.

"The more exposed people are to them, the less fear there is. But there's still a bit of a stigma attached to being in a nursing home - and to those who put people in. It's a shame, because there needn't be."