It carries the financial impact of monthly mortgage payments, the social consequences of a longterm relationship and the medical potential for saving - or losing - a life.

So why do so many of us select a skilled nursing facility or assisted living home in less time than it takes to purchase a new lawn tractor?

According to Char Broesch, manager of care management at Kootenai Health, "Definitely shop around. Making a selection takes time and it's not a decision you want to make on the spur of the moment."

But the search for perfect elder-housing rarely comes at you at life's most optimal moment.

Often it involves a tight deadline: You've got to find a place for Aunt Margaret who'll be released from the hospital in two days. Or, it's time to face the fact that dad's going to burn down the house if he continues to leave the stove on. Or maybe you've been postponing a decision about Uncle Julian because you know it will involve hurt feelings and family arguments.

"In the end, it's always the patient's choice," Broesch said. "What we do (at Kootenai Health) is lay out the facts, look at the needs and have a frank conversation with both patient and family.

"We ask the patient if he thinks our plan is realistic at this point in time, because in order to go home from the hospital, you have to be functioning at an independent level. Sometimes people don't realize how much surgery can set them back."

Family encouragement and involvement, Broesch said, are major factors in patient success.

Selecting the necessary level of care is the first decision to be made when searching for an elder care residence. The primary contenders are: skilled nursing facilities and assisted living homes.

Dr. Susan Melchiore, medical director at On Site for Seniors said, "There's a huge selection out there. I'd say a skilled nursing facility is called for if the patient needs IVs or is on a complicated oxygen regimen or maybe on insulin. Short of that, if you're just looking for assistance with meds or help with bathing or cooking, you're looking for assisted living."

According to Ruthie Dearing, admissions coordinator for Coeur d'Alene Homes, "In assisted living, people still function very well - they're usually ambulatory and oriented. They just may need help remembering to take their medication and maybe they aren't as capable preparing food as they used to be."

State law requires that following an initial patient assessment, an RN must visit each resident in assisted living every 90 days or whenever there is a change in that resident's condition. According to Jan Young, regional ombudsman for the Area Agency on Aging, most skilled nursing facilities are full-time staffed with nurses and certified nursing assistants, while the majority of assisted living residences may have an on-call RN, CNAs, medication technicians and trained personal care givers.

Once you've decided the type of facility you're looking for, and the specific amenities you'd like to find there, make a list of available options and start calling and asking questions. To obtain a list of local facilities, you can contact the social service department at Kootenai Health.

You can compare local options for skilled nursing facilities at http://www.medicare.gov/nursinghomecompare/

Once that's done, it's time to get out of the house and knock on facility doors.

When choosing a facility, Melchiore suggests that one of your most important criteria be location.

"Location, location, location," she said. "It's like the Realtors say. You want it to be close to family and visitors so that when the resident needs an advocate, they can quickly get there to assist."

The American Association of Retired Persons suggests that you keep in mind when you first tour a residential facility that, "the person you speak with (at this time) will most likely be a marketing or sales representative whose job is to promote the residence."

In shopping the world of elder care you need to be intensely aware of your surroundings. The most important part of the initial visit is the tour. Young's advice is to walk in unannounced.

"If you make an appointment," she said, "you're going to see nothing but the good. If you walk in unannounced, you'll see the good, the bad and the not so good."

She advises starting your tour with all five senses on full alert.

"Notice how the residents look and what they're doing. Are they interacting with other residents and staff or are they just parked in front of the television? Is their hair done? Are they wearing clean clothes? Pay attention to the way staff interacts with residents."

Are the bedrooms clean and cozy or dirty and impersonal? Are there bad odors in certain areas of the facility? Does the food look hot and appetizing?

You might offer to pay for your lunch and join the residents at mealtime. Run for the hills if any facility tries to keep you from talking to the residents.

Ann Johnson, director of development and marketing at Coeur d'Alene Homes said, "When you take a tour, you get an impression if the facility is a good fit for your needs. Don't be afraid of asking a resident if they like living there. And you don't need to purchase a meal with us - we'll invite you to sit at the table, enjoy your food and interact with our residents."

If you're interested in a particular facility, it is recommended you visit several times before making a final decision - be sure to go at different times of the day and week.

The state licensing agency conducts an annual survey of all elder-care facilities and Young recommended you ask to see a copy of the latest one. Inspectors enter the facility - unannounced - and check out the condition of the premises and the level of resident care provided.

A good state site for checking both facility certification, complaints and awards is http://www.healthandwelfare.idaho.gov/Medical/LicensingCertification/StateOnlyPrograms/AssistedLiving/tabid/273/Default.aspx

"Among other possible violations, facilities could get tagged for medication errors, not answering call bells or not addressing changes in resident conditions," Young said.

Once you've finished your tour and are at the point of discussing specific features of the facility, start thinking about money.

"Be familiar with your insurance carrier and know your plan," Broesch said. "Medicare does not cover assisted living facilities and it will cover a SNF only if a patient is admitted following inpatient status in a hospital. It's good to ask if the facility provides speech therapy, occupational therapy or physical therapy opportunities and whether there is an additional charge for these."

As to whether the elder family member should be along on the initial tour, there's no firm answer. Dearing said, "With most people I see, the daughter and/or son will come first and we'll give them a tour. If they like what they see, they'll often want to come back the following time with their family member."

So much of choosing the right residential placement for an elderly family member is about attitudes. It's a hard sell if placement is looked at as a prison sentence.

According to Broesch, "Many people think that going to a nursing home means being there forever and that's not the case. While these (facilities) can provide longtime care service, the majority of patients will be there for the short term to receive a variety of therapies. After that it's back home or to assisted living."

In the end, Young said, "We are very fortunate with the facilities we have in this area. They are pretty darn good."

Top 10 points to

consider when

choosing a residential care facility

* Do I want to live there?

* Is the location close to family, friends, doctors, hospitals?

* What is facility's reputation and do they have a history of abuse/violations?

* How much will I pay and what does that money cover?

* What will happen to me if my funds run out?

* How is the food?

* What are visiting hours - are they convenient for family and friends?

* What special services and activities are offered and what will they cost?

* What level of assistance can I expect from the staff?

* Can minimally-mobile patients feel safe in an emergency and what is the evacuation plan?

- from the staff of Coeur d'Alene Homes