When Carolyn Polchow and her siblings approached their mother with the idea of her moving into an assisted living facility, the matriarch's response was a firm no. Catherine Moore, then in her early eighties, had lived in her San Diego home since 1960, but she was beginning to show signs of dementia. She was getting lost walking around her neighborhood, not going to exercise classes because she'd forgotten how to get there, and often refusing to allow a private caretaker into the house, thinking the woman was a stranger.

"Her safety was becoming a problem," says Polchow, 61. "She needed to be in a place where she could get care, and she needed to be closer to her kids."

Due Diligence

Despite her mother's resistance, Polchow began researching facilities with memory care services near Los Angeles, where she and her brother both live. She read online incident reports about various centers compiled by the state of California, then visited about 25 different facilities. She didn't like places that limited memory care to one floor or area, finding the click of the locking doors too prisonlike. She also shunned places with dark rooms.

Then Polchow visited a Pasadena facility devoted to memory care. She walked in and "it felt like home," she says. When her mother received a diagnosis of Alzheimer's disease a few months later and agreed to leave her home, Polchow was ready to help her make the move.

Thoughtful but Firm

"I put a deposit down and hired movers before my mother could change her mind," says Polchow, who successfully resettled her mother, now 88, five years ago. "My advice to everyone," she says, "is don't wait, but take the necessary steps. People need to take the plunge, but they also need to know they're doing the right thing."

Seeking Stimulation

Tom Doyle, 65, was diagnosed with younger-onset Alzheimer's disease in 2016 and soon after retired from teaching. Then he and his husband, Levi, moved from California to Illinois to be near Tom's family, but Tom began to feel depressed. "With Levi at work all day, I was lonely and bored, and I finally said, 'I can't live like this,'" says Doyle, who serves as an Alzheimer's Association national early-stage adviser. "That started the process of us looking for senior living facilities."

After visiting multiple places, the Doyles narrowed their choices to two. One, located in Chicago, had the diverse population and enrichment opportunities the interracial couple was looking for. But the other, located in the suburbs, cost $400 less per month.

The Doyles were about to go with the lower-price option when the preferred facility "brought its price down so it was competitive," says Tom. The couple, their therapy dog, Ellie May, and their cat, Chelsea, moved into their new home, a 34-story high-rise near Lake Michigan, in October. "I'm a city boy, and the facility is a mile from the church where I was baptized, so this is like coming home," Tom says.

The facility also has extras that Tom appreciates. It offers senior fitness classes, including water aerobics, LGBT social hours, and book groups. "These different social activities are what I need. People with Alzheimer's need social stimulation, and I wasn't getting that," says Tom, who eats two meals a day in the facility's dining room and has someone help him manage his medication. "I no longer worry about cooking meals, washing dishes, or managing medication trays."

Fitting In

Levi, 58, says he initially wondered how he'd adjust to a community for people 62 and older, but his primary concern was how his husband would adjust. The facility offers different levels of care, including memory care and skilled nursing. "Tom seems more hopeful now," Levi says. "As for me, I feel like a teenager there."

A New Reality

Moving a loved one into an assisted living facility—or choosing one for yourself—is a life-changing decision often fraught with fear, worry, uncertainty, and sometimes guilt. It's a topic frequently raised by people calling the Alzheimer's Association's 24-hour help line, says Ruth Drew, director of information and support services for the association.

"I hear people say, 'I don't want to go into a home' or 'I promised Mom I wouldn't put her in a home.' They're picturing a place where you put people, then leave. Perhaps they're basing it on an experience they had 30 or 40 years ago or they're imagining something they saw on television," Drew says. "Often this doesn't match the reality at all."

Judgment Call

The first step is determining whether it's time for assisted living. "A simple question may be, 'Does my relative need help?'" says Nate O'Keefe, co-founder and CEO of Roobrik, a company that developed a free personalized decision-making platform for families. The software—which does not recommend specific providers and is based on insights from co-founder Judy Conway, who cared for her mother and in-laws for more than 17 years-includes questions about driving, at-home help, safety, isolation and loneliness, and the stress level of the primary caregiver. (Assisted living facilities that offer the software on their websites pay Roobrik for it.)

Ask Tough Questions

Does your loved one still drive, and are you worried about it? How much help does your relative need with personal activities such as getting dressed, bathing, and using the bathroom? Can your mother or father still cook and clean? Could any of your parent's or spouse's actions cause harm? These are some of the questions caregivers need to answer when determining whether it's time for assisted living, says O'Keefe.

Even if it's difficult, caregivers must be honest when assessing the situation. Have you resorted to hiding your father's car keys? Did your mother burn one meal too many when she forgot what was on the stove?

Broach the Subject

If assisted living does seem like a good option, the next step is talking about it. That's another challenge, and many people providing care for family members say they feel a tremendous amount of guilt, stress, and anxiety about it. On Roobrik, the most popular article is titled "9 Strategies for Having the Conversation."

"For many people, the idea of talking with a family member or a parent about making a change is the hardest part. It reverses the parent/child dynamic," O'Keefe says. "We see the conversation as really a series of conversations—planting the seed, listening, finding the right time to explore it from different angles, validating concerns, and walking down the path together."

Listen Carefully

It's important to listen to your loved one's concerns and be respectful of their wishes whenever possible, says Jean Accius, vice president for independent living and long-term services and support for AARP. After all, a vast majority of people say they want to stay in their homes or communities, according to an annual AARP survey on the matter.

"Perhaps the most important way you can help loved ones prepare for a move is through open, honest, and loving communication," Accius says. "Remind them that while your day-to-day dynamic may change, you will remain their greatest advocate."

Look for a Facility

A great place to start your search is with the long-term care ombudsman program in your state, says Robyn Grant, director of public policy and advocacy for the National Consumer Voice for Quality Long-Term Care. A federally required free service, the ombudsman advocates for residents of assisted living facilities and nursing homes and can provide information about facilities and how to choose one.

Leave Time for Research

"It's better to have thought about assisted living and done some research before a crisis," Grant says. "Assisted living in this country is very complex, and what's available varies greatly from state to state. There are no national standards. I've heard assisted living described as 'the Wild West under a roof.' If you've seen one assisted living facility, you've seen one, which is why so much falls on the consumer to learn what exactly these facilities offer and what a consumer has the right to expect."

Plan a Visit

Once you've found some facilities online, the next step is to schedule a visit, says Rachel Reeves, director of communications for the National Center for Assisted Living. A visit, which can usually be arranged through a facility's administration or admissions office, helps you get a feel for the place, says Reeves.

Stop By at Mealtime

Many care experts also recommend visiting at mealtime to observe the ratio of staff members to residents. Are all diners receiving their meals in a timely fashion? Are special requests—for condiments or a beverage, for example—being met? Sample the food and try to get a feel for the dining room. Is it comfortable? Attractive? Do residents seem engaged with each other and their surroundings?

Before Tom and Levi Doyle moved into the facility in Chicago, the staff invited them to come to dinner. The couple was seated with residents the staff thought would have similar interests. Tom immediately clicked with a woman who had also been a college professor. They even knew some of the same people.

"The facility was already helping us become integrated into the community," he says. "I can't believe that everybody knows our names. Even the CEO."

Drop In Over a Weekend

"If you really want to do some double-checking and make sure you feel comfortable with the care, visit on weekends, when less staff is working," Reeves suggests. A good test for any facility is seeing how the staff operates under pressure. How do they react to unscheduled visitors? If visitors are not welcomed, that could be a sign the facility is hiding something.

Inquire About Enrichment Programs

The Doyles' Chicago facility offers gardening opportunities, a program that pairs residents with local students, regular happy hours, fitness classes, and about 30 different "Brain Health University" classes. One popular course is Slang 101, which teaches modern lingo while building memory function.

Must-Ask Questions Before Moving to Assisted Living

1. What care and services do you provide? Understand what services are part of the base rate. For instance, is help with tasks like bathing, dressing, and managing medication included or extra? If extra, what are the costs? Consider the level of care or service your loved one may need in the future, as it may not be offered at every facility. Also, look for extras that aren't related directly to care, like a "community fee" to maintain the grounds or remove snow. If possible, have a lawyer review any contract before signing.
   You want to avoid any surprise fees or rules that may get your relative discharged from a facility, says Robyn Grant, director of public policy and advocacy for the National Consumer Voice for Quality Long-Term Care. "Some people might say, 'I know Mom can only stay here until she needs two people to help her get in and out of bed, but this is such a great place, I want her to be here until then.' Others don't want to have to move."
2. Does your facility offer a transitional option for people who may eventually need more care? Some facilities offer different levels of care—for example, independent and assisted living, memory care, skilled nursing and rehabilitation, affordable senior housing, and short-term stays—and allow residents to move between them.
3. What medical services do you provide? Find out if the facility has 24-hour nursing on staff and if they monitor patients to ensure their safety. For example, do they issue wristband alarms or other safety devices? Additional medical services include medication management with reminders, on-site pharmacy or deliveries, and general wellness checks. Common skilled nursing services include wound care, intravenous medication administration, and respiratory therapy or treatments.
4. Do you accept people who already have dementia? Some independent living facilities will not accept residents who may need increased care in the future, even if the facilities have the resources and staff. Always ask what services are available for the time being and further down the line.
5. What activities and other quality-of-life programming are offered? "It's easy to get wrapped up in the cost of assisted living and whether the facility can meet your loved one's care needs, but it's also important to assess whether the facility will enrich your relative's life," says Rachel Reeves, director of communications for the National Center for Assisted Living in Washington, DC. "Staffers should get to know new residents and what activities will engage them, and families can help with that." Ask if the facility has lectures, classes, music events, birthday celebrations, or any community involvement.
6. What forms of payment do you accept? Many people pay for assisted living care without government assistance, and it can be expensive. The national median cost of assisted living is $48,000 a year, according to a 2018 survey by Genworth Financial. The company produces an annual Cost of Care report based on data collected from more than 15,500 surveys representing facilities in every state and the District of Columbia (http://bit.ly/Genworth-CostofCare ). Medicare does not cover assisted living, says Reeves. She also notes that Medicaid coverage varies by state and does not include assisted living in six states (Alabama, Kentucky, Louisiana, Pennsylvania, Virginia, and West Virginia). Some assisted living residents pay through long-term care insurance. In fact, the Urban Institute found that about 11 percent of older adults living in community settings were covered that way in 2014.

"It's important to talk to facilities about costs to understand their payment structure and whether that is feasible given your personal finances. Ask up front what your options are if your money runs out," says Reeves. "About 15 percent of assisted living residents rely on Medicaid for daily care. If you spend down your resources, how do you become Medicaid eligible? Does the facility accept Medicaid?"

Assisted Living Resources

• AARP: aarp.org
  AARP offers care guides to help start the conversation about assisted living and create a plan that clarifies overall goals and reduces the amount of stress for everyone involved. The organization also has a list of suggested questions to ask when visiting facilities: a Nursing Home Checklist and Assisted Living Questions.
• Alzheimer's Association: alz.org
  The 24-hour helpline and tip list assist families in finding the right residential care for a loved one with Alzheimer's.
• Long-Term Care Ombudsman Program: theconsumervoice.org
  Every state has a state ombudsman and local/regional ombudsmen. Contact the local/regional ombudsman based on your address. To find the ombudsman for a specific facility, determine the county it's located in and then find the ombudsman for that county. More information about the long-term care ombudsman is available at ltcombudsman.org.
• National Center for Assisted Living: ahcancal.org
• National Consumer Voice for Quality Long-Term Care: http://bit.ly/NCV-AssistedLiving